Trauma and Migration

Abstract

Over the past two decades, there has been an increasing interest in the question of trauma among refugee populations. This body of research has largely focused on the immediate psychological aftermaths of armed conflicts in light of the well-described associations between these psychiatric disorders, displacement, and generalized forms of violence (Morina et al., Morina et al., .Frontiers in Psychiatry 9:433, 2018). In general, the literature attests to the greater mental health difficulties among refugees compared to general populations within host communities.

Over the past two decades, there has been an increasing interest in the question of trauma among refugee populations. This body of research has largely focused on the immediate psychological aftermaths of armed conflicts in light of the well-described associations between these psychiatric disorders, displacement, and generalized forms of violence (Morina et al., 2018). In general, the literature attests to the greater mental health difficulties among refugees compared to general populations within host communities. High levels of post-traumatic stress, anxiety and depression have been documented, as well as other mental health issues such as psychosomatic disorders, grief related disorders and crises of existential meaning (Copping et al., 2010; de Arellano & Danielson, 2008; Kirmayer et al., 2010; Lambert & Alhassoon, 2015; Morina et al., 2018; Schweitzer et al., 2006; Steel et al., 2009; Sturm et al., 2010; Van Ommeren et al., 2001; Weine et al., 2001). Significant rates of medically unexplained pain and somatoform disorder have also been highlighted (Drožđek et al., 2003; Van Ommeren et al., 2001).

This high prevalence of mental health problems is not surprising. Refugees are typically exposed to a multitude of traumas—not only in their countries of origin but all along their migration journey (Crepet et al., 2017). As summarized by Neace et al. (2020)

refugees are also people who have survived the severe trauma not only of whatever caused them to flee their homelands in their first place – things like war, famine, genocide, natural disaster—but of all of the trauma associated with fleeing. Their contexts tend to be of the need-thwarting type, and most refugees do not leave their home by choice, causing a loss of autonomy (p. 13).

Yet, increasingly, studies focusing on pre-migration traumas exclusively have been criticized for a skewed focus on isolated traumatic events experienced pre-migration. The argument is that this focus neglects the repeated and prolonged stressors to which refugee communities are typically exposed. In a recent key critical review of the literature, Hynie (2018) concludes that.

historically, the focus of mental health research and interventions with these populations has been on the impact of pre-migration trauma. Pre-migration trauma does predict mental disorders and PTSD, but the post-migration context can be an equally powerful determinant of mental health. Moreover, post-migration factors may moderate the ability of refugees to recover from pre-migration trauma. (p. 297).

Research over the past decade is indeed starting to shift focus towards the impact of the post-migration environment on the mental health of refugees (Korup Kjærgaard & Koitzsch Jensen, 2018; Li et al., 2016). Unsurprisingly, this research has highlighted the importance of post-migration factors in predicting the maintenance of PTSD symptoms in resettled refugees—including unemployment, family separation, constant mobility and ongoing conflict in the country of origin (Lie, 2002; Schick et al., 2016). The respective impact of these potentially traumatic stress factors continues to be the subject of increased debate. Some scholars argue that exposure to extreme stressors such as war trauma or torture is the strongest predictor of PTSD, whilst others have argued that it is the impact of post-migration stressors upon resettlement in the host country (Song et al., 2015).

In this chapter, I present an overview of the literature examining the factors which influence trauma among refugee populations both pre-, peri- and post-migration. The trauma experienced by refugees during these three stages of migration has been referred to in the literature as the “triple trauma paradigm” (TTP), where “through each of these stages the refugee or asylum seeker experiences and re-experiences the traumatic events, events that vary during each stage and depend on the particular adverse circumstances and situations they confront” (Ringler-Jayanthan et al., 2020, p. 82). As useful as it is to highlight the factors characterising each phase of the migration journey, what we need to bear in mind (as we embark on this “mapping”) is the interrelation of all of these factors. There is evidently a dynamic, complex and ongoing exchange between all of them—a point to which I return later on in the chapter.

Pre-migration

Given the very nature of the refugee experience, many refugees by definition have been exposed to a variety of traumatic experiences prior to leaving their country of origin—including trauma related to war and conflict, persecution, violence and torture experienced by themselves as well as loved ones. Among a sample of 420 refugees living in Sweden, Steel and colleagues (2016) found that 89% reported having experienced at least one traumatic experience prior to migration. Common sense would dictate that some of the most significant pre-migration factors related to PTSD would be that of exposure to wartime atrocities inherent to contexts of conflict—a hypothesis which has unsurprisingly been well documented in the literature (Bogic et al., 2012; Heeren et al., 2014; Morina et al., 2018). Several studies have indicated a robust dose–response relationship of trauma to the development of PTSD (Kartal & Kiropoulos, 2016; Mollica et al., 1998; Momartin et al., 2003; Silove, 1999; Silove et al., 1998; Steel et al., 2009).

Torture

Torture represents an extraordinary exception in the psychopathology field. Past torture is well documented to be a particularly triggering factor for PTSD It is consistently shown in the literature to be significantly and consistently associated with emotional distress, even years after the event (Carlsson et al., 2006; Hodges-Wu & Zajicek-Farber, 2017; Kira, 2010; Le et al., 2018; Liddell et al., 2017). This is particularly true in the case of prolonged exposure to multiple types of torture (Song et al., 2015, 2017). Research indicates that it is the perceived uncontrollable nature of, rather than the exposure to, torture, which most accurately predicts PTSD (Le et al., 2018; Liddell et al., 2017). The variety of complex psychological responses to torture, linked to higher prevalence of PTSD, include alterations in emotion regulation capacity (notably anger), impaired interpersonal processing, reduced perceptions of control, and identity loss (Liddell et al., 2017). The particularity of torture as pathogenic is linked to the fact that the act itself is taught, organized, elaborated, and perpetrated by humans against other humans (Sironi, 1999; Viñar, 2005a). It destroys the fabric of the social network of which we humans form an integral part. It disrupts our connection to all that make us human. Moreover, it is another human being who has deliberately constructed this unimaginable madness (Goguikian Ratcliff & Strasser, 2009; Viñar, 2005a).

