The number of refugees across the globe is growing dramatically—a trend predicted to continue due to a global increase in social and political instability as well as socioeconomic conflicts. In places where violence is seen as a necessary factor in achieving peace, ongoing armed conflict, and displacement will likely contribute to continued psychological impairment and suffering among those affected (Morina et al., 2018). Indeed, research overwhelmingly attests to the alarmingly high rates of PTSD among this population (Schouler-Ocak et al., 2019). This is no surprise. What is surprising, however, is the lack of knowledge concerning refugee experiences of potentially traumatic events from a sociocultural perspective. As recently noted by Zipfel and colleagues (2019):

we still know very little about how evidence-based concepts of assessing and treating mental health conditions actually work when applied to traumatised refugee populations... Also, the interplay between pre-migration adverse or potentially traumatic experiences, various stressors during the flight, post-migration living difficulties, and mental health is far from being understood (p. 22).

Within humanitarian interventions targeting refugee populations, “trauma” seems to be something taken-for-granted and assumed. It is a ubiquitous buzzword permeating discourse. Yet, there continues to be very little critical reflection—or indeed consensus—on what it actually is. Having worked as a clinician in mental health projects with displaced populations—across a variety of cultural contexts—this was a constant source of personal frustration and concern. I would repeatedly be called upon to report on the number of refugees with PTSD Repeatedly, I would sit in front of individual refugees for whom the diagnosis made little sense. It seemed a ludicrous discrepancy. Similarly absurd was the implicit assumption that the mental health of this population had very little to do with their current daily reality. I was working as a psychologist, not a social worker, lawyer, or human rights advocate. Yet the social, legal, and economic needs of the beneficiaries continually found their way into our consultations. From a personal perspective, this compelled me to develop this body of research. Importantly, it is research intended to speak to the concrete reality of the humanitarian field. It is research intended simply to make sense.

Given the ubiquitous nature of the diagnosis in popular discourse in general, and humanitarian discourses centering on “suffering refugees” in particular, what is missing is an understanding of the context in which experiences of potentially traumatic events are embedded. The staggering discrepancy in rates of PTSD noted among refugee populations (Morina et al., 2018) could be seen as a further indication that we need to go beyond the diagnosis to see what is happening “in the field.” This is not to say that we need to disregard the diagnosis. This book does not intend to position itself as being “for” or “against” its use at such. Rather, the intention is to peek behind the metaphorical curtain and explore the stories behind the high prevalence rates of PTSD—and to explore the borders of the diagnosis itself. Echoing the research aims of Shala and colleagues (2020), the intention is thus “to go beyond such labelling to explore participants’ assumptions about the causes of their suffering, their implicit concepts of how body and mind interact, how language is used to express psychological distress in a culturally congruent and socially acceptable manner, and what expectations people hold about the course (and relief) of their suffering.” (p. 19).

The notion of the “traumatised refugee” is a complex one. It holds symbolic power. There is a complete narrative behind this tragic figure. Many have seen the images flashed across the media: devastated and impoverished communities, sinking ships, abandoned children, fences and barriers and brutal European regimes attempting to control the influx. There is no denying the brutal reality facing refugees arriving in Europe. The suffering is real, and multifaceted. Trauma does not stop at the border.

However, the results of this research have highlighted the existing tensions among conflicting narratives of trauma circulating among the actors involved. They bring to light the discrepancies in the way in which experiences of potentially traumatic events are understood, and in which narratives of trauma are used across legal and medical activity systems. Broadly speaking, the way in which “trauma” is understood by lawyers is different to that of health professionals such as doctors and psychologists, and again to that of refugee populations themselves. Furthermore, the way in which experiences of potentially traumatic events and their sequelae is i) understood or made sense of and ii) (re)presented in narratives, addressed to other actors across settings, changes to adapt to the context, and changes over time. The use of a diagnosis of PTSD in particular seems to be unnervingly context-dependant. A doctor may diagnose PTSD strategically, to inform an individual treatment plan within a medical context, but not to inform the asylum tribunal to assist them in their decision-making process—or vice versa. A lawyer may decide to focus on the “headline” of the potentially traumatic event in representing the narrative to a judge—and encourage a refugee to frame this narrative within a certain way that is most easily understood by the court. Refugees may decide to present the trauma narrative in one way to a psychologist, and in another way to their lawyer. They may go to the psychologist with the explicit intention of receiving a medical certificate attesting to a diagnosis of PTSD for use in the legal system. They may deny being traumatised altogether—the implicit understanding of “trauma” inherent to a PTSD diagnosis seemingly too far from their own subjective understanding of what was happening to them. The results indicate that PTSD as an instrument circulates among the different actors yet with specific meanings and functions within each activity system, and which change over time.

Not only are there multiple tensions associated with such a diversity of narratives of trauma, but there is an inherent hierarchy within medical and legal activity systems which places the knowledge of one group as superior to another. The narratives are not created equal. They are embedded within sociocultural and political structures with very real political, economic, and social consequences for refugees. Within this system, it appears that the medicalized narrative of trauma, as manifested concretely in the diagnosis of PTSD, holds particular political power. Neither the health professionals nor the refugee research participants appeared naïve to the potential benefits of using PTSD as a cultural tool to be used in the asylum seeking procedure in particular. PTSD as a diagnosis appears instead to have been used strategically by the various actors in a way that was explicitly interactive, communicative, and purposeful. It is not a politically neutral tool.

The results also clearly highlight the changing nature of the subjective experiences of exposure to potentially traumatic events by individuals over time. For the individual refugee research participants—negotiating complex legal and medical systems had a substantial impact on their mental health. It confirms what is increasingly being highlighted in the literature: there is very little “post” about the post-traumatic stress being experienced by refugee populations in Europe. It seems absurd to focus on the “headline events” of what happened in the country of origin when individuals are struggling to survive—today and every day. Yet it is not a question of “here or there,” “past or present.” No such dichotomies exist. Rather, the potentially traumatic experiences of the past echo the current reality. Trauma begets trauma.

Another issue explored in the book concerns that of the use of the diagnosis of PTSD as a cultural tool: for what, by whom, and for whom? None of the refugee participants in the research were familiar with the concept of PTSD before being diagnosed with it themselves. What strikes me is the way in which this diagnosis was appropriated and/or contested by various participants. There were a variety of responses to being confronted with this novel, medicalized notion of suffering. For some participants, it appeared as though the notion was so far from their own conceptualisation of what was happening that very little appropriation took place. The diagnosis was something for western health professionals, from western health professionals, that was of very little direct concern or consequence. As such, it was not so much of a rejection of the diagnosis. It was a rendering it irrelevant. For others, it was a useful tool. In this latter case, it seems that the use of the tool lay in its concrete political, legal, and social relevance. It was a tool for use within various medical and legal activity systems—not a personal usefulness as such, but a practical and concrete usefulness in the sociocultural environment. In such cases as these, there similarly seems to have been very little appropriation of the diagnosis at a personal or subjective level among participants. In other words, PTSD as a cultural tool was used with certain concrete intentions in mind. For example, it was useful to have the diagnosis as evidence of refugee status within the asylum tribunal. The diagnosis was a cultural tool used to act in the world, but not to further a process of psychological rehabilitation, or to make personal sense of suffering. None of the participants seemed to have drawn upon the diagnosis to inform their own personal way of making sense of potentially traumatic events or as a significant factor in their journey to recovery.

