Europe is living through a refugee crisis of historic proportions, with subsequent evolving responses having now become one of the continent’s defining challenges of the early twenty-first century (Médécins Sans Frontières, 2016; UNHCR, 2015). Assessing the thousands of applications of asylum claims on a case-by-case basis remains one of the most significant challenges for host countries. In the face of significant anti-migration sentiment, procedures for testing refugee claims continue to be applied by most countries of the West in order to manage and restrict the flow of displaced persons by drawing on increasingly harsh policies to justify “humane deterrence” (Silove & Mares, 2018; Steel et al., 2004). Therein lies the many contradictions between the emerging human right discourse and the appalling reality of asylum (Wenzel & Drožđek, 2018). Within this “adverserial” (Crumlish & Bracken, 2011, p. 57) context, the burden of proof of refugee status rests upon the individual asylum seeker. Refugees may feel pressured not only to prove persecution, but also that they’ve also been damaged by it (Joles, 2018).

In terms of Article 1, Chapter 1 of the Geneva Convention of 1951, a refugee is defined as being 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. Therefore, 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) (Fassin, 2011). As noted by Steel and colleagues (2004), the refugee determination process therefore represents a point of intersection between the domains of psychology and administrative law, a setting in which these frameworks may well collide. Such a setting, it is argued, “starkly demonstrates the ineluctable intersection of mental health, human rights, ethics and social policy” (Silove & Mares, 2018). d’Halluin (2009, 2016) similarly demonstrates the dangers inherent in this contentious relationship between immigrant, psychiatry and social security, arguing that a diagnosis of PTSD risks ultimately becoming a ‘pre-requisite’ for validating the experiences of migrants, thereby reifying and reducing these experiences by placing them within an exclusively psychiatric paradigm. Furthermore, she contests, by pathologizing asylum seekers, mental health damages inherent to this population have been used in anti-immigration public discourse to highlight security issues related to refugees as a damaged, diseased “other.”

As such, PTSD as a political tool historically has limited and controlled the influx of migrants. For this reason, as recently stated in an article by Peter Ventevogel, senior mental health officer for the UNHCR, trauma is not part of how the agency evaluates asylum or settlement claims: “a resettlement interview is not meant as a therapy session, the goal is to get as much information is as needed to prepare a good, credible resettlement case” (Joles, 2018). However, it is nation states which have the primary responsibility for determining the status of asylum-seekers, and around the world, a diagnosis of PTSD continues to feature in the refugee determination process. In the Greek context in particular, Eleftherakos and colleagues (2018) have recently argued that “a vulnerability status can potentially help in accelerating the asylum procedures, the transfer to a better accommodation or to the mainland through the lift of geographical restrictions. The identification of vulnerability however is subject to constant modification and prolonged delays, and therefore migrants become obsessed with the pursuit of (potentially) necessary documents” (p. 6). Being diagnosed with PTSD is one such marker of vulnerability.

In this chapter, I explore the multiple and often contradictory role PTSD plays as a psychiatric diagnostic category in the refugee determination process. Firstly, I review the literature related to PTSD among refugee populations and the criticisms levelled against PTSD in this context, then turn to the role it may play as a specific legal category in the refugee determination process and the implications for professionals working within the asylum system. By drawing on case studies of victims of torture claiming asylum in Greece, I highlight the ways in which PTSD is understood by the various actors concerned throughout the asylum procedure—including among lawyers, health professionals as well as asylum seekers themselves. I argue that PTSD is a cultural tool, serving to narrate the lives of asylum seekers during the refugee determination process and how, as a cultural tool, it “embeds institutional values, power relations, circumstances of the physical environment and individual motivations” (Dauite, 2013, p. 7).

PTSD Among Refugee Populations

Despite the popularity of PTSD as a “sexy diagnosis” (Struwe, 1994) and its dominance in Western cultural discourse as an integral part of humanitarian interventions for refugee populations, various criticisms levelled against the diagnosis have long been documented in the literature ever since the period leading up to its codification as a disorder in the DSM-III (Bracken, 2001; Bracken et al., 2016; Steel, 2001; Summerfield, 1999, 2001; Young, 1995). Questions remain about the common elements underlying the diverse experiences of people across the world exposed to trauma. The work of anthropologists (Young, 1995), psychiatrists (Bracken, 2001; Bracken et al., 2016, 1997; Summerfield, 2001) and sociologists (Fassin & Rechtman, 2009), among others, have long criticised PTSD as a heavily politicized and westernised social construct. This is in light of the plethora of research indicating that sociocultural and linguistic heritage influences what experiences are interpreted as ‘traumatic,’ the manifestations and expressions of post-traumatic symptomatology, the interpretation of symptoms, narratives of distress as well as culturally-informed healing models (Drožđek, 2015; Janoff-Bulman, 1985; Kirmayer et al., 2010; Kleinman & Good, 2004; Luno et al. 2013; Marsella, 2010). As a diagnostic construct developed for use in Western contexts, PTSD has been criticized for ignoring this significant variability among symptoms evident in different cultural settings across the world (Hinton & Lewis-Fernández, 2011; Kirmayer et al., 2010; Momartin et al., 2003; Steel et al., 2009; Tummala-Narra, 2007). Further criticism is based on the fact that one cannot always link post-traumatic symptoms directly and uncritically to a single event in the life of an individual—a pre-requisite of a PTSD diagnosis by its very definition.

As noted by Young (2016), this research calls into question the validity of using the current version of the DSM for legal purposes without modification. The literature attests to the risk of PTSD reifying and minimizing the trauma experienced by refugee populations by within an exclusively psychiatric paradigm in order to render narrative accounts of asylum seekers believable in the refugee determination procedure (Fassin & d'Halluin, 2005; Maier, 2006; McFarlane, 1995; Rogers et al., 2015; Wilson-Shaw et al., 2012; Young, 1995). According to Summerfield (1996) such a politically loaded use of PTSD may lead to “absurd” (p. 14) situations whereby victims of torture and other atrocities fear not being believed unless they can ‘check off the tick list of symptoms’ required by PTSD.

Despite these criticisms, as Young (2016) concludes:

Despite what some might contend in their narratives about PTSD, it is not a mental disorder that has no validity and, if it is diagnosed, it is not often reflective of malingering. Unlike the opposite point of view, it is valid, it can be validly diagnosed, and malingering does not confound it to any great degree. This opposition in views on PTSD illustrates that there is much work to do forensically to improve assessment and diagnostic procedures (p. 239).

In other words, we cannot disregard the diagnosis entirely and throw the metaphorical baby out with the bathwater. Rather, this literature emphasises the necessity of deepening our understanding of trauma as it affects refugee populations.

