Trauma and Resilience Among Displaced Populations

Front matter

Gail Theisen-Womersley

Trauma and Resilience Among Displaced Populations

A Sociocultural Exploration

Contents

Conceptualising Experiences of Trauma and Migration

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Chapter 1 A) Introduction E

We are now witnessing the highest levels of displacement on record. According to the United Nations High Commission for Refugees (UNHCR), there are 70.8 million forcibly displaced people worldwide. This includes over 41 million internally displaced people, 25 million refugees and 3.5 million asylum seekers. This is a challenge of historic proportions. Evolving responses having now become one of the defining challenges of the early twenty-first century (Farhat et al., 2018; Médécins Sans Frontières, 2016; UNHCR, 2015). Not least among the difficulties are public health challenges of the multiple traumas faced by displaced populations. The loss of loved ones or caregivers and/or livelihood, the destruction of property, insecure living conditions, war, torture, imprisonment, terrorist attacks, abuse, and sexualised violence are among the traumatic experiences that characterizes experiences of displacement. Furthermore, trauma does not stop at the border. A plethora of literature attests to the traumatic impact of post-migration factors with which many refugees! are faced upon arrival in host countries (Bhugra & Gupta, 2011; Greene et al., 2017; Greene et al., 2019; Heeren et al., 2014; Schick et al., 2018; Schouler- Ocak et al., 2016; Sijbrandij et al., 2017; Silove et al., 2017; Ventevogel et al., 2019; Wenzel & Drožđek, 2018). In the post-migration context, stress and trauma may be related to harsh living conditions, the erosion of mutual social support mechanisms, limited access to basic needs and services and lack of opportunities for maintaining livelihoods and education (Greene et al., 2019; Weissbecker et al., 2018). Furthermore, displaced populations may be facing these stressors in situations where the capacity for self-help and mutual support has been negatively impacted by forced migration, the separation from families and communities, collective violence and mistrust (Sijbrandij et al., 2017).

The severe impact of exposure to potentially traumatic events on the mental health of this population are pervasive and profound. Trauma constitutes an urgent threat to human, social, cultural, and community development (ď’ Halluin, 2009; Médécins

1 Throughout the book, the term “refugee” as defined by the Geneva Convention of 1951 is used to include both refugees legally recognised in a host country as well as asylum-seekers.

© The Author(s) 2021 1 G. Theisen-Womersley, Trauma and Resilience Among Displaced Populations, https://doi.org/10.1007/978-3-030-67712-1_1

Sans Frontiéres, 2016; Ventevogel et al., 2019; Wilson & Drozdek, 2004). It is transmitted intergenerationally. The unprecedented number of displaced populations around the world are not only carrying the emotional scars of the traumatic events to which they’ve been exposed, and to which they continue to be exposed. Many are suffering from the effects of intergenerationally transmitted trauma—and may risk continuing to transmit these effects in a way which perpetuates ongoing cycles of violence and conflict.

The impact of trauma has become an object of increased attention since the turn of the century, both in the scientific domain but also within public discourse regarding the influx of migrants into Europe and North America (d’Halluin, 2009). In the realms of journalism, social media and public discourse more generally speaking, the idea of trauma is revoked repeatedly to testify to the significant level of mental health difficulties (Summerfield, 2000b). Attention to trauma has also increased in the humanitarian field over the last decade in particular. Programmes focusing on mental health and psychosocial support now routine elements of a humanitarian response to refugee crises (Weissbecker et al., 2018). It has even been suggested that all forced migrants experience some degree of post-traumatic symptomatology (Copping et al., 2010). Furthermore, the psychological consequences of exposure to trauma and/or ongoing environmental stress in host contexts may impede process of adaptation and acculturation (Steel et al., 2016). The vastness of the phenomena of trauma and migration has therefore led it to become an urgent area of inquiry—with research into the ksey determinants of refugee trauma and potential opportunities to improve mental health now a pressing concern (Hall & Olff, 2016; Tessitore & Margherita, 2017).

