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 refugeesFootnote 1 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 (d’Halluin, 2009; Médécins Sans Frontières, 2016; Ventevogel et al., 2019; Wilson & Drožđek, 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 post-traumatic 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 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; Viñar, 2005a). It disrupts our connection to all that make us human (Viñar, 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 Frontières 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 Frontières, 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 Drožđek (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‐Fernández, 2011; Janoff-Bulman, 1985; L. Kirmayer et al., 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‐Fernández, 2011). One example of this 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; Drožđek & 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 & Drožđek, 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),

  • Firstly, PTSD is not the only mental health problem in humanitarian setting

  • 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

  • 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

  • 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

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 (Drožđek, 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 (Drožđek, 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 & Drožđek, 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).Footnote 2

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 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 (Drožđek, 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 Frontières, 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 & Drožđek, 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 & Drožđek, 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 Frontières, 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 & Drožđek, 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 & Drožđek, 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 … (Drožđek & 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:

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

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

  • 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,

a new research approach that considers the interactive effects of past trauma, contextual stress, and psychological symptoms on torture survivors could enhance the ecological validity of 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.

Why Read 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).

Chapters two to five offer the theoretical framework in which to understand experiences of trauma among forcibly displaced populations. Here I review the literature on pre-, peri- and post migration factors affecting trauma, examine prevalence rates of PTSD, and argue that we need to move beyond the diagnosis towards a more culturally relevant conceptualisation of trauma. Chapter’s six to eight conceptualise experiences of trauma among displaced populations—as well as their resilience, imagination, and aspirations for the future—from a collective, sociocultural perspective. Chapter’s nine to eleven address some applications for professionals: working with shame and trauma, working with cultural mediators, and working with PTSD in the asylum procedure. Final reflections are offered in the concluding chapter twelve.

Theoretical Framework

Chapter Two: Trauma and Migration

In a multi-agency guide on the mental health of refugee populations released in 2015, UN agencies and other international humanitarian organisations have highlighted that 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 stress factors. A plethora of key literature from the field attests to the detrimental impact on mental health of the migration journey (including prolonged detention, stays in often unsafe refugee camps, exposure to trafficking rings) as well as the asylum-seeking process. Post-migration factors, such as unemployment, an insecure residency status and fear of repatriation, insufficient proficiency in a host language, social discrimination, and difficulties with integration have similarly been shown to be correlated with mental challenges among displaced populations. The psychological impact of these factors and other “daily stresses” are a relevant consideration in light of the additional critical life events with which displaced populations are faced. This chapter will explore the myriad of interrelating pre- and post-migration factors affecting the mental health of displaced populations.

Case study: Two case studies will be presented based on multiple interviews conducted with a victim of torture arriving in Greece and suffering from psychotic episodes exacerbated by his current living conditions, and of an asylum seeker from Switzerland after he set himself alight in a town square and survived—in his own words in order to protest asylum conditions. The cases will serve to illustrate the substantial psychological impact of current material realities of displaced populations, as they adapt to their new environment in transit and destination countries. An interpersonal-social model will be presented which examines various post-migration “feedback loops” influencing post-traumatic symptomatology.

Chapter Three: Prevalence of PTSD Among Displaced Populations

The literature attests to substantially higher prevalence rates of mental health challenges among displaced populations compared to the general norm, documenting statistically significant higher levels of post-traumatic stress, anxiety, and depression. In terms of PTSD prevalence specifically, a landmark meta-review conducted by Steel and colleagues in 2009 (2009) revealed an average prevalence rate of PTSD across all surveys of 30.6%. Prevalence rates of PTSD reported in other long-term refugee populations screened using the Harvard Trauma Questionaire (HTQ), include 45,5% among earthquake survivors in Wenchuan China (Kun et al., 2009), 37.2% among Cambodian refugees living on the Thai–Cambodian border camps (Cardozo et al., 2004), 29,3% among populations living in conflict-ridden southern Lebanon (Farhood et al., 2006), and 11.8% among displaced Guatemalans living in Chiapas, Mexico (Sabin et al., 2003).