It is perhaps understandable that PTSD be used as a tool by various actors attempting to negotiate the complex procedure that is asking for asylum. It may even perhaps be viewed as a question of the survival of certain refugees. We need, on one hand, to be shocked by the potentially traumatic events—and to bear witness the impact of this on their mental health. To recognise this, in the concrete form of the diagnosis, is imperative. The wounds are real. What I find more surprising, however, were results indicating the same power struggles playing out in the court playing out in the consultation room. From a personal perspective, it has lead me to reflect on the implication of this for health professionals working with this population. Might refugee patients be rehearsing their trauma stories for the psychologist, as they do for the court? Might they experience being seated in front of a psychologist in the same way as being seated in front of a judge?

I refer back to the words of one refugee with whom I had a conversation:

The people asking you questions [in the tribunal], it’s like you’re sitting across from a psychologist. They’re professionals who know their work…for 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.

His words suggest a deep distrust in mental health professionals. It also highlights how different the subjective experience of being seated in front of a psychologist may be for refugees to that of what we might imagine it to be. For him, the psychologist is similarly playing a game. He himself is a toy in this context, being manipulated by the medical system as much as the legal system. For many who have experienced torture in particular, it sadly seems to echo the deep sense of powerlessness at the hands of an aggressor experienced in their countries of origin. There are inevitably power imbalances inherent to the relationship. There are inevitably differences in how we make sense of trauma, how we narrate trauma to ourselves and others. As there are multiple traumas, there are multiple stories of trauma, and multiple listeners to the stories.

Trust is central to these dynamics. Within the dialogical approach adopted throughout this book, trust is considered as positional: “social power holders insist upon a positional monologization of trust…we are assumed to trust institutions [and] all that monogolization happens through words -words inserted into specific locations.” (Linell & Marková, 2013) p. xi). Yet, “trust is a dialogical feeling in which the person relies on someone else based on expectation of positive ethical reciprocity…thus trusting psychotherapy, in a macro-sense, implies to trust a distributed institution, in which social roles are established, as well as the generic rules that govern the activity that may reach a legal format” (Salgado, 2013) p. 110). In the consultation rom, refugee victims of torture are expected to trust the mental health professional when diagnosed with PTSD They are socially and institutionally in the (inferior?) position as the patient within this dynamic. For some of the refugees I encountered, trust in the mental health professional was a given. For most, however, there was a marked ambivalence around how much the professionals charged with their care could be trusted. In light of the multitude of potentially traumatic events to which this population has been exposed—all along the migration journey—the lack of trust is not surprising. Indeed, for some, the implicit obligation to trust the professional may prove an impossible task. Being in the privileged and arguably hierarchically superior position of health professional in relation to refugee “patient” therefore comes with an ethical responsibility to be aware of the discrepancies in trauma narratives, and the power dynamics inherent to this context of which trust is a core component.

What is further worth highlighting in reflecting upon these results is the notion of agency or the will and ability to extend one’s power to act (Clot, 2011; Clot & Béguin, 2004; Clot & Litim, 2008; Kloetzer et al., 2015). None of the research participants–refugees, health professionals, community leaders–were passive in engaging with these legal and medical activity systems. To some degree or another, there was more or less power to act as individual agents. This power extends to the refugee participants themselves. Despite the inevitable imbalances of power characterising these systems, and the multitude of barriers faced, all of the refugee participants found ways to act within the system in order to survive and thrive: rehearsing a speech for the tribunal, disagreeing with a psychologists’ interpretation of their symptoms, actively seeking the support of a local community … even within the most ostensibly powerless positions, there is a power to act, there is resistance. Research participants, refugee victims of torture, found the will and ability to exert power over a seemingly hopeless situation.

To summarize, this book highlights.

  1. (i)

    the way in which a PTSD diagnosis is being used strategically as a cultural tool by various actors within medical and legal activity systems put in place to address the large influx of refugees arriving in Europe

  2. (ii)

    the changing development of experiences of potentially traumatic events over time. This includes the substantial impact of the current (sociocultural, legal, economic, and political) environment on refugee trauma trajectories

  3. (iii)

    the culturally diverse narratives of trauma informing refugee mental health, which may compete, contradict, or conform to the narrative of trauma inherent to a diagnosis of PTSD This includes the substantial lack of the use of the PTSD diagnosis as a resource for personal recovery among participants

  4. (iv)

    the ways in which refugee victims of torture manage to draw on multiple resources in order to exert and extend their power to act as active agents, despite being positioned as “victims”.

Towards a Sociocultural Definition of Trauma

I begin these reflections by returning to psychoanalytic conceptualizations of the term “trauma.” According to Freudian psychodynamic theory, trauma is defined as a frightful experience which overwhelms the psyche to such an extent that images, words or other memories related to the event are unable to be integrated into the system of representations which structure the experience of the individual (Garland, 2002; Sturm et al., 2007). Within this paradigm, one commonality of trauma experience is the feeling of a chaos of seemingly unutterable experiences collapsing into that “wordless nothing” (Larrabee et al., 2003, p. 354). As eloquently expressed by Lester (2013):

Pushed to the very precipice of physical and/or psychological annihilation, the bonds that tether a person to the everyday world become stretched, distorted, and even torn; sometimes irreparably so. Such a state of ontological alienation is profoundly distressing. To regain their footing, people often turn to culturally available practices, symbols, and structures to help reorient them to the world (p. 753).

What this research demonstrates is the mediating impact of narrating potentially traumatic experiences to Others, in processes of recovery. This is because telling a story of a potentially traumatic event or reliving it necessarily occurs in a larger dialogical matrix of narrative and social praxis (Kirmayer, 1996). The communicative function of language as a tool, concrete semiotic and symbolic devices provide the connections to an Other and to one’s Self (Daiute & Lucić, 2010). As such, symbolic elements in socio-cultural practices are resources for repairing ruptures in intersubjectivity. They are lenses through which experiences may be collectively and individually reflected upon. Language is central. Cultural representations, carried through language, are considered in their function not only as shared symbols but also as subjectively appropriated and emotionally invested representations (Sturm et al., 2010). It is therefore through language that one is able to constitute and actualize a coherent sense of Self. Furthermore, this can only take place in the context of “interlocution” or “addressivity” (Bakhtin, 1978, 1981, 1986)—towards and with an Other. There is evidently a continual dialogue between the person’s inner world and the socio-cultural context in which internalized configurations or representations of potentially traumatic events are processed (Lemma & Levy, 2004). The critical issue here is that of the notion of reciprocity (Van Der Kolk, 2015) inherent to social recognition (Marková, 2016).