Mental Health of Refugee Populations

The literature overwhelmingly attests to significantly high prevalence rates of posttraumatic stress disorder (PTSD), anxiety and depression among refugee populations when compared to the general population of host communities (Abbott, 2016; de Arellano & Danielson, 2008; Kirmayer et al., 2010; Lambert & Alhassoon, 2015; Schweitzer et al., 2006; Steel et al., 2009; Sturm et al., 2010; Van Ommeren et al., 2001; Weine et al., 2001). In a recent study of over one million people in Sweden, Hollander and colleagues (2016) found that refugees granted asylum were, on average, 66% more likely to develop schizophrenia or another non-affective psychotic disorder than non-refugee migrants from the same regions of origin. This finding confirms a previous meta-review of the literature by Porter and Haslam (2005) who found evidence that refugees from the former Yugoslavia suffered significantly more mental health impairment then non-refugees from the same region across multiple studies.

Exposure to torture has emerged as a particular triggering factor of PTSD symptomatology (Haenel, 2015; Hodges-Wu & Zajicek-Farber, 2017; Mollica et al., 1998; Silove et al., 2017; Song et al., 2017). This is no surprise, given the multiplicity of

Mental Health of Refugee Populations 3 challenges to which refugee Victims of Torture (VOTs) are exposed. The dual trauma inherent in being both a VOT as well a refugee is related to a myriad of losses, human rights violations and other dimensions of suffering linked not only to torture experienced pre-migration, but to different forms of violence experienced during and after migration as well. Indeed, refugee VOTs “often present a complex constellation of symptoms further complicated by cultural variables and post-migration factors including immigration legal issues, economic challenges, diminished social networks, shifting power dynamics, bereavement, and other prolonged stressors” (Hodges-Wu & Zajicek-Farber, 2017).

Torture itself represents an extraordinary exception in the psychopathology field. The particularity of torture as pathogenic is linked to the fact that the act itself is taught, organized, elaborated, and perpetrated by humans against other humans (Sironi, 1999; Vifiar, 2005a). It disrupts our connection to all that make us human (Vifiar, 2005a). As such, the psychopathologic disorder of the survivor cannot be reduced to the intrapsychic plane. It is not an individual act, but a social one. It does not only have individual consequences, but social, legal, and political ones for those who survive. It damages different spheres of an individual including body, personality, hope, aspirations for life, identity, integrity, belief systems, the sense of being grounded and attached to a family and society, autonomy, community relationships, and a sense of safety. These far-reaching effects may interact and manifest in complex and diverse ways, mediated by culture, gender and other aspects of the context of the torture survivor, the context of torture and the context of the recovery environment (Esala et al., 2018; Patel et al., 2014).

The Problem with PTSD

Despite the high prevalence rate of PTSD noted among refugee populations, the authors of the above-mentioned meta-reviews examining epidemiological data have all highlighted the substantial variability of prevalence rates across symptoms—with a variability range as wide as 0-99% noted by Steel for example (2009). This discrepancy remains unexplained (Bogic et al., 2012). Larger and more rigorous surveys were found to report lower prevalence rates than did smaller studies, but significant variability persisted across the board (Fazel et al., 2005; Silove et al., 2017). Furthermore, a re-analysis of the data of the meta-review by Steel and colleagues (2009) conducted by the World Health Organization in 2013 yielded rates of only 15.4% for PTSD (Nickerson et al., 2018). A number of factors, such as the level of exposure to potentially traumatic events before, during and after migration, as well as resettlement conditions in the host country are thought to influence the prevalence rates—which appear to be dose-dependent (determined by the level of exposure to trauma) and occurring in a curvilinear pattern across the resettlement period (Copping et al., 2010; Schick et al., 2016; Turrini et al., 2017).