Case study: This chapter will present prevalence rates of PTSD noted among displaced populations in Iraq, the Philippines, and South Africa, screened using the HTQ. These results are taken from three independent studies I conducted:

  • A study in South Africa I conducted with Médecins Sans Frontières among refugees and asylum seekers from other African countries who fled to displaced camps after a flare-up of xenophobic violence occurred in Durban, revealing a prevalence rate of PTSD of 85%.

  • A study in Iraq with the Free Yezidi Foundation, I conducted among displaced Yezidi communities in the context of an internal evaluation of the Free Yezidi Foundation’s mental health intervention, revealing a prevalence rate of PTSD of 82%

  • A study in the Philippines with the Global Initiative for Stress and Trauma Treatment (Gist-T), I conducted with colleagues among displaced communities affected by the recent conflict in Marawi in the context of a mental health needs assessment, revealing a prevalence rate of PTSD of 78%.

Chapter Four: Beyond PTSD

Despite the high prevalence of PTSD noted among displaced populations, there have been significant concerns raised in the literature over the cross-cultural validity of PTSD itself as a diagnostic construct. This is particularly problematic for humanitarian interventions. Critics argue that the medicalisation of trauma on an individual level, linked to specific “traumatic” events in the past, risks rendering us blind to other ongoing aspects of interpersonal, political and social violence on a more global scale. This includes significant post migration factors that may be deemed equally traumatic by displaced populations. Futhermore, treatment models developed in Western cultural contexts have been criticized for ignoring significant variability among explanatory models of distress evident in different cultural settings. There is a lack of standardized measurement tools for posttraumatic stress responses among culturally diverse populations. This speaks to the significant void in our knowledge regarding the relation of culture to trauma, and the way in which a diagnosis of PTSD is used and interpreted among displaced populations. This chapter will highlight the politicised history of the diagnosis, and discuss the implications for its use among displaced populations in humanitarian contexts.

Case study: The chapter will present a critical comparison of representations of trauma (and PTSD in particular) among refugees and health professionals. I compare the way in which trauma is understood and described by refugees (in interviews with victims of torture in Athens) to how it is understood and described by health professionals (in 43 interviews I conducted among psychiatrists and psychologists from thirteen different countries across the E.U., all of whom work with refugee populations). A specific focus will be on the ways in which a diagnosis of PTSD is contested, appropriated, and used strategically for different purposes.

Chapter Five: Culturally Informed Manifestations of Trauma

The burgeoning field of cultural psychiatry highlights how cultural variations in ways of life and social contexts shape the embodied experience of trauma. It demonstrates how particular symptoms or behavioral expressions of distress vary with cultural knowledge, beliefs, and interpretations and that individuals interpret and respond to their own symptoms with culturally varied coping strategies that may influence the experience of trauma. In other words, experience of trauma is an intersubjective, temporal, dynamic process shaped by culture, among other factors. This approach goes beyond a reductionist focus on “cultural differences,” wherein “culture” is perceived as a reified, crystallised concept and viewed as a potential barrier to be overcome in a process of psychiatric classification. Instead, it focuses on ever-changing cultural and social systems which determine the various forms of an individual subjective experience of illness, an experience inevitably in constant flux.

Culture is considered in this chapter as both as a set of practices physically executed in a tangible and observable sense by the group, as well as integral to belief systems lying internally within individual members. Each level mutually reinforces the other. Furthermore, culture is not static but continually adapts to ever-changing environments: created, maintained and sustained among groups through dominant narratives or discourses. This chapter will provide a definition of culture from a dynamic ecological and sociocultural perspective. It will further explore the impact of cultural systems on the various ways in which the cultural environment informs the manifestation of trauma.

Case study: Examples of culturally informed manifestations of trauma will be explored by drawing on clinical examples from my work in the field—notably the case of 8 women from the Murle tribe affected by conflict in South Sudan who experienced an episode of mass fainting spells, as well as the case in Greece of a refugee victim of torture from Guinea confronted with a different cultural belief system of trauma between herself and her psychologist in Athens. These cases will notably explore belief systems around trauma, the meaning given to the traumatic event, culturally determined idioms of distress and symptom manifestations, as well as implications for health seeking behaviour and explanatory models of healing.