Zittoun (2004) argues that:

The embodied quality of experiences is, in its origin, given as a brutal happening. To be apprehended mentally, these experiences have to be linked to semiotic mediations. Mnemonic traces of previous comparable experiences, in their minimal definition or socially shared signs, either previously internalized, or available in one’s environment, have to be attached to them. Semiotic mediation minimally authorizes the grouping of fuzzy embodied impressions and then designate these groups of impressions (by a linguistic term, or also just by attaching them to any image), and eventually to include them into an articulated sequence in the flow of thinking. Thus, semiotic mediations can allow experience to become part of, and thus transform, other thoughts. Thanks to semiotic mediation, normal elaboration of experiences allows processes of linking and transformation through which they progressively fade in the flows of memories and thinking. (p. 484).

Reflecting on the process by which semiotic mediation allows for memories of potentially traumatic events to be processed and ultimately stored in the flows of memories and thinking, a traumatic rupture in this very process would lead to the usual semiotic work of making sense, which demands to bind traces of events to other traces, in time and in experience, not taking place. The potentially traumatic events and the actual sphere of experiences are disconnected. Should this prove to be the case, the lack of connection of past and present can also be understood as preventing the emergence of possible futures. From within this dialogical paradigm, this lack of connection to the future is intrinsically linked to a severe disruption of the relational processes by which meaning is dialogically created—the bedrock of which is social recognition. Viewed through the lens of a dialogic systems sensibility, the traumatic world’s slipping away from the categories of meaning can be seen as a severe disruption of those relational processes in which meaning is formed (Sucharov et al., 2007).

Within a sociocultural framework than, trauma may be defined as that which cannot be elaborated through semiotic means. I would argue that, implicitly contained within this definition, is the idea that the Self is inextricably connected to the Other, and that it is language which acts as the mediating conduit between the two. Trauma has a social and a cultural dimension. For the transformation of memories of potentially traumatic events into semiotic forms which connects it through language to its rightful place in time, the elaboration needs to be socially situated and “intersubjectively acknowledged” (Zittoun, 2014, p. 485). Here, I refer to a Vygotskian conceptualization of language as a system of signs. This does not necessarily mean that the elaboration needs to be conducted verbally. Language is more than words. Many processes of recovery from potentially traumatic events have resulted from making use of alternative ways in which to elaborate upon the experiences. Drawings, puppets, dolls, sandtrays, to cite a few examples, have all been used to facilitate this process of elaboration in creative ways without depending on words.

A sociocultural definition of trauma, sees it first and foremost as relational, intersubjective experience. It relates to a crisis that is situated, negotiated, and sometimes mended in relationships. From this perspective, mental health comes into view as “a problem of social Ecology, which may involve crises of kinship, of relations of reciprocity and obligation, of maintaining proper relations with ancestors, and, importantly, the therapeutic relationships” (Bemme & Kirmayer, 2020, p. 13). Trauma should be seen as a social phenomenon, viewed at communal and societal levels (Daiute et al., 2006).

Due to the fact that the experience of trauma unfolds within the complex ecology of sociocultural systems, it is nonlinear and non-dose dependant. Being exposed to a “dose” of potentially traumatic event(s) will not result in a directly proportional symptomatic response to these events. Rather, the experience is mediated through language, and through our connections to others. The way in which post-traumatic symptoms may manifest is similarly nonlinear: symptoms do not necessarily gradually weaken over time. Furthermore, as explored in chapter eight, the suffering is not in direct opposition to aspects of resilience and growth.

A sociocultural understanding of trauma takes into account notions of temporality. Social resources provide a time orientation, and, consequently, a self-continuity between past and future (Kadianaki & Zittoun, 2014) necessary for the construction of a coherent narrative, and, ultimately, the Self.

This begs an essential question: is “refugeehood” necessarily traumatic? By definition, refugees are people who have faced severe threats in their countries of origin, and many experience violence during their flight or in refugee camps. Disruption of social networks and separation from or loss of family members are common consequences of forced migration and are associated with an increased risk for subsequent mental health problems (Kirmayer et al., 2011). For many refugees who have arguably been exposed to a plethora of potentially traumatic events both before, during and after migration—what is potentially lost is the ability to draw on meaningful socio-cultural symbolic resources to make sense of these events as well as the ear of a listening Other to whom and with whom the process of sense-making of potentially traumatic experiences may be addressed.

Yet, I would argue that the experience of refugeehood, like any experience of migration, and indeed any general human experience, is complex. As much as the book has highlighted suffering, my hope is that aspects of growth and development in the face of this suffering have equally been highlighted. In short, the state of “refugeehood” is not necessarily traumatic in and of itself. I would instead return to the above definition of trauma, and argue that experiences of refugeehood may be considered traumatic when there is no possibility of these experiences being elaborated through semiotic means. Sadly, this is too often the case. Facing potentially traumatic events, as well as significant ruptures from a sociocultural context in which these events may be made sense of, a vast number of refugees are traumatized by their experiences of migration. We need to bear in mind that it is not only the period before and during migration, but also upon arrival in host communities: a period typically characterized by a social and political marginalization leading to isolation, withdrawal, distrust, non-recognition and rejection, as well as being torn from one’s communal and social fabric.

In this sense, a sociocultural understanding of “refugeehood” itself would consider it as a social phenomenon, beyond the “traumatized” isolated figures of individual asylum seekers. Rather, it considers “violent displacements as embedded in geo-political systems mediated by human language” (Daiute et al. 2020, p. 15). Refugeehood, in other words, is an embededness in refugee systems. The recent unfolding of the refugee “reception crisis” in Europe is inextricably linked to the development of society as a whole. Responses and reactions to the crisis are indicators of the maturity of society. Instead of focusing on individual refugees, a sociocultural approach would consider the dynamic interrelatedness of individuals and broader “refugee systems.”

Implications for Mental Health Clinicians

As summarized by Drožđek and colleagues (2020),

core aims of all psychotherapeutic interventions for survivors of war and violence are to help them to regain control over their lives, restore self-efficacy and a sense of agency, reattach with humanity, give meaning to traumatic experiences and suffering, and regain hope for the future. These therapy aims go beyond the goals of simply reducing symptoms of PTSD, depression, and other comorbid conditions, although reduction of symptoms and associated suffering are important. (p. 9).

How may mental health clinicians obtain these aims? What might a sociocultural approach teach us about experiences of potentially traumatic events among refugee populations? I now explore the implications of such a sociocultural understanding of “trauma” for mental health clinicians working with refugee populations.

The Role of Narrative Activity

Throughout this book, I have defend the view that we are narrative beings, constructing and reconstructing our Selves through stories, locating our biographies and life projects in discursive webs of shared meaning. One consequence of this sociocultural perspective is that understanding the human capacity to produce, think in, and transact with narrative must play a central role in clinical practice. Narrative capacities, skills, practices, and specific content can contribute to the causes, course, and outcomes of psychopathology as well as to processes of coping, resilience, healing, and recovery. Narrating our lives mediates our lives. For refugees, the activity of narrating is a critical part of their “making sense of what is going on in their environment, trying, and sometimes succeeding against great odds to re-create meaningful sustainable life for themselves, for their children, their communities, and natural environments” (Daiute & Gómez, 2014, p. 157).