A growing body of research demonstrates the substantial and negative impact post-migration factors may have on mental health (Li et al., 2016). This includes socioeconomic difficulties, as well as stressors relating to the asylum seeking process. For example, a recent study conducted by Médecins Sans Frontiéres among asylum seekers in Italy (2016) found that significant differences in prevalence rates were related to gender, the state of vulnerability, nationality, the waiting time before being seen by a specialist, and exposure to traumatic events before, during and after migration. This is a particularly relevant consideration for the mental health of refugees in light of the multiple and arguably ongoing environmental stressors and potentially traumatic experiences with which they are faced. In a multi-agency guide on the mental health of refugee populations released in 2015, UN agencies and other international humanitarian organizations have highlighted the fact that—for most refugees and migrants—potentially traumatic events from the past are not the only, or even most important, source of psychological distress but that the majority of emotional suffering is directly related to current stresses and worries and uncertainty about the future (Eleftherakos et al., 2018; Médecins Sans Frontiéres, 2016; IASC, 2015; MHPSS, 2015).

So where and what exactly is the trauma? Cross-sectional epidemiological studies do not allow for a clear distinction to be made between symptoms of trauma related to current contextual stressors within the environment (for example, facing refugee populations in host communities) and a diagnosable mental disorder—based on a psychiatric formulation of mental health located at the level of the individual (Silove et al., 2017). The medicalisation of trauma on an individual level, linked to fixed ‘traumatic’ events in the past, risks rendering us blind to other ongoing aspects of interpersonal, political and social violence on a more global scale, including significant post migration factors which may be deemed equally traumatic by refugees (Maier & Straub, 2011; Silove et al., 1998; Silove et al., 2000; Weissbecker et al., 2018). It also neglects the broader socio-political context within which it occurs (Marsella, 2010; Summerfield, 2001; Young, 1995). Narrowing refugees to stories of trauma, it is argued, stabilizes their experiences too firmly within personal histories of victimisation and injury. It focuses attention on therapeutic outcomes rather than a political response to the structural issues that led to trauma (Pratt et al., 2015). Among refugees, this criticism could also extend to scant attention being paid to their current social, political and economic realities and lived daily experiences in host countries (Silove et al., 2000; Watters, 2001). As recently noted by Wenzel and DroZdek (2018), the emphasis on vulnerability tends to minimize refugee resiliency and agency, and may not adequately representing the heterogeneity found across refugee populations.

Furthermore, what about the influence of culture? There have been significant concerns raised in the literature over the relevance and cross-cultural validity of PTSD as a diagnostic construct being used among displaced populations (Bracken, 2001, 2002; Fisher, 2014; Hinton & Lewis-Fernandez, 2011; Janoff-Bulman, 1985; L. Kirmayer etal., 2010; Marsella, 2010; Staeuble, 2004; Summerfield, 2001; Tummala- Narra, 2007; Wasco, 2003; Young, 1995). Notably, the diagnosis has been criticized for ignoring significant variability among symptoms evident in different cultural settings across the world (Hinton & Lewis-Fernandez, 2011). One example of this

The Problem with PTSD 5 variability which continues to attract considerable debate is the prevalence of psychosomatic symptoms found among some cultures and not others (Eagle, 2014). Not only do our reactions to trauma differ according to cultural norms, but the very appraisal of what is or what is not traumatic may similarly be informed by socio-cultural context. Various cognitive and psychodynamic theories purport that the individual’s processing of traumatic events (i.e. their cognitive appraisal or making sense of the event) is informed by internalized representational constructs, both influenced by and reflected through language and culture (Brewin et al., 1996; Drozdek & Wilson, 2007; Sturm et al., 2007; Sturm et al., 2010). The way in which trauma is experienced is thus thought to be significantly determined by larger cultural systems and historic contexts (Carlson, 2005; Kirmayer et al., 2010; Marsella, 2010; Marsella et al., 1996; Mattar, 2011; Cecile Rousseau et al., 1997; Tummala-Narra, 2007; Wilson & Drozdek, 2004).

A singular construct of PTSD is simply inadequate to grasp the complexity inherent in how different human beings in different cultures respond to terrifying events (Marlowe, 2010; Steel, 2001; Summerfield, 2001). Scholars such as Momartin et al. (2003), Tummala-Nara (2007) and Afana et al. (2010) highlight how little attention has been given to the impact of traumatic experiences on migrants from diverse religious and cultural backgrounds. They argue that displaced populations in particular are exposed to a multiplicity of challenges including losses, human rights violations and other dimensions of suffering. However, the “benign universe” model inherent to the construct of PTSD, is inherently based on white middle-class populations where traumatic events are considered to be infrequent and outside of the range of normal human experience. The relevance of a PTSD diagnosis is therefore questionable among certain cultures continually exposed to traumatic stressors (Afana et al., 2010; Marsella, 2010) where traumatic events may actually validate instead of violate one’s assumptive worldviews (Tang, 2007).