The Importance of Correctly Identifying Trauma in the Refugee Determination Process

There is an increasing body of scientific evidence looking at the assumptions recorded by authorities in their asylum decisions and the psychological processes at play during the court proceeding. This literature suggests not only that there may be marked uncertainty in how to reach the correct determination, but also that there is often the potential for bias against the person genuinely fleeing from trauma and persecution. This is because trauma negatively impacts the credibility and consistency of verbal accounts. PTSD has been shown to impair memory and capacity for coherent verbal recollection. It may even itself be seen as a disorder of memory: traumatic stress overwhelms the brain’s ability to store autobiographical memories in the normal way, and fragmented memories of traumatic experiences are typical (Crumlish & Bracken, 2011). As noted by Linton (2015), “ironically, the fraudulent applicant is better situated to relate a detailed story with appropriate demeanour than the genuine applicant” (p. 1085).

Furthermore, the varied responses to traumatic events (including dissociation or emotional numbing, for example) may fall outside of given cultural norms surrounding expectations of how a traumatised individual “should” act (Bögner et al., 2010; Linton, 2015; Mueller et al., 2011; Rogers et al., 2015; Schock et al., 2015; Silove & Mares, 2018; Turner, 1992, 2015). 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 (Silove & Mares, 2018). Such a consideration is particularly pertinent when seen in light of the literature which demonstrates that the refugee determination process risks being a traumatic event in and of itself (Rogers et al., 2015; Schock et al., 2016, 2015; Turner, 1992, 2015).

Within the asylum seeking procedure itself, 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). Thus, identifying the impact of trauma—and accounting for cultural and linguistic barriers—may avoid discrepant accounts being seen as evidence of fabrication (Crumlish & Bracken, 2011). 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 (Silove & Mares, 2018).

There is therefore a need to explore these tensions surrounding the controversial use of PTSD as evidence in court, as well as to deepen the way in which the impact of trauma among refugee populations is understood. Nowhere is this more pertinent than in the refugee determination procedure, where questions of legitimacy are central.

PTSD and the Question of Legal Causality

According to Young (2017) causality (or causation) is central to every legal case, yet its underlying philosophical, legal, and psychological definitions and conceptions vary. Based on the five-point scale he outlines regarding causation in psychological inquiry, drawing on a diagnosis of PTSD as proof of refugee status would fall in the level 1 explanation, defined as the following:

The index event is the “sole cause” of the resulting psychological condition (disorder(s) and/or functional effect(s)). There are neither overt nor latent psychological conditions evident in the pre-event state, that is, there are no pre-existing psychological vulnerabilities or risk factors. The psychological condition at issue would not have occurred, either in the present or later on, had the subject event not occurred. (pg. 12)

Indeed, it could be argued that PTSD is the only psychiatric diagnosis that tells a story. By its very definition, it is based on the following premises:

  1. (i)

    There were no pre-existing psychological vulnerabilities or risk factors

  2. (ii)

    An event occurred (criteria A according to the DSM V, (Association, 2013))

  3. (iii)

    This event was experienced by the individual as being traumatic

  4. (iv)

    As a result, the individual responded with a specific set of thoughts, feelings and behaviors as outlined in the criteria of the diagnosis of PTSD

  5. (v)

    The traumatic event was the sole cause of this response

In order for a PTSD diagnosis to be made, a traumatic event needs to have occurred by definition and this denotes an implied level of believe in the asylum seekers’ narrative—thus fulfilling a legal requirement that it be credible (Maier, 2006). Conversely, “if rape/torture/persecution happened to someone then they would have psychological difficulties” is prey to the counter-argument “we don’t believe it did happen, so we don’t accept that the difficulties are genuine,” as frequently seen in responses to medico-legal reports themselves” (Good, 2007, p. 203–204). The political implications for asylum procedures are clear. For example, PTSD may serve as evidence of the trauma which they experienced in their country of origin, their subsequent “well-founded fear” of being persecuted if forced to return, and therefore, ultimately, as a justification of their claim to refugee status.

The premises outlined above are based on a universalist model of trauma situated in western psychiatric discourse and developed only after the second World War. As highlighted by Bracken and colleagues (2016), this universalist model—the dominant paradigm in psychiatry—is technological. With it’s origins in the European asylums of the nineteenth century, it responds to the technical challenges of the refugee determination procedure requiring a scientific response: to classify accurately, to identify universal causal factors and pathways, and to seek efficient forms of interventions. However, this universalist model of trauma rejects a priori any notion of singularity, or of ethnic or cultural differences (d’Halluin, 2009, 2016). Understanding trauma in the context of the refugee determination procedure 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 (Van der Riet, 2009, 2012). I therefore explore the refugee determination procedure as a system of activity—arguing 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 for the refugee determination process.

The Refugee Determination Procedure as a System of Activity

I explore the refugee determination procedure is an activity system (Kloetzer et al., 2015; Roth & Lee, 2007; Toomela, 2014; van der Riet, 2012), defined according to Vygotskian cultural-historical psychology as a system of settings, institutions, physical environments, formal and informal, social relations, and events wherein a multitude of actors intersects. This includes, for example, the lawyers, doctors, psychologists, bureaucrats, and asylum seekers themselves, for whom PTSD has a different meaning. Here, the activity of individuals are considered as inherently embedded in social context and mediated by cultural tools (Kloetzer et al., 2015). I draw on Dauite’s (2014) definition of a cultural tool as “symbolic process developed in human relations for interacting purposefully in the world” (p. 23). From a Vygotskian perspective, therefore, cultural tools act on others and on the world, coordinating actions. In other words, by examining PTSD within the asylum activity system, it is considered as a cultural tool purposefully aimed at “conduct[ing] human influence on the object of activity” (Vygotsky, 1980, p. 55), circulating at the crossroads where asylum seekers’ narratives meet a ‘centered’ bureaucratic language system (Maryns & Blommaert, 2001).

To examine the use of PTSD as a cultural tool used both in a medical and legal sense in the treatment of asylum seekers, I propose to take a narrative approach to examining how a human story is translated into legal one (Di Donato, 2014). Such a narrative approach, significantly developed by the likes of Jerome Brunner (Amsterdam & Bruner, 2000; Bruner, 1990, 1991, 2003) and others, examines how “the client’s story gets recast into plights and prospects, plots and pilgrimages into possible worlds…this endless telling and retelling, casting and recasting is essential to the conduct of the law…stories construct the facts that comprise them. For this reason, much of human reality and its ‘facts’ are not merely recounted by narrative but constituted by it. To the extent that law is fact-contingent, it is inescapably rooted in narrative” (Amsterdam & Bruner, 2000, p. 110). In other words, cultural tools used in a court of law shape the world not according to how it is but according to its very own categories. Such categories are, according to Bruner (Amsterdam & Bruner, 2000) “the badges of our socio-political allegiances, the tools of our mental life, the organization of our perception” (p. 19). They produce theories and about causes and connections in the natural world (for example, that experiencing a single traumatic event in the past would logically lead one to display symptoms of PTSD). As such, cultural tools may be regulative, overtly normative and potential instruments of power in that they institutionalize customs and traditions. To categorize an asylum seeker with PTSD is therefore “an act of meaning making” (p. 29) which may become entrenched in the habits of medical and legal institutions with very concrete social, material and legal consequences.