Kirmayer and colleagues (2018) highlight the fact that it is the moral emotions (shame, guilt and humiliation) that are intently used to inflict the most damage in torture. Such moral emotions inevitably reflect the cultural systems of meaning:

All forms of torture follow an affective logic rooted both in human biology and in local social and cultural meanings of experience. Understanding the impact of specific forms of torture on individuals requires knowledge of their learning histories, and of the personal and cultural meanings of specific kinds of violence. Exploring cultural meanings requires attention to over-arching discourse, embodied practices, and everyday engagements with an ecosocial environment (p. 84)

To reflect on the consequences of torture from an ecological, social and cultural perspective, they present a model of adaptive systems affected by torture (p. 87): Table 2.1

Table. 2.1 Adaptive systems affected by torture

As indicated by the model, the psychopathologic disorder of the survivor cannot be reduced to the intrapsychic plane. It is not an individual act, but a social one. It does not only have individual consequences, but social, legal, and political ones for those who survive. It damages different spheres of an individual including body, personality, hope, aspirations for life, identity, integrity, belief systems, the sense of being grounded and attached to a family and society, autonomy, community relationships, and a sense of safety. It recreates a social order colored by suspicion, shame, and secrecy (Barudy, 1989). Family disruptions, collective fear and community dysfunction and decomposition have all been noted in the literature as consequences of trauma (Barudy, 1989; Hodges-Wu & Zajicek-Farber, 2017). As noted by Liddell and colleagues (2017), General Comment 3 of the United Nations Committee Against Torture published on Dec 13, 2012 (which explains the signatory States’ responsibilities under Article 14 of the UN Convention Against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment) is significant in that it explicitly recognises that the effects of torture extend beyond individuals to encompass their immediate families and dependents. These far-reaching effects may interact and manifest in complex and diverse ways, mediated by culture, gender and other aspects of the context of the torture survivor, the context of torture and the context of the recovery environment (Esala et al., 2018; Patel et al., 2014).

Migration

It is not only what is lost in leaving one’s home but similarly the migration experience itself which necessarily disrupts family and cultural systems and separations from the family and ethnic community, including stays in unsafe refugee camps during the migration process (Lambert & Alhassoon, 2015). Arriving in Europe, and often not necessarily to the country of their choice, some refugees arrive and are fighting to stay—yet some soon discover that things are not quite as expected and realise they must either go back or proceed to another destination (Gkionakis, 2016). Nathan (1986 as cited in Sturm et al., 2010) argues that the experience of migration is necessarily traumatic—as the “cultural envelope” can no longer hold traumatic, non-elaborated or psychically ‘indigestible’ experiences. In a multi-agency guidance note released in 2015 in collaboration with the UNHCR (MHPSS, 2015), the following factors related to the mental health of refugees and migrants during migration were observed and noted by a conglomerate of humanitarian aid agencies:

Refugees and migrants who come to Europe often faced war, persecution and extreme hardships in their countries of origin. Many experienced displacement and hardship in transit countries and embarked on dangerous travels. Lack of information, uncertainty about immigration status, potential hostility, changing policies, undignified and protracted detention all add additional stress. Forced migration erodes pre-migration protective supports – like those provided by extended family – and may challenge cultural, religious and gender identities. Forced migration requires multiple adaptations in short periods of time. People - especially but not only - children, become more vulnerable to abuse and neglect. Pre-existing social and mental health problems can be exacerbated. Importantly, the way people are received and how protection and assistance is provided may induce or aggravate problems, for example by undermining human dignity, discouraging mutual support and creating dependency. (p. 3).

Among a cohort of 200 asylum seekers attending a centre run by Médecins Sans Frontières (2016) in Italy, 86.9% said that they experiences difficulties in post-migration life—difficulties which were significantly associated with a diagnosis of PTSD The most common difficulties in life during the asylum seeking period were found to be “the feeling of uncertainty and fear for the future” (18.8%), “concern for the family back home” (13.8%), “conflicts within the authorities” (11%), “fear of the asylum request being rejected” (8.8%), “the feeling of being neglected” (7.2%), “the inability to integrate and feel integrated"(7.7%), “prolonged waiting times for the [asylum] Commission's outcomes” (5.5%), “lack of daily activities” (3.9%), “a sense of loneliness and boredom” (2.2%) and, to a lesser extent, other difficulties such a widespread sense of injustice and feeling unable to control events.

This is a period which Métraux (1999a) has described as suspended or “mute” time, which he defines as “being absent from all temporality, the social time of [refugees] being also a waiting period, a suspended time, a time dissolved in the heart of an indeterminable parenthesis¹” (p. 52), a temporary immobility which only either a forced expulsion, or a negative or positive response to the request for asylum would be able to end.

Requesting Asylum

The majority of research regarding forced migration and mental health has focused on refugees, with a more limited number of studies looking at asylum seekers. While there is a crucial difference in the legal status of refugees and asylum seekers, only few scholars have made a distinction between the two in examining risk factors for mental health problems (Georgiadou et al., 2018; Nakash et al., 2017). In general, the little research that exists does indeed attest to the impact of legal status on mental health, in particular prevalence rates of PTSD (Georgiadou et al., 2018). Among such scholars exploring this is Betty Goguikian Ratcliff (2016; Womersley et al., 2017). She identifies the period before and after being granted asylum as being two distinct periods in the psychological lives of migrants, noting that both stages involve substantial psychological stress, but for different reasons. She identifies the following stressors related to the period in which asylum is sought:

• Delays in the processing of asylum application

• Fear of repatriation

• Exclusion from the labor market

• Forced dependence on social welfare

• Loneliness, boredom

• Discrimination, marginalization

• Poor housing conditions

• Prolonged uncertainty, insecurity, lack of control.

These factors are further confounded by unstable conditions wherein individuals may be forced into a rhythm of perpetual displacement. Many are moved from one center to another, experiencing delayed asylum procedures and poor living conditions in reception centers—often poorly accessible by public transport to main economic and social hubs. Left with a life in limbo, activities of social integration and personal development are hindered under such conditions. The longer one waits for asylum, the less likely one is to find employment (Hynie, 2018), and the higher the risk for psychopathology (Laban et al., 2004). Furthermore, a recent meta-review observed associations between length of stay in asylum centres and poor mental health (Korup Kjærgaard & Koitzsch Jensen, 2018).

Hauswirth and colleagues (2004) identify the following specific stressors related to the request for asylum:

• applying for asylum involves a submission of oneself to more powerful authorities, without necessarily have knowledge of the language and administrative functioning necessary to be able to keep a sense of control over key decisions.