Briefly put, one could deconstruct the very notion of “PTSD” by breaking it up into its various linguistic constituents (Post, Traumatic, Stress and Disorder) in order to examine some of the major criticisms which have been levelled against it. The first word, ‘Post, refers to a discrete event of the past, thus denying the mental health impact of any ongoing factors of mental distress based on current economic, political and social hardships faced by displaced populations. The second word, ‘Traumatic, is problematic insofar as whether an event is perceived to be ‘traumatic’ or not is in part influenced by the individual’s subjective perception of the event, in turn significantly informed by socio-cultural and historical context. The third word, ‘Stress’ implies a specific reaction to the event based on a pre-determined range of psychological symptoms, thereby neglecting the wide range of possible reactions an individual may have to a traumatic event. The fourth word, ‘Disorder,’ necessarily pathologises this reaction, placing it at the level of the individual and squarely within the framework of Western medical discourse. Such reductionist medical discourse arguably stabilizes experiences too firmly within personal histories of victimisation and injury (Pratt et al., 2015). Therefore, rather than portraying refugees as homogenous and pathologised “passive victims” suffering from mental health problems, critics have argued that attention should also be given to the resistance of displaced individuals and the ways in which they interpret and respond to experiences. This includes challenging the external forces bearing upon them and allowing space for the articulation of experiences in their own terms (Harvey, 2007; Tummala-Narra, 2007; Watters, 2001).

Apart from putting into question the validity of a PTSD diagnosis among displaced populations, the significant discrepancy among prevalence rates provides us with an important reminder that not all refugees are traumatized—a seemingly logical yet oft-neglected fact. The myriad of mental health experiences of displaced populations are indeed far more complex than can fit into overly simplistic discourses of trauma. Marlowe (2010) is among the many authors who have highlighted the importance of considering alternative discourses around forced migration “for developing more sophisticated understandings of how people have responded to trauma beyond the “event-worthy” underpinnings of forced migration” (p. 1). She implores a move beyond the “refugee” label, noting that “the story of a person’s experience(s) of trauma associated with forced migration and how it has negatively influenced his/her life can overshadow other co-existing stories which can emphasize something very different about what a person values and readily identifies with.” (p. 1). Loizos (2002) similarly problematizes the term “refugee” as often dependent on sometimes arbitrary political decisions. He criticises accompanying discourses around the label fuelling common myths such as the idea that a refugee is usually or necessarily traumatized by the experience of forced migration; that a refugee is a helpless and dependant person; that a refugee is socially isolated; that a refugee will have difficulty in adjusting to life in a new country because of ‘cultural differences; and that a refugee needs ‘across the board support. Indeed, it has similarly been noted that the process of migration may in fact reinforce internal and group psychological resources (Sturm et al., 2010). As noted by Papadopoulos (2002a), “refugees are defined not as a group of people exhibiting any specific psychological condition but merely as people who have lost their homes” (p. 9).

As neatly summarized by Ventevogel and colleagues (2019), e Firstly, PTSD is not the only mental health problem in humanitarian setting

e Secondly, in many cultural settings, people do not have words or concepts for ‘trauma-related’ mental disorders, or, if they have, these are remarkably different from the prevailing psychiatric definition of PTSD

e Thirdly, there has been sharp conceptual criticism of posttraumatic stress disorder as a ‘psychological construct’ that obscures the driving socio-political causes of emotional distress and transforms human suffering into a mental disorder in need of treatment

e Lastly, the emphasis on past traumatic events in the development of current emotional distress may ignore the pathogenic role of everyday stressors and the multiple hassles to survive in situations of hardship