There are inherent power imbalances found within the activity system of the refugee determination process. Cultural tools, such as PTSD, are embedded in systems of resources hierarchized in terms of functional adequacy (Blommaert, 2001a). Blommaert and colleagues (Blommaert, 2001a, b; Maryns & Blommaert, 2001), for example, argue how asylum seekers narrating their experiences in the context of the asylum procedure are confronted with a complex set of administrative procedures which presuppose access to various codes (for example, psychiatric or legal codes) requiring a very specific set of westernized narrative resources which may not be available to migrants. Added to this is the power imbalance inherent in the process of diagnosing asylum seekers, as outlined above, which privileges western above local knowledge. Here, as chillingly noted by Blommaert (2001b), “Foucault’s image of subjects being transformed into knowable objects of clinical observation by means of a multilayered complex of discursive and material practices is looming large” (p. 31). I would argue that PTSD as a cultural tool may represent just such practices.

According to Blommaert (2001a), “the resources controlled by the narrators and their interlocutors are part and parcel of the interpretations given to their stories, and given the central role of the stories in the asylum procedure, matters of resources may influence the outcome of their asylum application” (p. 23). Medical certificates stating PTSD among asylum seekers therefore “come with a history of use and abuse; they also come with a history of assessment and evaluation… put into a legal/procedural framework, in sum, that every step in the systematically and uniformly performed process involves not replication but far-reaching transformations of the ‘original’ story” (Blommaert, 2001a). The story of trauma, then, is also replicated and transformed into the form of a medical certificate attesting to PTSD, a “narrative shaping of individualized experience through contextualization processes [which] entails a shaping of linguistic and narrative tools that operate as contextualization cues” (Maryns & Blommaert, 2001, p. 62). These “contextualization cues” permit the very concept of PTSD to circulate as a “boundary object” (Star & Griesemer, 1989) understood differently by various actors. The messy story of trauma then is decoded and converted into a “depersonalized case” (Maryns & Blommaert, 2001, p. 65) based on “overly tidy stories” (Bruner, 1990, 1991, 2003) and thus easily convertible into established legal categories.

To explore this further, I propose to usefully shift to dynamic storytelling from the perspectives of those involved (Daiute, 2017) and to investigate the roles of those actors in constructing the legal facts (Di Donato, 2011). The investigation is based on the results of a yearlong research projects among asylum seekers diagnosed with PTSD as well as their treating health professionals (including doctors, psychologists and psychiatrists) in a center for victims of torture in Athens, Greece. I explore how PTSD circulates as a cultural tool among the various actors within the asylum activity system, specifically in relation to social structures, power relations and each actor’s diverse activities and objectives.

Case Study

I conducted 12 months of research among asylum seekers and refugees in a center for victims of torture in Athens, Greece run by Médecins Sans Frontières and their local partner, Babel. This longitudinal study involved participant observation as well as qualitative, in-depth interviews with 74 various actors. This included a year-long follow up of 10 victims of torture seeking asylum (interviewed an average of five times)—as well as in-depth interviews with 43 health professionals working with refugee victims of torture from a variety of humanitarian organizations, including cultural mediators working in psychosocial interventions for individuals diagnosed with PTSD Furthermore, I conducted qualitative, in-depth interviews with 21 community representatives and leaders of diverse refugee associations around Athens in order to explore culturally determined narratives of trauma.

Framework analysis.

To analyse the data, I specifically draw on a systemic framework analysis to examine the refugee determination process as an activity system—particularly the various and often contradicting ways in which PTSD serves as a cultural tool drawn upon by the different actors within this activity system. This enables an exploration of the activity of the various actors concerned, in order to identify the various narratives they draw upon to understand trauma and highlight the various dilemmas with which they are faced in the refugee determination process.

The five stages to conducting this framework that I followed, based on the method as outlined by Pickup and colleagues (2014), were:

  1. (1)

    Familiarising myself with the data

  2. (2)

    Delineating overall narratives concerning trauma and/or PTSD in relation to the refugee determination process

  3. (3)

    Identifying the various actors within the refugee determination process to determine a framework of themes and subthemes

  4. (4)

    Indexing specific responses by copying relevant participant quotes from interview transcripts into this framework

  5. (5)

    Iteratively reviewing and revising the initial framework

  6. (6)

    Mapping and interpreting the subthemes with a summary of the main descriptive comments

  7. (7)

    Selecting representative quotes and individual cases for each subtheme


Asylum seeker

Tell his or her story to be granted refugee status

Used to testify (to fear/suffering), reinforces the story

Culturally informed

To tell the “trauma story” (risking retraumatization) or not, how to tell the story in a credible way

Medical professional


Used to determine course of treatment


To diagnose PTSD or not, to write the medical certificate or not

Bureaucrat in asylum procedure


Used as evidence to assess the case

Legal, institutional

To grant refugee status or not, to believe the asylum seeker or not

As indicated by the framework analysis above, the results highlight the various ways in which trauma is seen and understood by various actors in the refugee determination process. For asylum seekers, the activity is narrating their story, their objective is to be believed, and the diagnosis of PTSD is used to this end as testament to their suffering. PTSD is coloured by culturally informed narratives of trauma, and they are the victim in need of assistance. For health professionals, their activity is diagnosing, their objective is to treat the patient, as well as to attest to their psychological state of mind and the diagnosis of PTSD is used as a tool to this end. PTSD is informed by a medicalized discourse of psychiatric categories and the asylum seeker is the patient. For judges and other officials in the asylum tribunal, their activity is to assess the legal case, their objective is to determine the refugee status of the individual in front of them and PTSD serves as evidence to this end. PTSD is colored by a technical, legal discourse and the asylum seeker is the defendant whose case is being assessed.

Asylum Seeker Perspectives

An analysis of the asylum seekers’ narratives highlight the following:

  1. (i)

    Discrepancies exist among the various narratives of trauma in the refugee determination process

  2. (ii)

    Existing power imbalances underlie these discrepancies, privileging westernized narratives of trauma above others

  3. (iii)

    Asylum seekers sometimes deliberately drew on specifically “westernized” narratives of trauma in order to best present their case, and

  4. (iv)

    Many asylum seekers appeared to be retraumatized by the refugee determination process.