• the seemingly random assignment to a place of residence, the obligation to to stay in a center, are all related to a loss of freedom and perceived control.

• access to the labour market is made difficult during this period because the individual is unable to guarantee the prospective employer a commitment in the long run because of its status.

A sense of de-individuation and diminishing feelings of self-worth and self-esteem may be exacerbated by the “en masse” treatment of migrants as they enter the host country. In research conducted among refugees and asylum seekers on the Greek island of Lesbos, Eleftherakos and colleagues (2018) noted that the “elimination of each individual’s identity was quoted by many migrants while the response to questions regarding information about their cases or complaints regarding living conditions was usually answered with another insult.” (p. 5). Maier and Straub (2011) unpack the psychological impact of this loss of identity: “through extreme trauma and forced migration, the [asylum seekers] seemed to be thrown back to a biographical ‘zero’ point from which they had to almost redefine their entire identity. The severity of their trauma and loss probably exceeded what any individual, social, cultural, and religious concept available could explain and integrate” (p. 243). Despite the fact that the majority of participants in their study attributed the main source of their current suffering to earlier traumatization, one third identified their actual living situation as the essential cause of their traumatic stress, more specifically the harsh conditions in the asylum-seekers camp which lead them to feel trapped, unconfident and with “a dark future” (p. 239).

It is not difficult to imagine that living with constant fear of authorities could similarly trigger old fears related to traumatic events experienced in the countries of origin as well as during the migration period. In examining trauma among asylum seekers on the island of Lesbos in Greece, research conducted by a team from Médecins Sans Frontières (Eleftherakos et al., 2018) noted that the majority of participants reported living in a context characterised by (a) a state of permanent emergency, (b) preoccupation with threats on present and future, and (c) absence of protective measures. Such a state of existence, they argue, is related to the concept of continuous traumatic stress, a concept notably developed by South African researchers (Eagle & Kaminer, 2013) to describe the psychological impact of being continuously exposed to traumatic stressors over an extended period of time. Living under continual threat of repatriation thus serves to reinforce a compromised and precarious political, social and economic position which significantly influences mental health (Bogic et al., 2012; Heeren et al., 2014; Kirmayer, 2001; Porter & Haslam, 2005; Silove et al., 1998). Put simply, the fear does not end.

Given the factors mentioned above, it is therefore no surprise that an insecure residency status has been shown in the literature to be one of the strongest predictor of mental health disorders (Heeren et al., 2014; Hynie, 2018; Momartin et al., 2003; Morgan, Melluish, & Welham). As noted in a key review by Nickerson and colleagues (2018), such an insecure status associated with impaired interpersonal functioning and persistent worry and social withdrawal. These may in turn exacerbate PTSD and depression symptoms regardless of pre-migration trauma. Indeed, a convincing body of literature clearly attests to the fact that stressors associated with the process of seeking asylum contribute to elevated psychological distress, including PTSD symptomatology (Nickerson et al., 2018).

Prolonged Detention

In a comprehensive review on the impact of mandatory, indefinite detention on the mental health of asylum seekers, commissioned as part of the independent review of policies and procedures affecting the welfare of those held in immigration removal centres in the United Kingdom (Bosworth, 2016), the following conclusions were drawn:

• Literature from across all the different bodies of work and jurisdictions consistently finds evidence of a negative impact of detention on the mental health of detainees.

• The risk increases the longer detention persists.

• The mental health impact endures long after release.

• Causes identified in the literature include pre-existing trauma (including torture and sexual violence); pre-existing mental and physical health problems; and poor healthcare and mental health care services in detention.

Their findings are echoed elsewhere in the literature (Korup Kjærgaard & Koitzsch Jensen, 2018; Loizos, 2002; Mueller et al., 2011; Robjant et al., 2009). A similar comprehensive review by Silove and colleagues (2007) highlights that the substantial issues related to mental health and prolonged detention include restricted access to work, education, housing, welfare, health care services, abuse, untreated medical and psychiatric illnesses, suicidal behaviour, hunger strikes, and outbreaks of violence reported among asylum seekers in detention centres. Another meta-review of the literature further highlights extended period of time in asylum detention centres, and the number of relocations as significant factors impacting mental health (Korup Kjærgaard & Koitzsch Jensen, 2018).

Court Proceedings

Typically following the period of detention is the court proceeding, which risks being a traumatic event in and of itself. The recent findings of Schock and colleagues (2015) working at a centre for victims of torture in Germany, revealed the stressful impact of asylum interviews on refugees which lead to a significance increase in post-traumatic intrusions. They and other authors have hypothesised that a deliberate avoidance of thinking of traumatic events initially serves as a survival strategy during the migration period, yet may be ruthlessly undermined during the testimony phase of a court hearing, consequently fostering significant potential for re-traumatisation (Jakobsen et al., 2017; Nickerson et al., 2018; Rogers, Fox, & Herlihy, 2015; Turner, 1992; Turner, 2015).

There is also 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, with mental health problems negatively impacting on the credibility and consistency of their verbal accounts (Bögner et al., 2010; Herlihy & Turner, 2018; Linton, 2015; Mueller et al., 2011; Rogers et al., 2015; Schock et al., 2015; Turner, 1992; Turner, 2015). Bögner et al. (2010), for example, investigated factors related to the disclosure of personal sensitive information during asylum interviews and found that those with a history of exposure to traumatic events (in this study, namely sexual violence) reported more difficulties in disclosing personal information in a coherent manner. The catch-22, as Linton (2015) notes, is that an acceptable demeanour and coherent and credible story remains the basis of being granted asylum:

Asylum seekers from oppressive regimes may have learned to distrust government officials and may be hesitant or frightened when speaking to authorities. Women in particular may have been taught not to make eye contact and not to reveal private details to strangers. These experiences and cultural norms may cause an applicant to look down, appear nervous and distrustful, sweat excessively, and hesitate during her hearing—all things that could lead an IJ to believe, based on her demeanour, that she is not telling the truth… Ironically, the fraudulent applicant is better situated to relate a detailed story with appropriate demeanour than the genuine applicant (p. 1085).

Paradoxically, trauma may decrease an asylum seekers’ capacity to recount a coherent narrative of their lives—the very coherence needed for “credibility,” for their claim to asylum to be believed (Herlihy & Turner, 2018). The high potential for asylum seekers not to be believed during the court proceeding and for their claim to be denied inevitably leads to a situation of increasing physical and psychological vulnerability. For victims of torture and other atrocities, both individual and collective, the responses of criminal and social justice systems in particular may also be importantly implicated in whether people transcend or continue to suffer the impact of traumatic stressors (Eagle, 2014).