Conceptualising Experiences of Trauma and Migration from a Collective, Sociocultural Perspective

Chapter Six: Collective Trauma, Collective Healing

It is not only individuals who face traumatic events but entire communities. Over the past few decades, a plethora of research has highlighted the importance of the sociocultural environment for the way in which individuals, and indeed entire communities, experience trauma and recovery. The trauma associated with forced displacement has a psychosocial impact not only on the individual, but also their family, community and the larger society. At the family level, this includes the dynamics of single parent families, lack of trust among members, and changes in significant relationships and child-rearing practice. Communities tend to be more dependent, passive, silent, without leadership, mistrustful and suspicious. Additional adverse effects noted in the literature include the breakdown of traditional structures, institutions and familiar ways of life, and deterioration in social norms, ethics and loss of social capital (Somasundaram, 2014).

Saul’s (2013) landmark definition of collective trauma highlights its larger social impact, occurring at multiple levels, with “shared injuries to a population’s social, cultural, and physical ecologies” (p. 1). In another seminal work on collective trauma, Erikson (Erikson, 1976) defines it as “a blow to the basic tissues of social life that damages the bonds attaching people together and impairs the prevailing sense of communality” (p. 154). Considering the development of collective trauma as a process, this chapter will highlight elements of the temporality of collective trauma, as well as the continual interaction of factors influencing trauma in a given social and historical context. Particular focus will be on the socio-political context and power dynamics at play in influencing the mental health of entire populations. Implications for mental health interventions will be explored.

Case Study: To explore the collective impact of trauma on entire displaced communities, this chapter will draw on two case studies from my work in Iraq and the Philippines first introduced in chapter three: the forcibly displaced Yezidi community of Kurdistan Northern Iraq, (200 women whom I interviewed in the context of a project evaluation), and displaced communities affected by the recent conflict in Marawi, Philippines (factors of collective trauma and recovery explored by myself and colleagues among 80 participants in the context of a mental health needs assessment). The analysis aims to explore how individuals may be traumatized at multiple levels including collective/social, personal/physical, and role identity levels. Results will highlight the substantial impact of the political, legal, and sociocultural environment on both the prevalence of collective trauma, as well as processes of collective healing.

Chapter Seven: Collective Resilience and Imagination

Continuing with the theme of the impact of the sociocultural context on the collective mental health of entire populations, this chapter will explore resilience and imagination as experienced by displaced populations from a collective perspective. As proposed by Ungar (2004, 2008, 2011, 2013), “resilience is both the capacity of individuals to navigate their way into psychological, social, cultural, and physical resources that sustain their well-being and their individual and collective capacity to negotiate for these resources to be provided and experienced in culturally meaningful ways” (Ungar 2008, p. 225). The burgeoning literature on resilience among displaced populations has begun to highlight the interaction of protective mechanisms with exterior risk factors. The more recent explicit focus is thus on the socio-ecological environment. Within this paradigm, resilience is not a fixed, individual trait. It is dynamic and variable. It reflects both the individual and the world around them. It’s considered essentially as a social and environmental attribute (Lusk & Baray, 2017a), and the capacity of a person’s “informal and formal social networks to facilitate positive development under stress” (Ungar, 2013, p.1). It is a collective endeavour. The chapter will argue that building resilience and imagining plans for the future are not solely individual projects, but communal processes involving reclaiming collective action, trust, and efficacy. Implications for community interventions will be explored.

The chapter further explores imagination among displaced communities. The paradoxes are multiple: (i) Migration is inherently imaginative, in the sense that the actualisation of migration begins with individuals imagining their destination (ii) however, trauma related to forced migration experiences in particular may impede imagination. To further add to the complexity: it may be imagination itself which acts as an essential component to resilience, and healing from trauma. The chapter explores the mobility choices of displaced populations and individual migration trajectories to provide insight into how the emotionality of subjective experiences, as well as the sociocultural context, are fundamentally involved in people’s resilience, their plans to migrate, and the development of their ever-changing imagination of a better future elsewhere. How do displaced individuals the resilience to overcome trauma? How do they navigate the “brave new world” in which they find themselves? What helps them to find the strength to imagine and negotiate a new and better life?