I explore these themes through representative case studies and quotes from participants.

Discrepancies in Narratives of Trauma

Discrepancies in how narratives of trauma circulated among various actors were reflected in seven out of 10 participants. One stated that “here, we don’t speak like in Africa.” Another said “because there [in their country of origin], there are many people who, when they have something, don’t write. They keep it [in their head]. When they have a problem, they just forget about it….here, they note it.” In the context of seeking asylum, the medical certificate was seen as a reflection of western values, knowledge, and ways of being, where the written word is privileged. This finding echoes the words of Blommaert (2001b) who argues that the “process of (re)structuring talk into institutionally sanctioned text involves a dynamic of entextualization that is based on power asymmetries” (p. 3). Differences were evident in individual asylum seeker’s experience of the asylum tribunal itself: “here, it’s a new world. I don’t know how things are done.”

Many felt at a loss as to how to narrate their trauma narrative in the face of these asymmetries:

What is happening to your country? how you can come here?” ... these are not questions you can answer.

I don't know what to tell them. I don't have words to explain the things.

What happened in Africa, it’s not easy to explain.

I have a fear that I don’t know how to explain.

According to one participant: “the people asking you questions, it’s like you’re sitting across from a psychologist. They’re professionals who know their work.” The professionalism of the bureaucrats in the asylum tribunal is highlighted—and, by extension, their superior position. An interesting comparison is made between the bureaucrats of the asylum tribunal and the psychologist: asking questions, probing, evaluating, judging from a superior position. In the words of one asylum seeker, it’s a situation “where one doesn’t understand anything.” Another participant drew a similar parallel: “The psychologist, it’s a game. It’s a toy. He asks you questions, and bases his deductions on your response—and the asylum [procedure] itself, it’s the same.” The metaphor of a game is an interesting one: on the one hand, it arguably denotes the power imbalance between those who are tasked with assessing their case—who take it as lightly as though it was just a game to be played, nothing more—and those whose lives are dependent on the outcome. On the other hand, the fact that asylum seekers recognized the procedure as a game may also be indicative of the fact that it is a situation to be played: a knowledge of the rules is needed in order to strategize and, ultimately, to win.

Asymmetries in Trauma Narratives, Asymmetries of Power: The Case of Dilraj

Dilraj is a 30-year-old Indian asylum seeker of Sikh religion. As a university student in India in 2007, he was arrested and tortured on numerous occasions due to his involvement as a Sikh political activist. The detainment and torture often lasted months at a time, and involved other members of his family as well is himself. According to him, his father was allegedly killed by the Indian Secret Services in 2009. He himself managed to escape from prison with the help of an uncle, and arrived, alone, in Athens to seek asylum in September 2015. He was referred to the centre for victims of torture in June 2016, where his treating doctor describes “a clear case of post-traumatic stress disorder,” including symptoms of flashbacks and nightmares, at the first consultation. Dilraj himself stated that:

Mr. Psychologist doctor, he gave me the report. In that report, he has written that I'm in very big depression. Actually, I don't know I'm in depression or not. I know only one thing, that my world is just only this room. If I'm going out, if I'm having any appointment with my social worker, or with doctor, then only I'm going out from this room... What I do all day long, I just go through all the papers. This is my life.

Firstly, Dilraj begins by addressing the doctor as “Mr Psychologist doctor.” On the one hand, it could be argued that the “Mr” and “Dr” is intended as a sign of respect, positioning the health professional as a respected and superior authority. On the other, it indicates some confusion as to the exact role or title of the professional. What is striking is that he refers to the report as stating that he has “depression”—despite the diagnosis being that of PTSD The report is seen as something “given” to him, as a passive recipient. He displays an element of doubt as to the veracity of the report: “I don’t know if I’m in depression or not.” Given this element of doubt, he relies instead to his own subjective experience that defies any psychiatric labelling. Despite his uncertainty as to whether or not what it says is true, the “papers,” seem to hold significance for him. The medical certificate is a cultural tool that has become an integral part of “his life” now. As such, his words imply an assumed respect and value for the papers. However, their inevitable role in his life appears to be met with ambivalence. He notes, “every time I go to the people they only write and they don't really listen to me.” Here, the activity of noting is seen as a communicative barrier between himself and the unnamed “they.”

His doctor noted:

He doesn't seem to understand it as an illness. He says that he feels abnormal, he feels wrecked; he says that he's not dangerous; that he is not crazy. Every time I say to him, “These voices is just a symptom of a disease that will go away eventually,” he doesn't seem to listen.

Again, there is a substantial difference in the way in which the symptoms are interpreted. Neither feels listened to by the other. Dilraj again does not seem to understand his state as fitting into a western, psychiatric narrative. For him, it is “not an illness.” Furthermore, the assumed superior authority of the health professional is implicit in his words “he doesn’t seem to listen” to the fact that it is “a disease.” Dilraj is positioned as a patient who simply needs to listen to the doctor. His illness is presented as an irrefutable fact to be understood. Western knowledge trumps local.

Adapting the Trauma Narrative: The Case of Jules

Arguably aware of the evident power asymmetries inherent in the way in which narratives of trauma are presented and perceived in the tribunal, many participants described successfully drawing on a specifically western narrative of trauma (as exemplified by the diagnosis of PTSD) in order to best present their case during the refugee determination process. In the words of one participant, “crying makes your story more believable.” To explore this, I present the case of Jules.

Jules is a Congolese 35 year old male who was arrested and tortured as a result of his political activism. He arrived in Greece in 2015 to claim asylum. Upon preparing for his appearance in front of the asylum tribunal, he was told by his lawyer to remove his earrings when he went in front of the asylum tribunal. He explained that the “flashy” jewellery reflected “joy” and that his narrative, to the contrary, needed to be one of trauma:

Between a made-up story and the story of what happened, it’s not the same...I can tell the story 1500 times, even 15000 times, without fault, because it’s what I experienced. It’s different to the story that they gave me. That’s another person. It’s different. It’s what you experienced but the way in which you tell it must necessarily change. Some people know how to talk – ‘they’ll believe this and believe that’ but it’s no longer the story, the real story. It’s the real story that they’ve complicated. It’s the lawyer who will say things and take out certain dirty things to be clean… All people who tell stories can tell made-up stories. You need to show people that this story really is your true story, so that they can accept that ‘no, he’s telling the truth.’ You can tell a good story, but you can also tell it without emotion.