Being Denied Asylum

As demonstrated by Mueller and colleagues (2011), failed asylum seekers showed as much severely affected mental health as pending and temporarily accepted asylum seekers. These are the trapped “invisible” (Sanchez-Mazas et al., 2011), coping with the daily threat of forced expulsion. Apart from the obvious physical, legal and material implications of not being granted refugee status, the psychological impact of the court proceedings, of not having one’s story believed and subsequently being branded ‘illegal,’ is one of many inter-related factors negatively impacting on the mental health of the immigrant. As stated by Sturm et al. (2007):

With migrant populations, we do not only have to work on loss, rupture and bereavement but also on the experience of feeling oneself ‘outside humanity,’ when the individual has lost confidence in others and may carry feelings of guilt and shame... The outcome of the asylum process is of major importance for the mental health of asylum seekers. It is linked to the recognition or not of the testimony (validation or not of experiences), the experience of being recognised as a victim of violence and injustice may be extremely supportive. At the same time, once the individual feels that he or she is in a secure place, they may be overwhelmed with traumatic memories or depressive feelings. Some experience guilt or shame in relation to those whom they have left behind. Others have to deal with the traumatic memories the current situation evokes (for example, not being granted asylum and fearing for the police, not having food or money or shelter… (p. 213-216)

The result is a loss of all one’s bearings, a sense of absurdity, a misunderstanding.

the situation in the face of doubts regarding the veracity of the abuse they suffered (Hauswirth et al., 2004).

Post-migration

Many stress factors related to seeking asylum mentioned above may indeed be alleviated by obtaining refugee status. However, after months or years of suspended and uncertain lives, this is a period where refugees are required to quickly adjust and integrate into their new environment. During this transition, many may lose access to benefits specifically allocated to asylum seekers (accommodation, social services, financial aid, etc.). As refugees, they are now expected to fully participate in a new sociocultural environment and locally reconstruct their lives, all the while maintaining their cultural identity. During this stage, new stressors specifically related to this stage of the migration journey may be encountered. Saechao and colleagues (2012), for example, identify six primary stressors during the post-migration phase: economic hardships, discrimination, acculturation due to language differences, enculturation, parenting differences, and finding suitable employment. Among one cohort of refugees diagnosed with PTSD, such stressors were deemed to impact 39% of sessions with treating clinicians (Bruhn et al., 2018). As noted by Goguikian Ratcliff (2009), a plethora of studies exist which convincingly demonstrate that psychological, social and cultural difficulties encountered in the host country after arrival have a more significant impact on mental health than pre-migration exposure to traumatic events.

Reception in the Host Country

Post-migration experiences, such as unemployment, insecure residency, fear of repatriation, and social discrimination have similarly been shown in the literature to be significantly correlated with mental problems in refugees (Bogic et al., 2012; Loizos, 2002; Tekin et al., 2016; Volkan, 2004; Watters, 2001). Volkan (2004) refers to the “Janus-face” (p. 14) reception of refugees by the host society, representing them as at once victims/heroes as well as diseased intruders. As numbers of migrants into Europe swell, attitudes harden with the transforming anti-migration political rhetoric that positions refugees as an economic and social threat. He argues that this serves to remodel refugees’ self-representations as they struggle with the process of integrating the new culture with the old and with the “survivor guilt” of having left loved ones at home in danger in the country of origin.

In a recent review of the literature, Kartal and Kiripoulos (2016) note that the relationships between traumatic events, migration, and mental health outcomes upon arrival in the host country are complex and poorly understood. Acculturative stress within the sample of refugees they examined was associated with greater experiences of cultural loss and nostalgia. This loss itself was found to exacerbate PTSD symptoms. They suggest that the influence of post-migratory demands on mental health differs not only based on the individual’s acculturation process alone. It also depends on the characteristics of the local context reflecting the acculturative preferences of the host society. The authors highlight these findings as a confirmation of Berry’s (Berry, 1997, 2003; Sam & Berry, 2010) acculturation model which delineates the mechanisms through which the host society impacts on the acculturation process of refugees by imposing either encouraging or less desirable acculturative strategies (either encouraging or oppose ethnic diversity and participation in the larger society) which in turn influences mental health. This model has been confirmed elsewhere in the literature: multiple comparative studies examining correlations between the post-migration context and refugees from the same country of origin yet who have resettled in different countries convincingly demonstrate the significant effect of post-migratory factors on symptoms of PTSD Bogic and colleagues (2012) for example, assessed 854 war refugees from the former Yugoslavia having resettled across three countries. They found higher rates of PTSD to be significantly associated with migration-related stress and having a temporary resident permit. Similarly, Kartal and Kiropoulos (2016) assessed a sample of 138 Bosnian refugees resettled in both Austria and Australia. After controlling for age, sex, and exposure to traumatic events, acculturative stress associated with post-migratory experiences predicted severity of PTSD Acceptance of the host society matters.

Multiple Losses and Social Isolation

As summarized by Fox (Fox, 2018):

They [refugees] have suffered unimaginable loss of family, friends, home, community, country and language. Once here, they find themselves subjected to poverty and discrimination as well as a loss of self-esteem, status and identity. Some demonstrate remarkable resilience and fortitude in facing psychological pain, dislocation and hardship…they remain in contact with a life force , a good internal object, that enables them to tolerate and endure these privations and losses. For some asylum seekers who are less resilient, it is the loss of contact with a supportive internal relationship that depletes their capacity for resilience, leaving them inadequately resourced to face and endure the realities of their situation. (p. 103)

In the process of migration, refugees suffer numerous losses, such as economic stability, familiar surroundings, and relationships that hinder their ability to thrive in their new place of settlement. The literature highlights one of the most powerful stressors experienced by refugees after arrival in the host country as being social isolation, typically associated with ongoing family separation, loss, and a breakdown in familiar social and community structures (Miller & Rasmussen, 2017; Nickerson et al., 2018; Schouler-Ocak et al., 2016). Among a cohort of refugees in Holland, 78% expressed an unmet need for company (Strijk et al., 2011). Among a cohort of refugees in Australia, such isolation emerged as a major predictor of PTSD and other mental health challenges (Chen et al., 2017). Perceived social support has been shown to serve as a significant moderator in the relationship between exposure to traumatic events and PTSD symptoms among asylum seekers (Nakash et al., 2017; Schweitzer et al., 2006). In a study among African asylum seekers in Israel, social support was associated with lower prevalence rates of PTSD (except in the case of extreme exposure to traumatic events where social support did not have a substantial impact) (Nakash et al., 2017).