Case study: In order to explore trauma, resilience, and imagination among displaced populations, I present the results of 12 months of research among refugees in a centre for victims of torture in Athens. This research includes 125 in-depth, qualitative interviews with victims of torture, health professionals, cultural mediators/interpreters, and leaders from refugee communities. The case study illustrates the substantial psychological impact of current material realities of refugee victims of torture as they adapt to their new environment and imagine a better future. Using a socio-ecological framework (Sleijpen et al., 2017), and drawing on the concept of imagination from the perspective of sociocultural psychology, the chapter explores the strategies used by this population in order to discuss additional insights of an interpersonal and communal perspective for the growing field of research on resilience after trauma.

Chapter Eight: Collective Aspirations

Not only are the aspirations of individuals constantly transforming as a result of sociopolitical developments; they are significantly shaped or contested by shared or collective aspirations of entire communities. This starts with collective aspirations of communities in the country of origin. It also extends to the constantly developing shared aspirations of displaced communities in host contexts. The theoretical background of sociocultural psychology allows for an exploration of these nuances—of the ever-changing and dynamic development of aspirations over time, and within sociocultural context. It evokes a methodology incorporating an exploration “not only of the subjective perspective, but also the dynamics by which the social and cultural environment guide and enable the person’s development” (Zittoun, 2017). Of particular interest in this chapter is the way in which aspirations are influenced by the encompassing fabric of the cultural collective, related both to the country of origin as well as humanitarian contexts of protracted displacement and a liminal permanent temporariness so often facing displaced populations.

Case study: Greece represents a unique context in which to explore the aspirations of asylum seekers entering Europe: perceived both as a country of transit as well as a final destination. Currently, many asylum seekers find themselves “stuck” in limbo in this context, unable to proceed with their asylum claim or continue their journey to the destination countries of Western Europe to which they continue to aspire. In order to explore the aspirations and experiences of integration of refugee communities within this context, I draw on the case of my fieldwork in Greece, introduced in chapter seven. To analyse the data, I emphasize the importance of non-linear temporality in the context of individual’s changing subjective current realities—as they weave together images of the past, present and future. This includes tracking the developing aspirations of individuals as they configure, reconfigure, and make meaning of the new realities in a receiving country. The results are illustrated using qualitative case studies of individual trajectories, and highlight aspirations as a powerful motivating force for migration.

Applications for Professionals

Chapter Nine: Working with Shame and Trauma

Despite the psychically toxic nature of shame, it has historically been under-researched and under-theorised. However, a recent burgeoning of literature has brought an increasing awareness of shame as a pathogenic force. Research in trauma over the past decade has seen the development of the concept of “posttraumatic shame,” with key authors stressing the importance of shame as a social emotion that impacts the severity and course of PTSD symptoms. Indeed, the experience of shame has even been revealed to potentially hold the same properties as traumatic events. Shame can trigger intrusions, flashbacks, strong emotional avoidance, hyper arousal, fragmented states of mind and dissociation. Shame and trauma are inextricably linked.

Unlike guilt (typically related to a particular action or behaviour), shame taints the entire landscape of the individual. It colours the very sense of self. It therefore could be considered to be a more complex intra-psychic process than guilt because it involves processes concerning attributes about the core dimensions of the self, identity, ego processes, and personality. Inasmuch as it lies within the interactional space between self and other, at the divide between the intimate and the public, the individual and society—it tries to hide itself by its very nature. As such, it often remains unnoticed. Its powerful yet seemingly invisible impact may be hidden behind a myriad of emotional cloaks—anger, dissociation, blame, and resentment. This is even more so in the context of clinicians working with displaced populations. In this context, a plethora of differently nuanced cultural cloaks may further obfuscate this noxious affect. Furthermore, shame-related cultural codes of behaviour might prevent migrants from directly reporting earlier traumatic experiences, from trusting the professional or from even attending appointments. As noted by Wilson and colleagues (2006), “the powerful emotions of posttraumatic shame are associated with a broad range of avoidance behaviours: isolation, detachment, withdrawal, hiding, nonappearance, self- imposed exile, cancellation of appointments, surrender of responsibilities, emotional constriction, psychic numbing, emotional flatness, and non-confrontation with others” (p. 138). These signs are easily misread.