To be granted asylum, he needs to be believed. To be believed, he needs to tell “a good story.” To tell a good story, it needs to be “clean.” Indeed, the literature shows the importance of the “emotional congruence” afforded by a PTSD diagnosis as a critical factor used to judge the credibility of asylum seeker’s narratives (Rogers et al., 2015). It could be argued that the “clean” story (or, an emotionally congruent narrative) required by the tribunal is reflected in the medical certificate stating that he has PTSD and which Jules insisted on using as evidence in the court. Using his trauma narrative as a cultural tool in order to be believed, he draws upon what Hymes (1998) refers to as “fully formed narratives” - narratives which display growing tightness and structure due to repeating instances of narrating. In other words, he rehearses. According to Jules, the difference between the “real” story and the rehearsed one is the fact that his real story is far more emotionally nuanced: throughout the course of our interviews with him, he constantly referred to his childhood and early adulthood where he represents himself as a strong and active member of the community. In the rehearsed story, he draws on what Amsterdam and Bruner (2000) refer to as a “script.” They define such a script as “stories that provide walk-through models of a culture’s canonical expectations” (p. 45). Jules realises that in order to “play the game” and be granted refugee status, he needs to construct a narrative of himself as a traumatized refugee. This leaves little space for a more complex picture of multiple aspects of his identity to emerge. He is, in essence, an actor rehearsing his script.

As noted by Blommaert (2001b), such rehearsals involve “an acute awareness of the categories and interpretive resources of the hearer” (p. 22). This awareness is reflected in Jules’ words, “you need to show people that this story really is your story.” He does this by drawing on a specific “clean” trauma narrative. This is a narrative that “they” (an unnamed yet present Other) gave him and which is based on specific socially, culturally, politically, and historically informed constructions of what it means to be a traumatized refugee. It has been circulating among various actors and passed onto Jules. Such fully formed narratives “testif[y] to the gradual and discursive practice-based construction of such refugee identities” (Blommaert, 2001b, p. 20). When Jules constructs such an identity, he notes that it is not his “real story,” it is a “made-up” self.

Following the script is not without difficulty. As with many other participants, Jules was confronted with the dilemma of how much to tell. He realises that to increase credibility, the narrative needs to be emotionally congruent, despite the significant potential of sharing the trauma narrative in the asylum tribunal for re-traumatisation (Rogers et al., 2015; Turner, 1992; S. Turner, 2015). Jules’ insistence on the importance of rehearsals is clear. However, he continued the interview by saying.

But it hurts to have to tell it…yes, it hurts. Even during the interview, it hurts you … but they’re looking for sadness, during the interview …

The dilemma centres on the emotional difficulty associated with sharing the trauma narrative, and the intended objective of being granted asylum status. Jules’ words indicate an acknowledgement that, despite the fact that sharing the trauma narrative “hurts,” it is a necessary and required condition for being granted refugee status. Even the “sadness” is used to validate his experience, addressed to his intended audience in the tribunal who are “looking for it.”

Jules walks a tightrope—the narrative is required to be formal (without being too formatted or rehearsed) but also emotional (without being too emotional), this optimal balance assumed to enhance credibility (Montagut, 2016). All of this comes at an emotional cost: having to follow the script may also run the risk of re-traumatization.

As was the case for Jules, six out of 10 participants referred to the emotional distress they experienced as a result of having to speak about potentially traumatic events in the asylum tribunal. Despite the risk of retraumatization, most appeared to face this psychological challenge with a resilient acceptance. As neatly expressed by one participant, Sylvain:

We are obliged to do it. You say that you want a paper, you’re obliged to explain why you left your country. We’re at a point where you’re obliged to say everything. You want the papers, you speak, you don’t want the papers, you don’t speak.

Health Professionals’ Perspectives

The health professionals similarly highlighted tensions around the use of medical certificates for the asylum tribunal. Many strategically and purposefully weighed up the risks and benefits of using a PTSD diagnosis across various settings and among various actors, recognising the activity of diagnosing as one loaded with political significance:

A certified traumatic experience opens many advantages, ummm, the doors to, ummm, asylum and added to the facts, it’s a way of saying that the, the health professional has more relevance to his words when he certifies the existence of trauma, more than the person him- or herself

In this case, the clinician has a certain power

Implicit power dynamics are highlighted in the above words, where the health professionals are placed in a superior position, their own medicalised narratives valued above the words of the asylum seekers themselves. Given this power, many alluded to the purposeful and strategic use of providing a PTSD diagnosis to help the asylum-seeker within the asylum seeking process:

[PTSD] is something that we can try to drag the process on for a while if we're getting a negative response.

They [the commission] can understand if you provide PTSD

It's about all the only ammunition that we have.

It was a way to protect them during the commission.

I guess [PTSD] is a construct which we have to work because um, that's the way we communicate about what trauma is and as for the asylum process we have to often say that somebody has PTSD because that's going to be important to sort of validate what they're saying happened to them.

Words such as “protect” and “ammunition” connote war narratives, with asylum seekers positioned as soldiers going into battle, the medical certificate the “ammunition” provided by their superiors (in this metaphor, the health professionals). We can infer that health professionals are not naïve to the legal weight given to PTSD They position themselves as one of the actors who influence the asylum process. “We” or “us” refers to either the group of health professionals (“the only ammunition that we have”) or to the health professional and the asylum seeker (“if we’re getting a negative response”); “they” or “them” referring to the commission or the asylum seeker (“a way to protect them”). Within these shifting alliances, the health professionals are not politically neutral actors. They described purposefully using PTSD as “ammunition” in cases where, in the words of one participant, the asylum seekers’ narratives are “not as psychiatric and not as theoretical and psychological as ours is.” The use of the word “construct” implies a recognition of the diagnosis as being socially constructed and relevant in certain situations, a cultural tool used to “communicate” about what trauma is—in this case to communicate to the actors of the asylum tribunal.

Like the individual asylum seekers themselves, the necessity of having a “coherent” and “linear story” was widely recognised:

They need something very sure to evaluate a demand, whether they will give asylum or not, which is the simplest way to have a coherent, and very linear story. The more linear and straightforward it is, the best [sic] it is for them.

The “clean story” narrative is one permeating the activity system, passed around among actors. One participant stated, “a very, very coherent and linear story is a story prepared with a lawyer.” What is implied in these words is the fact that (a) it is impossible for any individual to have a very, very coherent and linear story, (b) the asylum seeking process may require it and (c) professionals may purposefully reconstruct the narrative to fit into pre-established legal categories. As an interesting aside, this particular participant seems to imply that, as much as it would be impossible for the “genuine” story to be coherent and linear, it would be impossible for the asylum seeker him- or herself to have reconstructed it.

The health professionals, therefore, allude to an implicit knowledge that their position is a powerful one. By virtue of the fact that they are able to diagnose an asylum seeker with PTSD, they are in a position to construct the narrative of the individual. The use of a clean and coherent (linear) narrative, however, was not perceived as being without complications. Many health professionals raised doubts about fitting the trauma narrative into such a “clean” story:

I'm afraid that it victimizes the person. I mean, I tell him, "Okay, you have PTSD and for this reason you can claim that." … And so, it becomes that he or she becomes passive, waiting for others to do things for him. Because he's vulnerable. Because he suffers with PTSD This doesn't have to do with PTSD This has to do with how the policy concerning refugees is formed and is applied.