As refugees struggle to maintain cultural identities and networks (Watters, 2001), such isolation brings the further risk of losing the “social capital” (Lecerof et al., 2015; Loizos, 2002; Tortelli et al., 2017) inherent to resources associated with economic status as well as social and professional identity. The loss of social capital, exacerbated by social discrimination and marginalization, has similarly been linked to poorer mental health outcomes (Brand et al., 2017).

Continual Exposure to Trauma

Research evidence suggests that refugees are continually exposed to multiple, sometimes extreme traumas such as torture, rape, or death of family members (Hollander et al., 2016; Kartal & Kiropoulos, 2016; Steel, 2001; Steel et al., 2009; ter Heide et al., 2016). In a recent analysis of all crimes reported across Switzerland from 2009–2012, Coutennier and colleagues (2016) discovered that cohorts exposed to civil conflicts/mass killings during childhood are on average 40 percent more prone to violent crimes than their co‐nationals born after the conflict. Furthermore, their analysis showed that conflict exposed cohorts have a higher propensity to target victims from their own nationality. Rousseau and colleagues (1997) similarly found that the culture of origin radically modulated the relationship between the pre-migration experience and the developing post-migration universe of refugees—mediated through experiences of torture in countries of origin leading to increased levels of violence and social isolation subsequently perpetuated within the family post-migration. Indeed, continuous or sustained exposure to trauma has been found to create a life condition that increases risk of exposure to a multiplicity of types of traumatic events (ter Heide et al., 2016). Furthermore, there is substantial evidence in the literature that refugees suffering from PTSD in the aftermath of an initial trauma are vulnerable to increased PTSD symptoms after subsequently experiencing a new traumatic event or ongoing daily stressors (Schock et al., 2016).

Unemployment

Many consider the lack of employment to add further fuel to this fire: unemployment and unstable working conditions do not only present serious economic challenges, but have understandable negative consequences for social integration and psychological well-being (Kartal & Kiropoulos, 2016; Goguikian Ratcliff & Rossi, 2015; Schick et al., 2016; Silove et al., 1998). As noted by Du and Winter (2020), “not only does unemployment itself threaten one’s identity and role in society, but the lack of recognition for one’s skills and prior career path can lead to further losses of one’s sense of self” (p. 39). Goguikian Ratcliff and colleagues (2014) allude to the phenomenon of ‘deskilling’ which they found to exist among refugee populations. They define this as a downgrade in terms of professional skills and educational levels of achievement recognised in the host country as compared to existing experiences in countries of origin. They attribute the phenomenon in part to restrictive institutional practices anchored in discriminatory legislation, institutional practices, and social representations of refugees. The difficulty in finding employment, deskilling, social isolation, and the significant differences between the pre-migration work expectations and encountered reality on the labor market upon arrival are likely to produce feelings of discouragement, injustice, self-deprecation, social and occupational worthlessness, and lack of satisfaction and, ultimately, are likely to harm mental health.

Referring to the psychological consequences of this lack of agency inherent to situations of unemployment, Holzkamp (2013) states:

Each individual’s existential orientation is a subjective aspect of the type and degree of her/his agency – that is, opportunities to act and constraints on those opportunities. Human suffering or, generally, any injury, including anxiety, has the quality of being exposed to and dependent upon other ‐ directed circumstances, dissociated from possibilities of controlling essential, long‐term conditions, i.e. constraints on possibilities to act… a real improvement in the subjective quality of my life is synonymous with enhanced influence over my objective life conditions – that is, with my opportunities for forming alliances, i.e. uniting with others. (pp. 20–21).

He continues to argue that ‘by attempting to obtain some discretion to act through participating in power and utilizing the allowed leeway, one concurrently confirms and reinforces the conditions of one’s own dependency.’ (p. 24). The implication is that an insecure residency status dependant on being vouchsafed by the particular authorities could be rescind at any time and only serves to perpetuate unequal power relations and negate legitimate freedom to act. The impact is two-pronged: the lack of employment opportunities has inevitable socio-economic consequences which in turn affect mental health—on top of being potentially socially demeaning or devaluing which in turn affects self-worth (Hynie, 2018). A meta-analysis of 56 reports published from 1959 to 2002, representing 22 221 refugees, found that mental health status was worse among those living in institutional accommodation or with restricted economic opportunity (Porter & Haslam, 2005). Successful recovery from traumatic experiences depends to a large extent on the social, political and economic conditions and opportunities in the receiving country (Heeren et al., 2014).

Race-Related Trauma

A plethora of research has demonstrated the psychological impact of discrimination and racism experienced by migrants in general (Akhtar, 1999; Kartal & Kiropoulos, 2016; Goguikian Ratcliff et al., 2014). Visible minority status leads to more post-migratory psychosocial adversity (Hollander et al., 2016) and even more so when it comes as a surprisingly new and disorienting experience (Akhtar, 1999). Indeed, race-based traumatic stress has been demonstrated to be significantly related to trauma reactions (e.g., dissociation, anxiety, depression, sexual problems, and sleep disturbance), especially in instances where individuals have endorsed negative race-based experiences as stressful. This race-based traumatic stress model is based on empirical evidence from the racial discrimination, discrimination, race-related stress, and life-event research literatures. Empirical evidence has been generated in support of the construct and measurement of race-based traumatic stress (Carter et al., 2017). Research confirms that stigmatization (linked to discrimination and racism) is strongly associated with a higher prevalence of current and lifetime PTSD, a decreased likelihood of spontaneous remission and lower therapy success beyond the well-known effect of trauma load (Schneider et al., 2018).