We do not just speak through language but use language to express meaning in context. People use narrating to interact in the world, to figure out what is going on in their environments, how they fit, and sometimes, how to change things (Daiute et al., 2015). The bridging role of language, therefore, should be central to refine the way that clinicians think about how local illness terms, expressions, and explanations relate to the kinds of problems they diagnose and treat. For example, cultural representations of potentially traumatic events and their sequelae held within language may also serve to articulate modes of experience and adaptation that contribute to resilience and well-being in the face of adversity (Lewis-Fernández & Kirmayer, 2019).

Clinicians, through the mediating impact of language as a cultural tool, may play a key role in facilitating narrative activity: assisting the memories of potentially traumatic events to be elaborated upon, made sense of, and placed within a meaningful temporal framework. It is this narrative activity which allows individuals to reconfigure a sense of themselves and their experiences—both of the past, the present, and the future—in order not to remain stuck within the wordless nothing. Through a process of semiotic mediation, we find the words to confront the wordless nothing. It is not only PTSD which may be used as a cultural tool by mental health clinicians and their refugee clients or patients alike. A sociocultural approach has allowed us to examine the ways in which language itself acts as a cultural tool with which to mediate potentially traumatic experiences—for example, in the narrative activity of the psychotherapy session. For many, the therapeutic context itself may function as another cultural tool—the rituals inherent to the therapeutic process unfolding within the session, and developed within the context of a human relationship, serving to facilitate a process of healing and recovery. Here, I return to Daiute’s (2014) definition of a cultural tool as “symbolic process developed in human relations for interacting purposefully in the world” (p. 23). Narrative activity within the psychotherapeutic process exemplifies such purposeful interaction.

The Collective Cultural Frame

At the core of this book is the idea that the experiencing of potentially traumatic events has a social and cultural dimension: “the manner in which people understand their afflictions is undoubtedly connected to beliefs about the origins of such afflictions. Such beliefs are central in devising appropriate therapeutic strategies for the alleviation and elimination of the afflications” (Honwana, 2006, p. 229). This book has explored “culture” in all of its dynamic unfolding over time. “Culture” is not static. It changes with experiences of forced migration, and over time, so clinicians should bear in mind the ever-changing local cultural communities and current issues and concerns. They should also be aware of their own personal and professional cultural assumptions (Kirmayer et al., 2011).

Some key implications for mental health clinicians, arising from a sociocultural exploration of experiences of potentially traumatic events among refugees, is the significant influence of collective histories of colonialism, racism, violence, and exploitation which may influence the development of a working alliance built on trust. People from refugee communities come with their own collective histories, living conditions, and social, moral, and political concerns that form the backdrop of their personal experience of potentially traumatic events. For survivors of torture in particular, the clinical situation may remind them of these potentially traumatic events—the interview leading to a sense of being interrogated, as was the case for some research participants. It is essential that clinicians be aware of the sociocultural issues framing experiences of potentially traumatic events. Such experiences may not be framed by refugee patients or clients as an “illness” as such, but rather seen in terms of the events’ social, moral, and political meanings. It is this cultural framing which substantially determines processes of healing and recovery, responses to therapy and the risk of psychopathology developing. Ignoring these different cultural framings may lead to a patient or client feeling discriminated against, misunderstood, or simply not believed—interfering with trust and disclosure.

Temporality

A sociocultural approach allows us to.

grasp the dynamics of interactions between resilience, psychological damage, context and time. These interactions are nonlinear, and contingently result in development of psychopathological phenomena when reaching a threshold during a process of accumulating potentially traumatic experiences over a survivors’ lifetime (Drožđek et al., 2020, p. 1).

What is highlighted in the approach is the nonlinear nature of the unfolding of experience. A sociocultural approach allows us to view the dynamic and bi-directional relationship between the sociocultural context and the individual’s internal, subjective experience of potentially traumatic events. As noted in the above quote, Drožđek argues that “in order to understand the complexity of this relationship, one should be guided by a string of causation principles and grasp the logic of fluctuation of psychopathology over survivor’s life trajectory” (p. 2–3). His model (p. 5) highlights this ever-changing dynamic over time, notably the influence of risk and protective factors within the sociocultural environment having an impact on the trajectory of an individual’s mental health. It highlights the roles of potential risk factors as well as potential protective resources, across time and across different scales (for example, the level of the individual, the level of close friends and family, to the macro level of the socio-political environment). In other words, at each stage/age of the individual, there are various risk and protective factors at play at different levels:

figure a

In exploring the individual trajectories of refugees impacted by potentially traumatic events, the results of the work similarly highlight the changing impact of the sociocultural environment (including risk and protective factors) in dynamic interaction with individual mental health, as represented in the above model. This calls into question assumptions of a linear trajectory from the experiencing of potentially traumatic events, to the experiencing of post-traumatic symptoms, to healing and recovery:

Assumptions about trajectories of actions toward presumed progress also implicate temporality, as in the term ‘resilience in war’ implying that ‘war’ is a temporary interruption and people can/must recover from such interruptions. When people narrate specific times, they interact with historical time, thereby using time to create meaningful connections of contemporary plights and dreams with events over a broader span of time, place, and consequence. (Daiute & Gómez, 2014, p. 159).

Mental health clinicians need to pay attention to these aspects related to temporality. The implications are twofold: firstly, in terms of the nonlinear fluctuation in subjective experiences of potentially traumatic events as noted above, but secondly in understanding the importance of reconstructing a subjectively meaningful temporality within the therapeutic process. For many refugees participating in this research, a significant part of their process of healing and recovery involved the re-establishing of a meaningful “linearity.” In line with the above quote, they indeed “create[d] meaningful connections of contemporary plights and dreams with events over a broader span of time, place, and consequence.”

Part of mediating potentially traumatic events is, through processes of linguistic elaboration, allowing memories of potentially traumatic events to be placed within a meaningful temporal order; in other words, placed alongside other memories of the past so as not to haunt the present, or the (imagined) future. As Daiute and Gomez (2014) have demonstrated among two of their Colombian research participants, Don Paz and Feniks,

Don Paz’s orientation to the past and Feniks’s orientation to the future interact with the physical and symbolic temporalities limiting their lives and holding possible alternatives. While there’s no perfect past for Don Paz nor an open future for Feniks, using time to imagine options is an important step. (p. 172).