It has to do with identity if it's totally stripped off, what he was before. He's like just an object. He's treated like an object from everyone.

They are very, they are basing all of their work on PTSD diagnosis, they completely medicalise and victimise people

The concerns of the health professionals centred on the fact that to have a “clean narrative” (as seems to be implied by a PTSD diagnosis) is to reduce the asylum seeker’s story. Their unique and individual “identity” is “stripped off” in order to make the story clean. Thus, a trade-off is implicitly recognised. On the one hand, the benefits of being recognised as a “victim” of PTSD (and by extension, having one’s story believed and being recognised as a refugee) are many. On the other hand, the very mechanism of reconstructing the trauma narrative in order to fit into, in the words of one participant, “a perfect victim template” risks reducing the individual to an “object” without identity. As a result, the use of the diagnosis is met with some ambivalence:

They want to victimize the patient. It's already a mistake from me that I talk about the patient. Sorry, I'm medical. I'm referring to people as the patient and very often people will not be a patient, neither psychiatrically or physically.

The above participant engages in a narrative (re)positioning. Firstly, like others, he refers to “they” (presumably the actors of the asylum tribunal) as intentionally looking to “victimize” the “patient.” There is an implicit recognition of, and disagreement with, such victimization. He then refers to the asylum seekers with whom he works as “patients.” Thereafter, he immediately repositions himself, by taking himself out of the normative, medical narrative within which he acknowledges he has placed himself unintentionally. He self-identifies as “medical,” using this as a justification for drawing on medical narratives of the individual asylum seeker as a patient. The reason he gives for it being a “mistake” is that, to be a patient is to imply, in some way or another, that one is a psychiatric or physical victim. There is an implicit acknowledgement of the complexity of individual asylum seekers’ narratives which extends beyond the medical narrative.

Furthermore, an attempt to reduce these complex narratives to a medical one paradoxically denies those whose narrative is not “clean” (linear, coherent, “medicalisable”) access to certain rights, recognitions, and privileges:

I think [PTSD is] being used to filter rights, to filter certain rights and access to certain services, which could be open to everybody.

This is extremely dangerous, because being a refugee doesn't mean that you have obvious consequences, even psychological. I'm very, very skeptical that people that they don't have symptoms, they might be considered liars. What should we do then?

I think there is a disconnection between what you see in the clinical setting and the evaluation process, there's a, there's a break in the system. And, it's very traumatizing also for the professionals working in such a setting, because you feel helpless. You see the case, and you see that, yes, this person is in need of support and help and is really traumatized, but his claim doesn't fit the official, what do you say, profile...

Implicit in the above words of the participants is an understanding of PTSD as a cultural tool with political significance, and furthermore that the narratives of many asylum seekers “don’t fit the official” narrative required. This clear “break in the system,” arguably resulting from conflicting narratives, places the health professionals in a “traumatizing” and “helpless” position. Referring to the conflicting narratives around trauma, another participant similarly stated that “we need a common knowledge to share with the commission.” The words of one participants reflects the strategies developed to negotiate this complex position:

for me the diagnosis is something that if you use it, you should know for what reason you use it. You use it because you want to understand better the patient, you use it because you want to help him with the asylum process and you know that if there is a diagnosis that this person will be helped, you use it because it’s a great way to communicate with other professionals, so if I say “PTSD” the other will understand, but for me it’s very important if you use a diagnosis to explain exactly what’s happening with this person, not only to say “okay, he has PTSD” and it’s not clear.

Her strategy includes an implicit understanding of the multiple ways in which PTSD is understood by the various actors. For herself as a professional, it is a way of better understanding the patient. For other professionals, it is a way to communicate this understanding clearly and efficiently. For the asylum seeker in front of her, it is a way to help him or her in the asylum procedure. Given the various ways in which PTSD is understood by the various actors, she highlights the importance of addressing medical reports to match the understanding of the intended audience being addressed.

Conflicting Narratives Across the Activity System

The health professionals found themselves having to negotiate a variety of conflicting discourses of trauma within the refugee determination process. Here, their activity of diagnosing patients similarly includes needing to address a variety of different actors, including bureaucrats of the asylum tribunal, lawyers, as well as the asylum seekers—themselves occupying multiple positions associated with being a patient, a client and an asylum seeker. The complexity of this is highlighted in the words of one participant:

Then you sit down, the interpreter, the professional, and the patient. The professional is reading the report with the interpreter and on the spot they explain to the patient what everything means. Then the patient receives the report. Very often he will say that, “This is wrong. With that what you write, you say that I'm crazy, I'm not crazy.” Then, of course, you have to try to explain to the patient that, “I don't understand what you meant by crazy, I never said that you are crazy. I say that you are suffering from post-traumatic stress disorder.

What is noteworthy is the multiple actors involved in the above-mentioned exchange. Present in the moment described are three actors: the professional, the interpreter and the patient (asylum seeker). Furthermore, there are a myriad of actors not physically present but implicitly addressed, including, for example, the lawyer or the bureaucrats of the tribunal. For the asylum seeker, having PTSD is equivalent to being seen as “crazy.” It is not evident, but we could suppose that this narrative is associated with a certain social stigma for the asylum seeker, who rejects the psychiatric labelling. For the health professional, PTSD is a familiar cultural tool of the profession. The word “crazy” does not enter into this medical narrative. It is also interesting to note the implicit power dynamics inherent in this exchange, as illustrated by the words “you have to try to explain,” indicative of the value given to his expert medical knowledge above that of the patient’s. This is similarly reflected in the words of other health professionals:

We will give the report to the patient who will read it and translate it to him and explain to him exactly what he has.

They don’t understand that they have it.

PTSD is implicitly acknowledged as fact, something that the asylum seeker “has.” Rather absurdly, despite the fact that it concerns the psychological condition of the individual, there is an implicit assumption that his own thoughts, feelings and behaviors need to be explained to him—in other words, fitted within a pre-established medical narrative. Conflicting narratives circulated among the actors, but appeared to create specific tension when it came to the written reports of PTSD:

Very often he will not accept it. Very often the beneficiary will tell you, “I don't want you to write that.

Health professionals reported a variety of reactions of asylum seekers to the medical certificate stating PTSD:

Some patients, they will insist to write something worse, exactly because they know that this thing I will use it like a leverage for my asylum… For someone it’s very important to know what they have: “I feel better to know that I have this so I can do that to be better” but for someone else, they don’t accept diagnosis. They don’t like diagnosis because they think that they are crazy or you are saying to them “you are not okay, something wrong is happening.