This literature highlights how, especially among refugees, there are many subtle and complex stressors linked to race-based trauma with significant negative consequences for mental health. These stressors may be perpetuated by being forced to discover a new sense of identity, when many external factors indicate a person’s “otherness.” In considering the role of ethnic identity in post-migration acculturation in particular, Tummala-Nara (2007) highlights how racial trauma can have a profound impact on an individual’s sense of self, identity formation, relationships with others, and perceptions of mental health care. She demonstrates how racially driven trauma poses distinct challenges to an individual’s development of a positive identity by arguing that this type of trauma has the effect of dehumanizing one’s sense of security in and identification with larger social structures. In other words, the experience of race-related trauma, such as misdiagnosis in mental health care systems, racism, and racially based violence on individual and group levels, has significant impact on individuals’ sense of cultural and racial identity and trust in larger social structures. This is particularly true in interactions with professionals of institutions with little or no training in how to think or react in multicultural contexts (Goguikian Ratcliff & Rossi, 2015).

Language Proficiency

A key specific aspect of the process of acculturation identified in the literature is that of language, and the role of language proficiency in determining social identity and power relations (Bucholtz & Hall, 2005; Kartal & Kiropoulos, 2016; Norton, 2000; Silove et al., 1998). Unsurprisingly, therefore, language barriers have been shown significantly to affect refugee mental health in both qualitative and quantitative studies (Hynie, 2018). Many authors in the field of socio-linguistics refer to the use of language and semiotic practices in determining social positioning within interactions between migrants and host populations, looking to notions of “indexicality” to examine the relationship between words and their social meanings (Bucholtz & Hall, 2005). The influential role of language in social integration (and by extension, mental health) is not to be underestimated. As Norton (2000) notes:

Relations of power in the social world impact on social interactions between second language learners and target language speakers. Language is not…a neutral medium of communication but is understood with reference to its social meaning. Identity construction must be understood with reference to relations of power between language learners and target language speakers. The very heterogeneity of society must be understood with reference to an inequitable structured world in which the gender, race, class and ethnicity of second language learners may serve to marginalize them. Subjectivity and language are … mutually constituted. (p. 5)

Kartal and colleagues (2018) recently developed a mediation model to examine the relationship between exposure to traumatic events, host language acquisition and mental health among refugee communities. Their robust model convincingly demonstrates that the indirect pathway from trauma to mental health via language acquisition was significant for PTSD.

Gender

The literature indicates that while refugees of both genders are exposed to stressful events to a similar degree, twice as much women develop PTSD in response to these experiences (Alpak et al., 2015). Tekin and colleagues (2016), however, have noted that gender differences in PTSD prevalence may simply be a question of how trauma manifests: their study revealed that women with PTSD reported flashbacks, hypervigilance, and intense psychological distress due to reminders of trauma more frequently than men, whereas men with PTSD reported feelings of detachment or estrangement from others more frequently than women. Whether or not women experience more symptoms of PTSD, or whether they just experience it differently remains open to debate. However, the literature consistently highlights gender as a significant factor influencing the experiences and subsequent mental health status of asylum-seeking and refugee women. Firstly, women seeking asylum are less likely to be granted refugee status than men, given greater structural and cultural barriers in the asylum process (Hollander et al., 2016). Gogukian Ratcliff and colleagues (2014) further highlight the link between language proficiency, gender and mental health, noting that refugee women in particular find themselves at the cross-roads of multiple motives for discrimination such as gender, race, level of education and language proficiency. In theorizing the gendered nature of refugee women’s experiences, Norton (2000) refers to the silencing that women experience within the context of larger patriarchal structures in society, exacerbated by a gendered access to the public world to which immigrant women in particular are limited (Norton, 2000). This powerlessness is inextricably linked to what Kiguwa and Hook (2004) term the “triple oppression” of women “in terms of race, class and gender” (p. 239). Among torture survivors in particular, gender has been shown as associated with severely impaired global functioning and poorer mental health including anxiety (Song et al., 2015).

Daily Stressors

Due to the very nature of the refugee experience, many typically encounter a myriad of chronic daily stressors in their host environment, including—for example—general and acculturation hassles. Such post-migration or displacement-related stressors have been observed to have a significant impact on the mental health of resettled refugees, compounding the dose–response relationship between past trauma and PTSD symptoms (Carswell et al., 2011). In a recent study conducted by Minihan and colleagues (2018) among Australian refugees, living difficulties emerged as the most consistent predictor of PTSD symptomatology. Indeed, the impact of these daily stressors may extend over and above the effects of past trauma (Li et al., 2016; Miller & Rasmussen, 2014; Nickerson et al., 2018; Porter & Haslam, 2005; Schock et al., 2016; Song et al., 2015) – a phenomenon referred to by Keles and colleagues (2016) as the “above-and-beyond trauma effect” of such hassles. In a recent study on the impact of new traumatic or stressful life events on pre-existing PTSD in traumatized refugees, Schock et. al. (2016) discovered that, “contrary to our expectations, new stressful life events influenced the symptom course more than the experience of a new traumatic event.” (p. 7, my emphasis). In their study, most of the mentioned stressors were related to an unsecure residence status and the related insecurity concerning their life and their future—as well as new or ongoing political unrest in their home county. Another study goes so far as to purport that individuals who are resettled longer may encounter a greater accumulation of daily stressors leading to a deterioration in mental health and increasing the predictability of PTSD (Kubiak, 2005).

Considering the Interrelation of Factors

It is clear that the road to recovery for refugees is a long and complicated one, and that the mental health needs of this population remain poorly understood. Many studies on traumatized refugees demonstrating the relationship of ongoing psychological impairment and overextending post-migration living conditions, even if formal safety is achieved (Bogic et al., 2012; Schick et al., 2016). In one example in the literature on mental health among resettled refugees in Switzerland, (Schick et al., 2016) participants in general showed remarkably poor integration, particularly in terms of labour market participation and language proficiency, and were subject to a high number of migration-associated living difficulties. This was despite comparably high education and long duration of residency in Switzerland typically over 10 years.

Although systematic research into the mental health of asylum seekers is in its infancy, there is growing evidence that salient migration stress facing asylum seekers adds to the effect of previous trauma in creating risk of ongoing posttraumatic stress disorder and other psychiatric symptoms (Silove et al., 2007, 2000). Once again, what is highlighted is the interplay of pre-migration and migration factors influencing mental health. This includes the physical and material hardships of the journey and poor treatment by authorities. Such difficulties encountered during migration risk perpetuating the structural violence, injustice and intolerance faced by asylum seekers in their countries of origin and once more during the asylum seeking process, thereby serving to reinforce physical and psychological vulnerability (d’Halluin, 2009; Fassin & d'Halluin, 2005).