Ethically, clinically, humanly, professionals working with traumatized populations cannot ignore shame. This is particularly true of work within multicultural contexts, where relations are so typically marked by power differentials in terms of race, class, nationality and socio-economic status. It is here, in this intersectionality of identities, that shame is located. In this chapter, aspects of migration and post-traumatic shame, and implications for professionals, will be discussed. New approaches to recognising and working with shame are needed for clinicians (both researchers and academics), which consider the interactive effects of shame and trauma within sociocultural contexts among such vulnerable populations.

Case study: As both a researcher and clinical psychologist working with displaced populations, I explore the myriad dimensions of shame within humanitarian contexts. This is based on personal reflections of my relationship with research participants as well as the burgeoning literature on this topic. Two case studies of shame will be presented, one a refugee victim of torture seeking asylum in Greece, the other a female survivor of sexual violence in Cape Town, South Africa. The analysis will track the ubiquitous manifestations of shame between researcher and researched to reveal how shame was unavoidably generated, exacerbated and maintained within the relationship. Implications for interventions are discussed.

Chapter Ten: Working with Cultural Mediators

As the number of refugee mental health programs increases, so has the use of cultural mediators. Without them, clinical services for displaced populations could not be provided. Here, the term “cultural mediator” is purposefully used instead of “interpreter,” in order to reflect the dynamic and complex nature of their work. This work often extends far beyond that of simple translation. These professionals are often the mediators between the world of the health professional and that of displaced communities.

In this chapter, I will draw on Wang’s (2012, 2016) notion that it is the complex “subjectivity” of the mediator that differentiates them from interpreters: they need to be focused on both the content and form of the discussion, as well as to pay attention to interpersonal relationships (Wang, 2016). This comes with challenges surrounding the need to be precise, emotionally detached, firm, to know how to behave in relation to a specific culture, and being neutral and impartial. This is particularly true in the context of mental health—a field which the literature highlights as being the most demanding for cultural mediators compared to their work with other professionals. This is a particularly pertinent consideration given the current influx of asylum seekers into Europe, many of whom have lived through horrors beyond description, indeed beyond words in any language.

Within this context, the role of cultural mediators is an essential one. These professionals have been shown in the literature to have to negotiate multiple positions including that of a cultural broker, community organizer and even a directly implicated co-therapist. Indeed, as stated by Summerfield (2005), the challenges they face are “not…of translation between languages but of translation between worlds” (Nicolas et al., 2015). They are active co-therapists. They are advocates of mental health. They are experts assisting health professionals to explore the culturally informed psychic worlds of displaced and traumatized individuals.

In this chapter, I will discuss issues affecting cultural mediators working with displaced populations. This includes an exploration of how the different representations and understandings of trauma are managed, contested, and negotiated in the complex relationship between patient, health professional and cultural mediator. Implications for health professionals and cultural mediators will be discussed.

Case study: The case study is based on my fieldwork in Greece—as seen in earlier chapters. The analysis will focus on cultural mediation within the intersubjective spaces between health professionals, cultural mediators, and refugees in consultation. Interviews with the cultural mediators highlight the variety of complex roles they play when translating between health professionals and refugee beneficiaries, particularly in the context of mental health. This involved assuming the role of the co-therapist, where many felt actively engaged in the therapeutic process and indeed often closer to the refugee beneficiaries on an emotional level than the health professionals themselves. In other cases, alliances lay more with the health professionals. For example, some saw their role as advocates of mental health when faced with refugee communities who don’t appear to understand the role of the psychologist: their own role therein being to convince refugee populations of the value of a more westernized understanding of mental health. However, another challenge emerging in the interviews was the complexity involved in working with health professionals whom the cultural mediators deemed to be culturally incompetent.