You see when they ask the report, that they expect to [see written in the report is] this vulnerable identity is that deep inside. They speak of vulnerability. They speak about, “I have to prove to them that I'm vulnerable because they didn't believe.

The above quote raises some key considerations (i) PTSD is used by some (but not all) of asylum seekers in a purposeful and strategic manner in their asylum seeking procedure as “proof” of vulnerability (ii) it is also used within a therapeutic setting as a helpful clinical diagnosis used to understand symptoms being experienced and receive appropriate psychosocial treatment (iii) many asylum seekers disagree with the diagnosis, due to a belief that it suggests something “wrong”—an indication of resistance to their symptoms fitting into a medical narrative of deficiency. The above-mentioned reactions also seem to be related to whom the diagnosis is addressed (for example, positively regarded when shared with the bureaucrats of the tribunal and with the treating health professional of the consultation room as compared to being negatively regarded within the asylum seekers’ community space where the diagnosis may carry a social stigma). As such, its use is highly context dependant and continually negotiated across activity systems.

Discussion: An Overview of the Various Critiques of PTSD Within the Asylum Process

For asylum seekers and their lawyers, the medical certificate, including evidence of PTSD, is an “open sesame” (Fassin & d'Halluin, 2005, p. 600); for officials and judges it is a piece of evidence among others; and for both it is an innovation in governmentality. This labelling of asylum seekers is supported by a system in which tabulation of numbers with psychiatric labels forms a crucial basis for the mobilisation of broader social supports (Watters, 2001) and a new form of the transnational administration of people (Fassin & d'Halluin, 2005). It risks tearing individuals away from the potential protection of their own resilience as well as from their community’s traditional means of coping with trauma (Losi, 2002). As Papadopoulos (2002b) argues, in our efforts to express our justified condemnation of the individuals, groups and policies that lead to political oppression and crimes against humanity, we offer as “proof” the fact that people have been “traumatized” by these despicable actions. In doing so, we ignore all psychological considerations of how people process traumatic experiences and, unwittingly, we end up doing violence to the very people we want to help through psychologizing the political dimensions of human suffering.

As noted by Daiute and Lucic (2010) ‘the almost-exclusive focus on psychopathology as a response to war defines traumatic reactions and recoveries in terms of the direct exposure of individuals to violence and reactions to these events as automatic emotional responses’ (p. 615). This medical narrative of trauma, 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 (Maier & Straub, 2011; Silove et al., 1998, 2000). Furthermore, “although there is evidence that some …people experience trauma and others interpret violence in terms of cultural values and practices, we know little about the broader range of strategies … people use to understand the myriad material and symbolic circumstances they encounter in their daily lives” (Dauite & Lucić, 2010, p. 616). By placing human suffering within this medical narrative, a thin description of the individual is created where other important socio-cultural and political considerations are easily lost or hidden (Marlowe, 2010). Such a shift away from a wider understanding of the political context from which asylum seekers may be fleeing, towards this medical narrative may equally lead to the moral disqualification and criminalization of unsuccessful asylum seekers who are not found to be “traumatized” (Sturm et al., 2010).

Deconstructing the “Traumatized Refugee” Narrative

An obvious but often neglected point is that not all refugees are traumatized. This assumption, Summerfield (2001) argues, reflects “a globalization of western cultural trends towards the medicalization of distress” (p. 1449). A narrative of refugees as invariably damaged, weak or scarred, manifest (as indicated by the diagnosis of PTSD), may have unintended negative consequences for refugee populations by minimizing strengths and positive adaptation mechanisms (Afana et al., 2010; Losi, 2002; Marlowe, 2010; Papadopoulos, 2002b; Sturm et al., 2010). The “traumatized refugee” narrative ignores systematic complexities such as the relational nature of the event’s impact among family, community and ethnic group members, as well as the effects of the wider societal discourses which colour the meaning, emphasis and quality of events and experiences (Papadopoulos, 2002b). It also neglects to consider the fact that different reactions or non-reactions to trauma—not matching those prescribed by PTSD—may indeed serve as a defensive and adaptive survival mechanism for individuals who may not have the “luxury” of allowing the experience of psychological distress to impede the urgent and daily task of surviving.

As such, the “traumatized refugee” narrative risks placing asylum seekers in the role of passive victims, their own choices, traditions, survival strategies and competencies ignored, and the role of Western “experts” and their technology in the field of mental health exaggerated (Summerfield, 1996). It may thus represent a form of western cultural imperialism (Steel, 2001) which denies the resilience of survivors (Marlowe, 2010) and serves to reinforce existing imbalances of power between Western “expert” and “victim-patient” (Summerfield, 1996). As stated by Pupavac (2002):

Internationalization and professionalization of adversity, indigenous coping strategies are thus not merely demeaned and disempowered. The community itself is pathologized as dysfunctional and politically delegitimized (p. 493).

The narrative further serves to detract attention away from the structural violence inherent in the asylum seeking procedure of host countries to which many asylum seekers are exposed - a “colonization of intimate psychic spaces” (d’Halluin, 2009).

Implications for Health Professionals Working with Asylum Seekers

Losi (Losi, 2002), an ardent critic of humanitarian interventions focused on PTSD, argues that the use of PTSD by professionals working with asylum seekers leads to a reductive assessment of their plight, victimization and a shift in the interpretation (and understanding) of the refugees’ experiences, where the reasons for their exile are no longer socio-political but belong to a more neutral, “technical” dimensions; a de-contextualization of the lived experience of refugees leads to languages and concepts being lost and replaced by medical jargon and obscure terms.

In practice, many health professionals are increasingly called upon to provide medical information in order for the state to distinguish between “true” and “fake” refugees. However, a number of criticisms have been raised regarding the potential subjectivity and partiality of health professionals providing a PTSD diagnosis as evidence in asylum procedures. Such criticisms perceive the diagnosis provided by the professionals to be less based on objective medical “expert” information and more on “therapeutic” clinical intuition (Dromer & Grandmaison; Hauswirth, Canellini, & Bennoun, 2004; Lechenne, 2012; Maier, 2006; Montagut, 2016). Such criticisms may pose a dilemma for the professionals themselves, who are often faced with their own doubts regarding the diagnosis and their attempts to be as objective as possible (Joksimovic, Schröder, & van Keuk, 2015; Maier, 2006). They may in fact be seen as agents of de-culturalisation and de-politicisation in that they transfigure the refugees’ accounts of atrocities into individualised pathology—a process refugees themselves may not be averse to as it may be the only avenue available to secure wider legal and welfare benefits. The resulting ethical dilemmas faced by health professionals is aptly described by Steel et al. (2004):

The life-and-death struggle implicit in the refugee claim process presents the mental health clinician with additional professional and ethical dilemmas. Clinicians working with asylum applicants often find themselves in a position where forensic demands—namely, the need to obtain trauma testimonies to support refugee applicants’ claims—can be of such a pressing nature that they outweigh usual clinical caution in delving too quickly into traumatic material that could undermine the emotional well-being of their patients (pg. 512).