Calls for a More Contextualised Understanding of Trauma 7

Calls for a More Contextualised Understanding of Trauma

Rather than portraying displaced individuals as “passive victims” suffering from mental health problems, critics have argued that attention should be given to the resistance of refugees and the ways in which they interpret and respond to experiences. This includes challenging the external forces bearing upon them and allowing space for the articulation of experiences in their own terms, including discourses of resilience and post-traumatic growth (Harvey, 2007; Tummala-Narra, 2007; Watters, 2001). The notion of “Adversity Activated Development” has similarly been conceptualised by Papadopoulos (2002a, 2002b, 2007) to refer to the phenomenon whereby individuals may not only be resilient in the face of exposure to potentially traumatic circumstances, but that such adversity may conversely lead them to develop as individuals with new psychological resources. A psychiatric diagnosis such as PTSD has the potential to deny these realities, to pathologise individuals and homogenously to identify all members of minority groups as passive victims. By placing human suffering within such an exclusively medicalised and trauma-focused paradigm, a thin description of the individual is created where other important socio-historical considerations are easily lost or hidden (Marlowe, 2010). It’s an approach which neglects “a concern not to impose order on the world but instead to allow the emergence of other voices and visions, even if this involves increasing complexity and ambivalence” (Bracken et al., 1997).

Individual responses to trauma are thus increasingly understood as unfolding within the context of systems of relationships which form the environment, as defined by Bronfenbrenner’s (1986) Ecological Systems Theory. As Harvey (2007) notes, this ecological perspective is needed to guide inquiries into the understanding of trauma resilience. This is because it incorporates a “resource perspective” which assumes that human communities, like other living environments, evolve adaptively and are deeply embedded in complex and dynamic social contexts in which resources are exchanged. Individuals within this system are capable of negotiating and influencing, as well as being influenced by, this system. Equally, symptom severity is not static but fluid and changing according to a continuum of pathological reactions (Drozdek, 2015b).

In recent years, there has indeed been a burgeoning of theoretical models for understanding trauma that situates individual refugee’s trauma sequelae and recovery within inter-personal, political, and social context. Maercker and colleagues (Maercker & Hecker, 2016; Maercker & Horn, 2013) have recently elaborated and extended a social-interpersonal framework model of PTSD incorporating a host of influential factors external to the individual. Harvey’s (2007) “ecological” model, Drožđek’s (DroZdek, 2015b) model, Marsella’s (2010) interactive model, and De Jong’s (2007) ecological-cultural-historical model of “traumascape,” similarly explore how culture influences the clinical parameters of the diagnostic criteria for PTSD by incorporating a systemic understanding of local representations and experiences of trauma. In the context of trauma among displaced populations in particular, Miller and Rasmussen’s (2017) ecological model highlights how “mental health among refugees and asylum seekers stems not only from prior war exposure, but also from a host of ongoing stressors in their social ecology, or displacement-related stressors” (p. 1). Such multisystem, ecosocial frameworks consider trauma among displaced populations as the endpoint of an imbalance in the multiplicity of countervailing environmental factors that impact on refugees rather than an expression of innate or intrapsychic problems at an individual level. In that sense, the distinction between normative and pathological responses is somewhat blurred and fluid, the vicissitudes of the ecological context determining the direction and extent to which individuals shift on a continuum of stress (Silove et al., 2017, p. 133).

Such perspectives take into account the fact that symptom severity is fluid, ever changing due to a myriad of interacting intrapsychic and external factors. This requires that we pay attention to the “various, context-dependent, long-term, and complex social, political, and economic measures” affecting the mental health of refugee populations (Wenzel & Drozdek, 2018).

Adapting Clinical Practice

As recently noted by Goguikian Ratcliff and Rossi, (2015), if illness is individual, then we understand that health is collective: the status, place and experience of the human face of health and disease, the modes of social responses and institutions are reconfiguring themselves in a logic of supply and demand, strongly influenced by contemporary social and cultural transformations (p. 8).”

It is crucial that experiences of trauma are understood as being situated within a specific sociocultural and historical context. Indeed, the past several years of mental health interventions for refugee populations in particular has moved from being exclusively focused on PTSD (and accompanying specialist interventions) towards a more inclusive and communal approach which recognises cultural variance in mental health as well as the need to develop resilience within already existing health, social and community systems (Weissbecker et al., 2018)—despite ongoing divisions in the field regarding these two approaches (Silove et al., 2017).