Chapter Eleven: Working with PTSD in the Asylum Procedure

Asylum and trauma is an urgent area of inquiry—in particular given the unprecedented transnational migration occurring in Europe within the past few years. In terms of Article 1, Chapter 1 of the Geneva Convention of 1951, a refugee is defined as someone with a “well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion.” The word “fear” here is of particular interest as it implies that a refugee is defined to some extent by his or her psychological response to events, not only by the events themselves. Furthermore, the burden of proof falls on the asylum seeker. When persecuted individuals seeking asylum cannot give evidence of marks on their body, they have the alternate possibility of proving the violence to which they have been exposed through what is sometimes designated as the “wounds of the soul,” notably a diagnosis of post-traumatic stress disorder (PTSD). However, the literature highlights the risk of PTSD becoming a “pre-requisite” for validating the experiences of asylum seekers, reifying and reducing these experiences by placing them within an exclusively psychiatric paradigm in order to render their narrative accounts believable in asylum procedures. Such a politically loaded use of PTSD indeed leads to situations whereby victims of torture and other atrocities fear not being believed unless they can “check off the tick list of symptoms” required to be diagnosed with PTSD.

Among the factors that require sensitive consideration are risk of cultural and linguistic misunderstandings and the effect of posttraumatic stress disorder and depressive symptoms on the capacity to provide a coherent narrative. Trauma may be simply unspeakable. Such a consideration is particularly pertinent when seen in light of the literature, which demonstrates that the asylum process risks being a traumatic event in and of itself. Here, a culturally sensitive recognition of trauma may assist judges and other decision makers in recognizing and being more attentive to the difficulties asylum seekers may have in verbalising and constructing their case as a result of a compromised mental state which “may impede the applicant’s ability to testify in a manner that appears direct, specific, and emotionally appropriate” (Linton, 2015, p. 1085). This recognition of impairment is critical to assist the comprehensive assessment of refugee claims—as it limits the risk of erroneous decision-making based on testimonies distorted by psychological trauma.

There is a need to explore tensions surrounding the controversial use of PTSD as evidence in court. There is equally a need to deepen the way in which the impact of trauma among displaced populations is understood. Nowhere is this more pertinent than in the asylum procedure. Here, questions of legitimacy are central. In this chapter, I argue that understanding trauma in the context of the asylum process should necessarily recognise the social-cultural context in which it occurs, in relation to the activity of which it is a part and within a broader systems of relations in which it has meaning. To do so, I explore the asylum process as a system of activity. I argue that such a systemic analysis allows for a broad contextualisation of practices around PTSD, revealing and exposing tensions and contradictions in how various actors involved in the asylum seeking process understand trauma among refugee populations and the implications this may have on their request for asylum.

In this chapter, I therefore explore the role of PTSD as a diagnosis functioning across an interconnected network of actors in the activity system of the asylum tribunal (including lawyers, health professionals, and asylum seekers themselves)—according to the various roles and activities of each actor concerned. By drawing on the case study of victims of torture claiming asylum in Greece, the numerous and changing functions of the diagnosis will be highlighted—including the way in which such functions may change over time even within the activity of each actor.

Case study: The case study is based on my fieldwork in Greece—as seen in earlier chapters. An analysis of the case study demonstrates how PTSD circulates among the different actors yet with specific meanings and functions within each activity system, and which change over time. It may be used by health professionals in certain activity systems to communicate among each other about the clinical symptoms experienced by the patient, and by the bureaucrats of the tribunal as evidence in court of the individual having survived a traumatic experience. The asylum seekers themselves experience the diagnosis in a myriad of different ways. Positioned as political subjects in the asylum procedure, as patients in the consulting room, as clients with their lawyers, as members of their community at home—PTSD appeared to have different meanings and functions across these activity systems. For the health professionals needing to address a variety of different actors outside of their clinical community, PTSD is helpful to explain (both to patients as well as to the bureaucrats of the asylum tribunal), to treat and, in some cases, to attest to the trauma experienced by the asylum seeker.


Chapter Twelve: Reflections on Working with Trauma in Humanitarian Contexts

In this chapter, I will conclude by summarizing the key themes raised throughout the book:

  • There is significant evidence of alarmingly high rates of psychological disorders including posttraumatic stress disorder (PTSD) among displaced populations

  • There is similarly evidence of significant resilience displayed by individuals faced with traumatic events

  • Culture impacts on conceptualization, expression and treatment of psychological distress

  • Not only do pre-migration factors influence trauma—the current political, social and economic environment has a significant impact on mental health

  • Trauma may be experienced collectively, by entire communities.