The authors note that “when people narrate specific times, they interact with historical time, thereby using time to create meaning in relation to contemporary plights and dreams” (p. 163). They show “how people use the cultural tool of imagined time to analyse their circumstances critically and eventually manage those circumstances” (p. 168). Drawing on the work of Ricoeur (1984), they point to how memories, including those of potentially traumatic events, are never set. Rather, the memory of any specific event can differ or appear different depending on the circumstances of recall and sharing. When refugees narrate their experiences of potentially traumatic events, there’s inevitably a “present of past things” (Ricoeur, 1984, p. 9). There is similarly a “present of present things” (Ricoeur, 1984, p. 9), the anchoring perspective of narrating time which expresses the narrative purpose and which is intricately related to the unfolding relationship between refugee and mental health clinician, as well as a “present of future things” (Ricoeur, 1984, p. 9). This projection into the future, they note, is imagined and fluid:

Considering the diverse meaning of explicit and implicit temporality in terms of the context raises implicit questions to guide investigations about how diverse narrators use time to make sense of situations, considering collective goals, and creating narratives of action (p. 167).

In the case studies explored in chapter seven, this imagination of possible futures was connected to hope. For many refugees, points of recovery and subsequent growth were inextricably linked to being able to imagine new possible futures. They were also connected to an individual’s ability to “question the inevitability of a certain future narrative” (Daiute & Gómez, 2014, p. 166). These possibilities of imagining and creating new futures formed part and parcel of their power to act—integral to processes of healing and recovery from the experience of potentially traumatic events. In the act of imagining the future, in other words through constructing narratives within hypothetical time, individuals “build on [their] own story to create a turning point expressing the awful realities of a suspended life, very possibly with no future” (Daiute & Gómez, 2014, p. 171).

Here, I again return to the point noted above: the experiences of potentially traumatic events are nonlinear. While the reconstruction of a meaningful temporality, through semiotic mediation, is integral to processes of healing and recovery from such events, clinicians need to be aware that this is a complex and dynamic process. In analysing Jules’ trajectory in chapter seven, article five presents a “loop model” of his possibility to imagine. Imagination in this article is conceptualised as a process which creates “loops” out of the present, here-and-now of experiences connected to the material reality of the current environment. The process is seen as being triggered by some disrupting event, which generates a disjunction from the person’s unfolding experience of the “real” world, and as unfolding as a loop, which eventually comes back to the current, actual experience (Zittoun & Cerchia, 2013). In concluding this book, and reflecting upon the implications for mental health clinicians, I would like to revisit this conceptualisation. The loop model presented a linear concept of Jules’ trajectory. It may not go far enough in capturing nonlinearity. It risks “retain[ing] a monocultural vision of linear time, in contrast to less formal unofficial perspectives occurring in everyday life of communities, and emerging movements” (Daiute & Gómez, 2014, p. 172). The reality is far messier than the model could suggest. Experiencing potentially traumatic events may disrupt a coherent sense of linearity. It may break any subjectively meaningful sense of temporality. Clinicians need to be prepared to meet this “temporal chaos.”

One way in which clinicians may pay attention to, and work with, such aspects related to temporality is to track nonlinearity within the narrative activity of their refugee clients or patients. Pay attention to the words of the individual in the consulting room:

The varied use of tense markers […] and the use of subjunctive in particular provide rich analyses of narrative time. Diverse verbal time markings interact with expected truth and imagination. All narrative time is symbolic, but past and present time markings imply actual experience, while the range of future, conditional, and possible time markings are more clearly imagined times. Narrated past events appear fixed and true because they are reported as having happened. Future, conditional, and hypothetical events have not occurred, so they are imagined, although often overlooked as such. Present tenses appear fixed in another way, often expressing the position of the narrator. The result of this interplay of time settings is the highlighting of meaning in the narrator’s imagined time (Daiute & Gómez, 2014, p. 170).

Considering aspects of temporality in narrative activity, and the relationship to the experiencing of potentially traumatic events, is particularly relevant for those refugees still waiting on a decision from the asylum tribunal. Many of the individuals who participated in the research waited months, if not years, for a response from the asylum tribunal. They remained held captive by the potentially traumatic events they had experienced in the past. They reported feeling stuck in time. If the experience of potentially traumatic events is understood as a radical disconnect from a meaningful past, present, and future; lengthy asylum delays function as an external mirror to this internal experience. I refer to the moving account of refugeehood provided by Clementine Wamariya (2018) upon arrival in her host country,

Time, once again, refused to move in an orderly fashion; the pages of the book lay scattered, unbound. This still happens to me. My life does not feel logical, sequential, or inevitable. There’s no sense of action, reaction; no consequence, repercussion; no plot (p. 33)

Using language as a cultural tool, the role of the mental health clinician is therefore to assist individuals in constructing and reconstructing meaningful plots to their lives. A sociocultural exploration has allowed us to explore how this narrative activity serves to re-establish a meaningful linearity between the experience of potentially traumatic experiences of the past, the present, and hopes for the future.

The Permeable Self

In exploring the impact of the cultural framework on experiences of potentially traumatic events among refugee clients or patients, one key element for consideration is the various ways in which the cultural framework determines the border or boundary of “self” and “Other.” As Tang (2007) notes: “cultures differ regarding their dominant ideas about the ontology of self as well as relationship between self and others, between self and the universe, and between life and death” (p. 129). In chapter eight, the case of Mr B is given as an example of a research participant who doesn’t experience himself so much as an individual but more as having a “family self” based on relational models. The analysis highlights how he frames his experiences of potentially traumatic events within the intersubjective realm of his family network—similar to the South Sudanese research participants presented by Tankink and Richers (2007). Here, it is worth considering that refugee patients or clients from cultural contexts which are more collectivist in orientation may have different degrees of permeability of ego boundaries—in other words, the boundaries between “self” and “Other” may be conceptualised as being more extensive, flexible, or permeable. In clinical practice, this perspective can guide us to a deeper understanding of resilience, healing, and recovery based not only on internal psychology or biological processes but also equally on social-interactional processes. The implications would be to integrate the knowledge of the individual’s life-world, their family, and community as the site of both challenges and resources with which to cope, adapt, heal, and recover.

Universality of Experience

Exploring mental health clinicians’ work with diverse refugee populations raises questions surrounding the universality of experiences of potentially traumatic events. What is culturally determined and what is universal? It must further be noted that clinicians working with refugee communities face very concrete linguistic barriers. Not only may they be working with translators among populations who don’t speak their language—they may be working with individuals for whom there simply are no words for “trauma” or “stress” in their language at all. What are the implications for mediating the experiences of potentially traumatic events in such an instance?

In exploring the exchange between mental health clinicians and refugee victims of torture—as in the case of Brigitte seen in chapter five—what strikes me is the way in which symptoms align with those appearing in the definition of PTSD found in the D.S.M. V (APA, 2013). However, despite the universal symptoms (in this particular example, experiencing nightmares), the way in which she understands these symptoms are culturally informed. Language plays a key role in mediating this sense making process—in connecting Brigitte’s cultural environment (in this case, African traditional spirituality—a worldview wherein ancestors who have passed away may still cast spells on the living) to the way in which she makes sense of and experiences these symptoms. It also fundamentally frames her process of recovery and post-traumatic growth. Believing the nightmares to indicate her ancestor’s continual displeasure with her actions, she continues to feel guilty—a feeling that impedes her own sense of Self, and her plans for the future.