Yet, despite this growing tend towards community based interventions aimed at privileging local cultural knowledge and practices, existing cultural and contextual information is rarely utilized effectively to inform the design of programs aimed at addressing the mental health of refugee populations (Greene et al., 2017). A significant void in our knowledge still exists regarding the relation of culture to trauma and the relevance of a PTSD diagnosis to refugee populations (Drožđek & Wilson, 2007; Mattar, 2011; Summerfield, 2000a). One striking example of this gap in our knowledge can be found in an interesting review of tools used to measure trauma among refugees conducted by Hollifield et al. (2002). They found that of the 125 different

2Loose translation from French.

Adapting Clinical Practice 9 instruments used among refugee populations, only 12 were explicitly developed in a refugee sample. This skewed focus on existing tools and concepts created for a western population is problematic as it neglects the cultural and linguistic heritage which influences which experiences are interpreted as ‘traumatic,’ the manifestations and expressions of post-traumatic symptomatology, the interpretation of symptoms, narratives of distress as well as healing models (Drozdek, 2007; Janoff-Bulman, 1985; Kirmayer et al., 2010; Kleinman & Good, 2004; Luno et al., 2013; Marsella, 2010; Steel et al., 2009).

Inflexible clinical practice drawing on Western diagnostic categories may not take into account the sociocultural context in which trauma unfolds for refugee populations—an understanding which could be essential in the interpretation and definition of a psychotherapy (Médecins Sans Frontiéres, 2016). From a public health perspective, the need for culturally relevant tools to accurately detect and predict traumatic responses among migrants is clearly of no small concern. Clinicians and academics working with refugee populations have similarly highlighted the continued lack of systematic knowledge regarding concepts of illness among traumatized patients, leading health professionals to ignore or misunderstand their needs (Faregh et al., 2019; Greene et al., 2017; Maier, 2006; Maier et al., 2010; Maier & Straub, 2011; Wenzel & Drozdek, 2018).

Addressing the Gap in the Literature—Implications for Research

As noted by Li and colleagues (2016) in a recent meta-review, the majority of research investigating the effect of post-migration stressors on mental health in refugees has focused on identifying which factors most strongly predict psychopathology in a rather static manner. Rather, there is a need to explore how the interaction of these factors affect mental health as it develops over time and within specific sociocultural and historic contexts. A plethora of key authors in the field have highlighted substantial gaps in the literature by calling for more longitudinal studies to add to our understanding of trauma from a more culturally, socially and politically relevant perspective. This includes a focus on life trajectories, dynamic processes and current material realities for refugees in host communities which goes beyond the individual to consider the interrelation of mind and society in human development (Eagle, 2014; Harvey, 2007; Nickerson et al., 2011; Goguikian Ratcliff & Rossi, 2015; Summerfield, 1996, 2001; Wilson & Drozdek, 2004). In addition, there are calls to enrich understandings of “historical trauma” (Gone, 2013) or collective, cultural, and identity-related trauma, with an emphasis on the social location of human subjects and a recognition that trauma responses may carry a sense of group burden and collective suffering beyond symptomatic individuals (Eagle, 2014). This call for more research has been echoed not only in the world of academia but by many international humanitarian organisations engaged in the implementation of mental health and psychosocial interventions with refugees across Europe and who are looking for more culturally relevant tools (which consider more local idioms of distress, for example) to better address the mental health needs of this population (Einhorn et al., 2018; Faregh et al., 2019; Médécins Sans Frontiéres, 2016; Hecker et al., 2015; Inter-Agency Standing Committee (IASC) 2015; Tol et al., 2014; UNHCR, 2015; Ventevogel et al., 2019).