Two key models highlight this interaction of factors influencing the mental health of refugees pre-, during and post-migration:

• (1) Drožđek’s (2015) model identifies factors of damage as well as resources during the pre-migratory phase, the period of forced migration and the period of resettlement. Furthermore, these are factors are mapped according to the ecological levels of the microsystem, the mesosystem, the exosystem and the macrosystem. Such a model thus incorporates the multiciplity of factors influencing mental health—including experiences of trauma as well as resilience.

• (2) Miller and Rasmussen’s (2017) social ecological model similarly expands the view beyond the field’s historical focus on premigration factors alone, by drawing attention to current stressors associated with the challenges of adapting to life in exile, or displacement-related stressors. They argue that such ecological conceptualisations of refugee distress show significantly greater predictive power than the more narrowly focused single-event trauma exposure model that has guided earlier research.

Such models, often based on the socio-ecological tradition of Bronfenbrenner (1986), conceptualise psychological distress associated with trauma as stemming not only from the violence and destruction of traumatic events such as war, but also from stressful life conditions linked to social and material conditions of everyday life following displacement.

The multiple stressors faced by refugees are continuous and interconnected—before fleeing home to after having spent years in a host country. Given this complex interplay of factors, it is questionable as to whether or not one could neatly separate the pre-migration, migration and post-migration periods as being distinct phases. The difficulties inherent to each of these speak among each other in a way which appears to be more circular than linear. Therefore, as useful as it is to “map” the factors affecting refugee mental health, one needs to move beyond such a static representation in our reflections. Let us consider the refugee who receives news of a beloved family member’s passing back home in their country of origin, yet who is left with little resources to mourn the death outside of his familiar religious community. Let us consider the refugee whose experience with the police force upon arrival in Europe echoes similar experiences with the police force of her country of origin. It is exactly this dynamic complexity of human experiences of migration and mental health that needs to be considered, and which will be highlighted in the following two case studies.

Case Study One: Trauma Among Displaced Victims of Torture in Athens, Greece

The first case study is taken from my doctoral thesis, which involved two years of fieldwork in a centre for victims of torture run by Médecins Sans Frontières (Operational Centre Belgium), in partnership with local NGO Babel, in Athens, Greece. Here, individual refugee victims of torture were interviewed multiple times over the course of this fieldwork, as well as their accompanying psychologists, doctors, and community leaders. Their individual trajectories were analysed based on the ecological models noted above (Drožđek, 2015; Miller & Rasmussen, 2017). The case described here also appears in a scientific article published in Intervention (Womersley & Kloetzer, 2018b).

The case study allows us to examine these contradictions in the importance of the socio-legal environment in refugee experiences of trauma. Many cultural factors, such as a specific socio-political identity, were evidently at play for this particular individual. Furthermore, the case clearly highlights the impact of particular legal and medical institutional pathways on psychosocial recovery. It further offers the possibility of triangulating the data obtained from this individual participant, his doctor and psychologist.

Case Presentation

The case presented is a 30-year-old Indian asylum seeker of Sikh religion, whom I interviewed multiple times from 2016 to 2018. In 2007, he was arrested and tortured on numerous occasions, often for months at a time, due to his involvement as a Sikh political activist. He 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. I first interviewed him in August 2016. From the very beginning of the very first interview, he highlighted his family’s collective identity as Sikh political activists, with a long history of trauma across the generations:

My father’s, my father family and my mom’s family – they are very, very connected with their religion […] from my mom’s family, I have seen a lot of dead bodies. They were innocent and they were killed by the Indian government police and the secret services, because of that, because we were fighting for our freedom.

Over the course of the following four interviews, he described the psychological impact of the various methods of torture to which he was subjected in minute detail, including sexual abuse, his legs being ‘ripped apart’ the meta-tarsals in his feet being broken, as well as electrification:

From the front, they were giving the electric shocks. They never give the scars on my body but they give me the scars on my personality. They give me the scars on my soul … lots of things from my mind has been wasted.

For the first 4 months after his arrival, he was living alone in a 30 m-squared hotel room in an old building recently repurposed to house asylum seekers. Alone, lost and scared of being recognised by other members of the Indian community, he barely left his apartment. At the end of August 2016, he was given an appointment for his asylum interview. However, the administrator responsible was not present on the day and he was given a new date for his interview in December. This seemed to symbolise a denial of his story, of his cultural identity as a Sikh political activist, of his very being. He explained that:

During the interview, I want to be wearing a turban because during the interview I want to tell them that I am a part of the Sikh religion because of my religion, because of my race, I have been persecuted in my country.

This fear seemed to echo the past traumatic experience of being tortured, a fundamental part of which involved the torturers removing his turban and mocking his Sikh identity. He consulted a doctor and a psychiatrist at the centre, who wrote a medical report to add to his request for asylum. The report stated that he was suffering from PTSD, yet this was a concept unknown to him and he continued to refer to his psychological state as one of depression:

P: “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 if I’m in depression or not. I know only one thing, that my world is just only this room … I’m just killing my time here until I’m not getting my papers or they are not going to take my interview […].”

Interviewer: ‘Tell me about the psychiatrist you said that you’re going to be seeing later.”

P: ‘Why I’m seeing a psychiatrist − well, without any reason. . . In my dreams, I saw this police officer because in front of me, he was kicking my mom’s stomach … I’m still having dark dreams …” Interviewer: “Is it helpful for you to see a psychiatrist?”

P: “No, it’s not- What he is going to do, I don’t think he’s going to help me in any way. The things that happened to me, what he wants to do, he’s just speaking, and speaking, and speaking, and talking about things, nothing much … Why I am coming to the people here, to see the psychiatrist and the doctor, because then they will know that I’m also here. There are thousands and millions of refugees here. If were to come in here, I will be in front of their face, and they will be knowing about me.”