The results of this research may lead us to consider that, while many of the experiences of potentially traumatic events remain universal, including symptoms indicated in the definition of PTSD, the way in which they are framed is culturally determined. It is this cultural framing which mental health clinicians need to pay attention to, as they accompany their refugee clients or patients in their narrative activity. As noted by Kirmayer (2019),

Beyond engaging with local contexts, attention to culture can advance social psychiatry by revealing both commonalities and variations in the experience and expression of mental disorders. In addition to improving the validity of clinical assessment and the appropriateness of interventions, cross-cultural comparative methods can identify new strategies for adaptation and recovery rooted in local traditions but potentially translatable and transportable to new contexts. (p. 31).

Here, Kirmayer refers to the need to “improve the validity” of clinical assessment—not to stop the activity altogether. Despite cultural variations in experiences of potentially traumatic events, he notes that we need to pay attention to “both commonalities and variations in the experience and expression of mental disorders” (my emphasis). Elsewhere, he and colleagues have noted that “understanding suffering in context may also challenge common assumptions about what we assume to be culturally different, but emerges as similar across contexts” (Bemme & Kirmayer, 2020, p. 12) (my emphasis). We are all human beings, and much of our experience as human beings is universal. It is therefore worth reflecting on many of the benefits of a PTSD diagnosis for refugee patients or clients. For many, there may be a sense of relief in having one’s experience understood. In other words, PTSD as a cultural tool may provide individuals with a framework in which their experiences may be made sense of. I remember discussing symptoms of PTSD with a South Sudanese woman who exclaimed with incredulity “but how can you, as a white woman, know that this is what is happening to me?!” It’s possible that at that moment that she had felt seen and understood, that she had been provided with words to explain the “wordless nothing.” Such a framing of her experiences meant that she was neither alone, nor crazy. What she had been experiencing was a “normal” reaction to potentially traumatic events.

The construct of PTSD may have some universal applicability, but the focus should be widened to recognize the multiple biosocial, cultural, and political processes that are essential aspects of experiencing potentially traumatic events—as well as resilience and recovery. The experience of these events and related suffering is both personally and socially value-laden:

The dilemma with the current emphasis on PTSD therefore, is that although the diagnosis may capture a universal pattern of fear conditioning, anxiety, and avoidance behavior, this pattern is only a limited aspect of the range of clinical problems that can be directly related to trauma exposure. Other dimensions of trauma experience have social and cultural meanings and dynamics requiring comparable clinical attention. (Kirmayer et al., 2011, p. 5).

We need to see “beyond the PTSD paradigm” (Drožđek et al., 2020, p. 2), but not disregard it altogether. A key message to be borne in mind is adequately summarized by experts in the Lancet commission for global mental health:

Mental health problems exist along a continuum from mild, time-limited distress to chronic, progressive, and severely disabling conditions. The binary approach to diagnosing mental disorders, although useful for clinical practice, does not accurately reflect the diversity and complexity of mental health needs of individuals or populations. (Patel et al., 2018, p. 1).

As disease models broaden and care practices become collaboratively stepped, shifted and shared among self, family and friends, community leaders, and medical providers—new conceptual and relational issues arise (Patel et al., 2018). A sociocultural framework allows us to understand the importance not only of a specific Other (for example, a psychotherapist) in this process of recovery and post-traumatic growth, but indeed the role of the entire sociocultural context as influencing the development of the individual. Narrative use integrates the individual with society (Daiute et al., 2015). In the following section, I therefore explore some implications for mental health and psychosocial (MHPSS) interventions within humanitarian contexts more generally.

Implications for Mental Health and Psychosocial (MHPSS) Interventions in Humanitarian Settings

Increasing awareness of the substantially elevated mental health and psychosocial needs of refugee populations has led to focused interventions for mental health and psychosocial support (MHPSS) for these groups. However, despite growing attention to MHPSS for emergency-displaced populations, there are still major gaps in programming and support. To foster social integration and improve post-traumatic recovery, it is crucial to better understand and address the specific needs of this highly vulnerable population (Schick et al., 2016). In light of the high prevalence of PTSD symptomatology and given the low uptake of mental care among resettled refugees noted in the literature (Schouler-Ocak et al., 2016; Slewa-Younan et al., 2017), interventions need to consider the myriad of complex and inter-related factors influencing refugee experiences of potentially traumatic events. Such a framework would “connect the risk and protective factors in the material and social conditions of refugees’ post-migration lives to broader social, economic, and political factors” (Hynie, 2018, p. 297). Furthermore, to ensure that psychosocial and mental health needs are met, MHPSS should be integrated as part of a continuum of care that is multi-layered. MHPSS is not the domain of one sector. It needs to be realised through coordinated and complementary actions of a multitude of actors within legal and medical activity systems (Faregh et al., 2019).

I base the following recommendations on a review of the literature, current trends in MHPSS interventions within humanitarian settings, and on the implications of the empirical results of this research:

A Community-Based Response

Trauma is a social as well as an individual phenomenon (Daiute, 2016). The sociocultural context in which we live and the quality of relationships we have are central to our mental wellbeing and contribute to risks of developing mental health problems. This is also true in terms of the social context within humanitarian crises. Furthermore, the contexts, roles, values, and demands produced by cultural communities may be a source of disadvantage, structural violence, and suffering as well as providing opportunities for adaptation, healing, and recovery (Kirmayer, 2018). Sociocultural dynamics are therefore integral to trauma trajectories as both a potential source of trauma as well as a source of healing and recovery. Here, I once more refer to results of the research which highlight the important sociocultural resources which participants drew upon to make sense of potentially traumatic events, to recover from these experiences, and, ultimately, to thrive. In the case of Jules explored in chapter seven, for example, it was the fact of remembering his father’s wisdom pertaining to times of hardship, making friends at church, falling in love, and creating plans for the future with family members in France, that facilitated healing.

The focus on the individual in the modern mental health field tends to under-emphasise the importance of social and structural drivers of wellbeing and illness. This calls for strengths and resilience-based approaches to interventions and supports that not only respond to problems, deficits, and prevalence of mental health conditions, but also build on existing strengths and resources within affected communities. We especially need to recognise the role that non-specialists and community members can play. In summary, we need an approach that recognises the sociocultural context of mental health—a perspective that goes beyond a purely individualistic view of treatment and recovery. Rather, as noted by Daiute (2016), focusing on social relations in humanitarian contexts involves building in individual capacities, interactions in communities, and the human right to continue developing these capacities:

By extending beyond the individual to the individual-in-collective, we [can address] the tensions not only in terms of individual […] voices, but also in terms of interacting shared narratives, diverse goals and opportunities within and across each context (p. 132).