Learning about the impact of dislocation, trauma and loss, of political persecution and human malevolence, and social systems involving abuse, neglect, and ethnic and cultural rejection is crucial in terms of guiding policy makers and clinicians to assist, and as advocates to address, the social and historical perspectives of trauma and their mental health consequences (Wilson & Drozdek, 2004). This is particularly pertinent given the migrant crisis currently being faced by Europe. What is needed is an increased understanding of the influence of context on psychological functioning and the empowering possibilities of ecologically informed interventions and public health strategies which do not unduly not unduly medicalize socio-political problems or psychologize human rights violations (Harvey, 2007; Wenzel & Drozdek, 2018). We have known for some time that culture matters when trauma is concerned; however, we need to fine-tune our knowledge of how culture matters in the definition of what is experienced as traumatic as well as the processes through which traumatic events are experienced and either accommodated or not:

Intercultural trauma treatment is a new field, one whose time has come. It reminds us yet again of the basic values of human encounters, beyond all sophisticated treatment techniques and devices, and it offers us ways for expanding the borders of our profession ... (Drozdek & Wilson, 2007)

Some key implications for researchers highlighted by experts in the field in a briefing paper on trauma and mental in forcibly displaced populations by the International Society for Traumatic Stress Studies (Nickerson et al., 2018) include:

e Implement community participatory designs to be conducted in collaboration with service providers, clinicians and policymakers where possible

e Investigate the full breadth of psychological disorders and symptoms in refugees, focusing on cultural conceptions of distress

e Implement longitudinal methods to identify mechanisms underlying refugee mental health and determine the temporal causal relationship between refugee experiences, mental health and other outcomes

They recommend that research should be undertaken in collaboration with refugee communities to increase understanding and treatment of psychological disorders amongst refugees and asylum-seekers, and that professional organizations can play an important role in facilitating, promoting and disseminating research on refugee mental health. In their reflections on research into the mental health of refugee torture survivors in particular, published in Lancet Psychiatry, Liddell and colleagues (2017) similarly state, anew research approach that considers the interactive effects of past trauma, contextual stress, and psychological symptoms on torture survivors could enhance the ecological validity of

Addressing the Gap in the Literature—Implications for Research 11 research. We propose that multimodal research that merges robust clinical and experimental research within appropriate ecological frameworks is needed to advance the field [...] to fully understand the effects of torture, clinical science must go beyond the traditional boundaries of psychiatric research to account for the influence of sociocultural contextual factors ”(p. 1).

It is now time to move on to broader and more operationally relevant research and for researchers to engage with contemporary notions of resilience and social ecology (Weissbecker et al., 2018).

The Context of the Research

This books aims to weave together both theory and practice. It is based both on my research as an academic, as well as my lived experience as a clinician working with displaced populations around the world: in police stations and clinics for rape survivors in South Africa, in refugee camps across central Africa, in prisons in the Ukraine, in clinics for torture survivors in Greece, and in shelters for Yezidi survivors of genocide in Iraq. I believe that both the theoretical knowledge and practical experience are needed for the exploration of refugee trauma I attempt to undertake in this book.

Globally, we are facing unprecedented levels of displacement. More than ever, we need to understand experiences of trauma—and of resilience—among displaced populations. More than ever, we need to understand the role of culture in these experiences. In order to address some of the needs for more research on trauma among refugee populations, this book aims to draw on a socio-cultural framework which focuses on the intersubjective, mediational space between the individual and culture-society-interaction (O’Connor, 2015) in order to try account for the experience of humans in time and in particular social and cultural environments. Such an approach presupposes human beings inhabit shared forms of life. Meaning is continually negotiated within the social sphere and “cultural products, like language and other symbolic systems, mediate thought and place their stamp on our representations of reality” (Bruner, 1991). As such, this theoretical framework thus highlights the heterogeneous, fluid and dynamic nature of individual subjectivities and the multitude of socio-culturally determined discourses which may be drawn upon to make sense of life experiences (Gee, 2014; Squire, 2008). As stated by Brunner, such an epistemological underpinning “brings profoundly into question not only the universality of knowledge from one domain to another, but the universal translatability of knowledge from one culture to another. For in this dispensation, knowledge is never “point-of-viewless.’” (p. 2). As such, the book aims to consider the possibilities of building collective politics through the examination of case studies of trauma within social and political context (Pratt et al., 2015).