Similarly, Fassin and d’Halluin (2005) quote the June 2002 newsletter of the organization Primo Levi which aptly asks, ‘does one need a paper to prove torture?’ The authors state:

For immigrants, the poor, and more generally, the dominated – all of whom have to prove their eligibility to certain social rights – [the individual body and mind] has also become the place that displays the evidence of truth…asylum seekers are more and more submitted to the evaluation of their physical sequels and psychic traumas, as if their autobiographical accounts were not sufficient… Medical authority progressively substitutes itself for the asylum seekers’ word. In this process of objectification, it is the experience of the victims as political subjects that is progressively erased (p. 597).

They argue that the medical certificate is detached from the lived experience of the victims of persecution, attempting a process of objectification through expert’s words and thus desubjectifying individual narratives. A health professional they interviewed is quoted as saying that “by issuing certificates, we’re busy judging who’s guilty and who’s innocent. What situation are we in? We’re neither experts nor jurists” (p. 601). Another explains: “it is part of a programme designed to destructure and depersonalize the individual” (p. 602). Elsewhere, Joksimivic and colleagues (2015) similarly quote a professional as saying “I’m not paid to write certificates for authorities, I’m paid to treat my patients” (p. 233). This highlights the multitude of challenges often posed to health professionals, torn between the “moral demand” for PTSD to be diagnosed at the risk of influencing the therapeutic relationship, which by definition is less based on ‘truth funding’ and more on an exploration of the subjective experience of the individual. For many professionals who find themselves on the horn of this dilemma: “it is their burden and their duty to testify” (p. 604). The other health professionals interviewed by the authors similarly perceived the gap between the meaning that potentially traumatic acts can have for the people who were subjected to them and the “semantic reduction” (p. 603) of the clinical examination and medical report.

However, despite the potential damage caused to the individual by the use of a PTSD diagnosis, it is critical to highlight that there are indeed instances where it can be used in the service of marginalized individuals or groups. A persuasive argument therefore is the co-occurrence with policies, rights, and benefits through providing a foundation for status claims (Daiute, 2017). For example, a PTSD diagnosis is a way of validating the violent acts and traumatic events to which the individual has been subjected—not only are people listened to, it is a recognition that the suffering has been seen. It thus carries a deeply symbolic value.


Making use of the PTSD diagnosis in asylum procedures may present a double-edged sword. On the one hand, it acknowledges the deep pain experienced by asylum seekers and assists them in getting their refugee status recognized. On the other, it risks becoming a trendy “catch-all” diagnosis open to various forms of political abuse or manipulation. In this chapter, I have explored how PTSD may limit and control, yet at the same time how it is a powerful tool for public recognition and political response. It has been examined it as a boundary object (Star & Griesemer, 1989) used differently by health professionals and asylum seekers to facilitate the asylum process yet “glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated and represented and by the various interests, institutions, and moral arguments that mobilised these efforts and resources” (Young, 1995).

As noted by Dauite (2014), “storytelling shapes public life, and individuals transform public life in their own personal stories. It is through storytelling that societies indicate who belongs and who does not” (p. 7). The asylum procedure is one in which storytelling—rhetorical accomplishments and discursive constructions of reality—are of critical importance; the politics of asylum is a politics of representation in which discursively constructed and disseminated gross categories are crucial political instruments (Blommaert, 2001b). The category of “traumatized refugee,” as reflected in a PTSD diagnosis, is one such instrument. It privileges certain events to develop a plausible version of the story in a context where the asylum seeker may be constructed as someone with a fragile memory, a fragmented subject who lies, an actor playing a role to deliver his subjectivity (Demazière, 2007).

The results indicate that neither the health professionals nor the asylum seekers are naïve to the potential benefits of fitting the traumatic events experienced into a narrative framed by PTSD, as a cultural tool, in the refugee determination process. However, there are apparent discrepancies in the way in which it is understood and used across the asylum activity system. Within this activity system, it functions as a “boundary object” (Trompette & Vinck, 2009), circulating among different actors yet with specific meanings within each sub-system. It is 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 across these spaces. 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.

PTSD represents a refocalisation of the trauma narrative in a way that:

shifts the epistemic center from the asylum seeker to the administrator processing the application… the story of the applicant is relocated in another space and time frame: that of the administrative procedure and its pace, that of its standard categories, criteria and textual formats…[it shifts] away from the local, away from the experiential, the affective, the emotional, the individual positioning of people in conflicts, towards generalizable categories and space-time frames (Blommaert, 2001b, p. 27)

As such, it is not politically neutral. Despite the many ways in which it can effectively assist asylum seekers who have indeed experienced significant psychological trauma, we cannot neglect the risks inherent to the “psychologization” (Rose, 1998) of persons and identities. In this context, not only are the accounts of the asylum seekers describing the persecutions they have endured and the risks they would incur if they were to return to their home country discredited, but their voice can no longer be heard: lawyers speak in their stead; volunteers help with their application, some even specializing in the so-called preparation of narratives; physicians and psychologists attest to their past experience (Fassin & d'Halluin, 2005; Fassin & Rechtman, 2009). PTSD risks creating narratives in which asylum seekers are seen in terms of deficits and security threats, which risks facilitating ongoing exclusion from human communities: if the asylum seeker is always represented as an individual victim of psychological damage, object of sympathy, scorn, or fear, initiatives for social inclusion are undermined (Daiute, 2017).

Yet despite the risks of victimization, psychological evaluation offers professionals a unique and privileged opportunity to help survivors to address and recover from the devastating consequences of trauma. As argued by Gangsei and Deutsch (2007), such evaluations may significantly increase an understanding of the survivors’ background and experiences as well as their manner of self-presentation in the courtroom or interview. A recognition of trauma thus empowers individuals to present experiences more fully and confidently, helps them understand the necessity of telling the story, illuminates the often poorly perceived link between current emotional suffering and past trauma, facilitates the development of cognitive and emotional control, and heals the wounds of mistrust, humiliation, marginalization and fear. Indeed, as noted by Hanewald et al. (2016), in the case of traumatized refugees, the coaction of legal and medical aspects has to be acknowledged seriously by the medical, legal and political parts involved. Professionals—both legal and medical—working with asylum-seeking populations need to incorporate a nuanced and contextually informed understanding of each individual’s trauma narrative.