This social justice approach, Daiute notes, emphasizes what needs to be done, whereas a trauma approach focuses what has been done. At the levels of public health and policy, a sociocultural perspective on trauma necessitates that we consider the powerful effects of structural violence, migration policies, and social inequality as determinants of health. This involves a recognition that social systems have their own dynamics which can amplify experiences of potentially traumatic events or conversely provide sources of collective resilience (Kirmayer, 2019). Any such community-based response should further heed the mediating influence on language in individual and communal experiences of potentially traumatic events and subsequent recovery. This includes, for example, focussing on and facilitating collective narrative practices organizing group activities, a dynamic and potentially transforming process allowing members to create solidarity, to reflect critically, and to imagine life in their own way:

just as narrative has been created by humans to interact, to solve problems, and to change culture over many civilizations, people across circumstances, including those in the least privileged and powerless situations, use narrating to interpret, to debate, to act, and sometimes to transform extremely challenging and tragic life circumstances (Daiute & Gómez, 2014, p. 157).

A Culturally Relevant Response

We need to situate experiences of potentially traumatic events in sociocultural context. Lack of attention to cultural context on the part of providers and decision-makers can lead to mistrust of mental health information and services and reduce motivation to engage with mental healthcare or adhere to treatment (Faregh et al., 2019). Exploring the influence of culture on experiences of potentially traumatic events among refugee populations—both related to their original and current sociocultural context—should be a fundamental consideration in the clinical assessment of this population, as well as the design and delivery of mental health interventions (Hassan et al., 2015; Kirmayer et al., 2018).

Such attention to culture and context in MHPSS interventions could include, for example, attempts to refine diagnostic criteria (finding the right level of generality and specification to work across cultures), the identification of new diagnostic variants, and the inclusion of more contextual assessments (Kirmayer, 2018). Much headway has been made in this regard over recent years. In the most recent version of the D.S.M. (APA, 2013) the term “cultural concepts of distress” has replaced the outdated terminology of culture-bound syndromes—a change intended to signal a broader, more inclusive understanding of culturally specific distress as something that changes over time and does not represent place-specific “exotica” (Kaiser & Jo Weaver, 2019). It should be noted that integrating culture in mental health services and systems is not just an issue for groups that face specific inequities related to their identity and social position but is central to person-centred healthcare for all. Indeed, the sociocultural perspective adopted throughout this book rejects any static or reified notion of “the cultural other … but with recognition of the developmental, social and political facts of our cultural being” (Kirmayer & Jarvis, 2019, p. 18).

A Longitudinal, Contextually Situated Response

Exposure to ongoing stress in an instable environment, together with individual vulnerabilities, coping styles, and limited availability of protective resources, seems responsible for the maintenance of post-traumatic symptoms over the life trajectory, combined with the decline of resilience by increased intensity or continued exposure to potentially traumatic events (Drožđek et al., 2020). Mental health and psychosocial support (MHPSS) needs do not remain static over time. They shift and change in response to both the external environment and an individual’s inner resources. This requires a wide range of supports to be offered in the response, based on individual or community needs, and at different stages of a crisis. Long-term, flexible approaches are needed that take into consideration that the mental health needs of refugees may change over time and that trauma trajectories are inextricably intertwined with the changing sociocultural, political, legal, and economic environment. Briefly put, we need not only to focus on “trauma” from an individual, clinical perspective. We need to understand the ways in which it is inherently connected to the macro level of immigration policies affecting migration trajectories over time: delayed asylum trials, unemployment, constantly changing accommodation arrangements, prolonged detention… these factors do not simply “add to” existing experiences of potentially traumatic events, they multiply and compound it through the constantly reinforcing effect of feedback loops—as shown in the case of Dilraj in chapter two (Womersley & Kloetzer, 2018b). What is needed is a “processual reconceptualization of wellbeing and distress” (Kidron et al., 2019, p. 28).

A Depathologizing Response

Diagnosing someone with PTSD does something in the world. A sociocultural approach to understanding experiences of potentially traumatic events among refugees, as adopted in this book, includes considering the concrete legal, political, and social implications of the use of cultural tools, such as medical diagnoses, on the individual. As succinctly summarized by Kirmayer (2018):

epistemic practices, including medical diagnosis and treatment, serve to bring particular configurations of distress into being by shaping individuals’ experience and expressions of distress in ways that then receive confirmation through medical attention and intervention. This social response then stabilizes the disease or disorder as a discrete entity and can increase its prevalence (p. 3).

He notes that calling something a “mental disorder” depends on a series of distinctions: a normative distinction between illness and affliction versus health and wellness; an ontological distinction between afflictions that are bodily, spiritual, or sociomoral and those that.

are specifically mental; and a pragmatic distinction that ascribes the problem to the domain of psychiatry as a discipline, profession, and social institution. A detailed understanding of the cultural construction and consequences of mental disorders, he continues, therefore requires consideration of the institutional apparatus and circuits of power and knowledge that co-constitute forms of suffering and their treatment. He and colleagues have therefore called for “culture-specific etiology, symptomatology, treatment approaches, and outcomes which diverge from biomedical taxonomies and illness constructs” (Kidron et al., 2019, p. 1).

This is not to say that the diagnosis of PTSD should be gotten rid of entirely. To the contrary, the diagnosis does have concrete ramifications for the daily life of the individual which may be to their benefit: not only for their personal psychological rehabilitation in terms of making sense of potentially traumatic events, symptoms and post-traumatic recovery, but also in terms of the political, legal, and social impact of the diagnosis. For many participants, the diagnosis was a validation of their suffering. It offered an important means of social recognition. Research by Kidron and colleagues (2019) among Holocaust descendants, for example, reveals how the “emotive scar” left by exposure to potentially traumatic events was seen by respondents as a culturally valorised form of commemorative remembering and worn as an empowering badge of honour. It is, however, necessary to stress the importance of considering PTSD as a particular cultural tool, within a particular sociocultural environment, understood and used differently by various actors. A sociocultural perspective insists upon the ethical responsibility to consider this concrete impact. This includes paying attention to how and why we diagnose PTSD.

These recommendations are in line with the recent Lancet commission on global mental health and sustainable development (Patel et al., 2018). The commission stresses the fact that psychiatric diagnoses can lead to unhelpful labelling that often oversimplifies and undervalues the complexities of personal circumstances. Moreover, labels can be stigmatizing, and the impact of stigma is often even more burdensome than the symptoms that have led to the diagnosis themselves. Importantly, the commission highlights the need for MHPSS interventions to be based on socioculturally informed narratives of trauma. As an alternative to the categorical diagnostic model, the Lancet commission proposed a staging model, which recognizes opportunities for intervention at all stages of the pathway from well-being to different stages of disorder. In other words, it recommends a rejection of the mental illness-health dichotomy in favour of conceptualising mental health as existing along a continuum and dynamically changing over time. In other words, it rejects the “deficit” narrative inherent to a pathologising framing of experiences of potentially traumatic events, in favour of a concept considering both “wounds and wellness.”

A Resiliency-Based, Forward-Looking Response

Given the potentially traumatic impact of forced displacement, as made evident in the research results, the possibility of healing and growth may seem small in comparison. However, the results also attest to the fact that human beings may be quite capable of restoring their identities and (re)finding their place in the world when given the chance to do so. The results highlight the multiple ways in which refugees may show resilience in the face of exposure to potentially traumatic events. They point to ways that resilience and vulnerability may interact, qualifying one another in the process of meaning making. In other words, they reveal the ways that refugee experiences of potentially traumatic events are embedded in complex networks of personal and collective meaning that may give rise to both resilience and vulnerability. Here, the notion of “resilience” is not a reified psychological state, that can be captured by yet another global measure of health and illness but rather “a hermeneutic process of meaning making that shapes the way that selves and communities experience and respond to distress in order to restore or enhance culturally valorized forms of wellbeing” (Kidron et al., 2019, p. 30). Resilience is thus understand from a sociocultural perspective as the capacity of a system to adapt successfully to the challenges that threaten system function, survival, or development. From this perspective, resilience is dynamic. It changes as the capacity for adaptation is distributed across systems. It further depends on the resilience of other systems (Masten, 2014a, b).

This concurrent experience of resilience and vulnerability challenges some key assumptions of “traumatised refugee” narrative. Contrary to the inhuman Narrative of a psychiatric diagnosis, human narratives are “dynamic, subjective, and imaginative of survival, justice, and thriving.” (Daiute & Gómez, 2014, p. 157). Refugees are active agents engaging in the new world in which they find themselves. They are not only patients, victims, seekers of asylum. They are dreamers, planners and doers, family members and friends, with hope for the future. They “interpret their circumstances, interlocutors, and options for making lives in this shifting world order” (Daiute et al., 2020, p. 2). This response involves helping refugees make meaning of their experience, focusing on their strengths, as well as fostering an environment where they are able to meet their basic needs. In a very powerful TED Talk, Luma Mufleh (2017), the founder of a refugee youth program and herself an asylum seeker from the Middle East stated, “Don’t feel sorry for them, believe in them.” So too must we consider experiences of forced migration from a trauma-informed lens, recognizing the unimaginable difficulties refugees have suffered as well as their strengths, resiliency, and capacity for hope (Ringler-Jayanthan et. al., 2020, p. 82). It is as important to consider resilience and wellbeing within local worlds as it is to consider distress (Kaiser & Jo Weaver, 2019), to recognize the strong sense of connection to places left behind while at the same time recognizing the possibilities of a constructive (re)building of connections to people and place (Sampson & Gifford, 2010).

Returning for a brief moment to the theoretical framework of sociocultural psychology informing this work, Dafermos (2015) notes that Vygotsky himself developed a theory that opens up new perspectives for the rethinking and overcoming of a crisis. In contrast to dominant psychological theories that describe the actual developmental level and presents forms of human being, the approach illuminates prospective human development. In other words, rather than seeing someone as “traumatised” (static, present), we need to respect and value their potential for growth and development (dynamic, future orientated). Challenging the concept of adaptation, Dafermos notes how Vygotsky proposed the idea of creative, future oriented activity, that “…makes the human being a creature oriented toward the future, creating the future and thus altering his own present” (Dafermos, 2015, p. 21). Elsewhere, Dafermos (2018) similarly reflects on the link between “crisis” and “creativity” within a sociocultural perspective. Here, he demonstrates how Vygotsky’s theory was developed as an attempt at the conceptualization of crucial issues associated with human development that emerged within the process of societal change: “the future focus, the orientation to what might happen rather than what has already happened constitutes a significant dimension of the human creative agency” (p. 233). Striving to overcome crises, Dafarmos argues, people can develop an active, creative, socially oriented activity. While drawing on the idea that individuals’ narrative activity always occurs in social relations, a sociocultural perspective allows us to shift from the assumption that powerful actors impose values on less powerful actors (in this case, refugee victims of torture) to an acknowledgment that people in vulnerable positions can act strategically (Daiute et al., 2020).

A resiliency-based intervention from a sociocultural perspective, therefore, should aim to:

  • Foster prosocial bonds at every level

  • Integrate systems of care

  • Provide opportunities for development

  • Support culturally based ceremonies fostering resilience

  • Support community engagement and collective action.

As we “move away from a categorical biomedical model toward dimensional and transdiagnostic approaches” (Bemme & Kirmayer, 2020, p. 3), we should similarly aim to develop more viable, clinically relevant tools for refugee populations, as well as contribute to a more critical, decentered literature on mental health and illness (Kaiser & Jo Weaver, 2019). This includes a focus on the broader structures or forces that are being contested, whether implicitly or explicitly, through the often-conflicting ways in which “trauma” among refugees is understood. In the ways in which we understand and (re)present narratives of refugee trauma, we must be careful to avoid presenting distress as reflecting solely individual psychopathology or equitably distributed distress. This is essential to avoid victim-blaming through a myopic exploration of only immediate causes of distress (Kaiser & Jo Weaver, 2019). Nowhere is this more relevant than in the context of the current humanitarian crisis of forced displacement.

We need to beware of “priorities and practices [which] amount to a neo-colonial imposition of Western knowledge that threatens traditional and indigenous forms of care and healing” (Bemme & Kirmayer, 2020) p. 4). Furthermore, as argued by Daiute (2017), “defining the problem in individual bodies of those labelled ‘refugees’ averts the analytic gaze from the broader problem, while a focus on ‘refuge’ shifts our gaze to the politics of displacement.” (p. 12). In other words:

Issues such as poverty, war, oppression, racism, violence, poor education, unemployment, lack of housing, or other forms of structural violence, critics have argued, may be at risk of being further obscured when distress is reconfigured into a psychiatric condition and only addressed downstream (Bemme & Kirmayer, 2020, p. 11).

Attention to the social and the structural are key means of avoiding these pitfalls. This necessitates a “move away from models dominated by implicit colonial hierarchies, racialized identities, and reified notions of culture as homeostatic or steady-state systems, toward “postcolonial” models of cultures as open, dynamic, heterogeneous, and hybrid social systems that offer individuals resources for self-fashioning and positioning.” (Kirmayer, 2018, p. 9). Furthermore, future work should continue to clarify the mechanisms by which societal tensions and dilemmas are transmuted into individual experiences of potentially traumatic experiences as well as resilience, including the extent to which individuals’ or families’ engagement with narratives of trauma and resilience helps them manage their social predicaments (Lewis-Fernández & Kirmayer, 2019).

My final hope is that this book has gone some small way in providing.

a rightful encouragement for clinicians and practitioners to consider the ways in which the implicit and explicit models from which we operate impact our understanding of refugees and limit the ways their stories are told, but also [a] springboard through which we learn to truly hear the stories of refugees as those of hope and resilience. That is to say, the way that we hear stories, the level at which we allow ourselves to be truly moved by them and the way that we choose to respond to them moreover, and the things on which we choose to focus are ultimately directly correlated with healing and restoration in those refugees whom we serve. (Neace 2020, p. 16).