The contradictions between his own explanatory model, and that of the psychiatrist, are striking. He reported not finding the consultations with the psychiatrist helpful, seeing little use in being required to ‘talk about things’. Not only did he not agree with the PTSD diagnosis, he mistook it for a diagnosis of depression. There seemed to be little correlation between the words of the psychiatrist and the “scars of [his] soul.” Despite continually being haunted by “dark dreams,” his focus was on being “seen” as a refugee. Never having heard of a psychologist or psychiatrist before, he saw psychotherapy as a useful way to obtain this legal goal. Towards the end of 2016, his psychological condition deteriorated. Due to financial reasons, he was forced to move out of his small hotel room into shared accommodation. He accused his Pakistani roommate of spying on him. Psychotic symptoms started to emerge, including auditory hallucinations and paranoia. Many of the voices were those of authority figures, including the torturers in India and, rather tellingly, police officers, bureaucrats and judges in the asylum procedure in Greece. He was hospitalised as a result. When interviewed about his hospitalisation and the deterioration in symptoms, his psychologist stated:

One voice said, ‘You will be homeless you will be homeless,’ and there is a possibility to be homeless. Or another voice said that, “They will not believe you they send you back to India,” and that is true … What he hears is normal, it’s his fear.

His doctor similarly noted the potentially harmful effect of forced hospitalisation:

Psychiatrists are not sure whether his post-traumatic stress disorder was that and only that or if he even before had some psychotic elements that now worsened. Hospitalization was difficult for him; it reminded him of prison. All the staff would kept visiting, bringing chocolates or to distract the prison-like atmosphere. I am worried about him, because he doesn’t seem to respond to treatment that well … It’s not a good time for him generally, because first he found himself living in an apartment with Pakistanis. They could speak the language; he got afraid. They were having drinking, smoking and things like that; he got very scared. That was when things really got bad and he went to this hospital … Then he heard from his relatives in India that his mother and father are in prison. His father is probably killed, because we hear from these relatives too, but he doesn’t know. He knows that his father has disappeared in prison. The news that he receives about his mother is that she’s in prison with an infected leg. She has nothing, just a rag to wipe the pus. That’s what he knows about his mother. This is another stress factor. Another very stressing thing for him is that his interview got postponed till August. That made him really angry and frustrated. All these things add up.

She also noted the impact of his current reality on the process of diagnosis:

I could see the face of the psychiatrist who at first said, ‘You think the secret services of India are after you?’ I could see the paranoia. Then [the patient] said his story. There he goes, Oh, oh, oh, oh. [laughter] This is not paranoia. This is real life.

Feedback loops

So what is “paranoia” and what is “real life?” To analyse the data, we draw on the concept of feedback or ‘looping effects’ (Kirmayer & Ramstead, 2016) defined by the authors as links in a causal chain “whereby individuals interpret and respond to their own symptoms with culturally varied coping strategies that may change the course of the illness, amplifying or reducing symptoms and distress” (p. 6). They argue that such socio-cultural feedback amplification extends beyond the individual to include a wider network of relationships and processes wherein the individual is embedded. We posit that such a series of “feedback loops” (which we define as a process whereby an effect is reinforced by its own influence on the process giving rise to it) impacted post-traumatic symptoms as well as the patient’s self-representation of his own mental health status. A number of feedback loops may be identified on an individual, interpersonal, and social level, as illustrated by the following model:

First Feedback Loop: Breakdown of Interpersonal Relations

The experience of being tortured is arguably a traumatic experience in and of itself. However, added to this is the fact that the patient is not the only member of his family to have been tortured. His father’s presumed death and mother’s alleged detainment and torture alludes to a traumatic experience extending far beyond that of the individual. Indeed, the torture of his family and subsequent forced migration, which he undertook alone, created traumatic ruptures in his interpersonal relationships and by extension, his broader social world. Paradoxically, such connections would have connected him to the very resources necessary to heal. These are both resources found on an interpersonal level in disclosure and sharing emotional experiences, and on a social level within secure group membership. Thus, a vicious cycle of isolation and disconnection is perpetuated, seemingly serving to exacerbate his fear. Furthermore, the disconnection cannot be considered as a “once-off” event, which occurred at a particular moment in the past: ruptures continue with each phone call bringing news from India.

Second Feedback Loop: Delayed Asylum Procedure

A long asylum procedure has been found in the literature to be associated with psychiatric disorders (Laban et al., 2004). For the patient, his insecure residency status increased uncertainty regarding his future as well as his ability to integrate, look for work, and create a life for himself. Waiting for his asylum interview, his fear was compounded by being in an irregular legal situation and the risk of being forced out of the country. This fear kept him from leaving his house and integrating into his new social environment. On an interpersonal level, this reduced opportunities for exchanges. On a social level, the delay arguably contributed to further disconnections in visibility, representation and the acknowledgement of the torture, which he had endured within broader, societal and political contexts, which were intricately linked to restorative justice perceptions contributing to the severity and course of PTSD (Maercker & Hecker, 2016). The loop returns to the level of individual, in the patients’ questioning of his own social, cultural, and political identity.

Third Feedback Loop: Living Conditions

The delayed asylum procedure prevented him from having the right to look for work and find an apartment on his own. Without more financial, legal, or social resources and, thus, still dependant on state services as an asylum seeker, he was moved from his own hotel room to new accommodation. Sharing with Pakistanis whom he did not trust, his interpersonal resources were further compromised and his social world further limited by not being able to find work. Such conditions seem to have exacerbated the post-traumatic symptoms, with auditory hallucinations telling him that he would be homeless leading to his hospitalisation.

Fourth Feedback Loop: Hospitalisation and Interpersonal Encounters in Medical Consultations

His post-traumatic stress symptoms exacerbated, he was hospitalised. Again institutionalised, finding himself once more at the mercy of the state, it was perceived as a further enforced period of detention where he was subjected to bodily treatments against his will. It triggered memories of the past torture he endured. Furthermore, it positioned him in the role of patient leading him to question, whether he was “sick” or not. He was promised by the hospital staff that they would not inject him. They did. This deepened his sense of mistrust, paranoia, and isolation creating further interpersonal ruptures. His hospitalisation and numerous encounters with medical staff lead him to question his own status as “sick” or healthy, “normal” or abnormal. His psychologist explained:

When I asked him what is his request and what is his reason and why he decide to visit psychologist, he said to me, ‘I don’t know, because of my doctor said to me that it’s good for me. My psychiatrist said the same, my social worker said the same, a police man who stopped me said the same.’ I asked him, ‘Then what do you think, why do all this people propose to you to come and see the psychologist?’ He said to me, ‘I don’t know, maybe they need a psychologist’.

On an interpersonal level, it speaks to the feelings of both shame and anger he expressed throughout the interviews in being seen as someone in need of psychiatric care. His doctor explained:

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.

Such discrepancies between his own explanatory model for his symptoms and that of others around him had an impact on his interpersonal relationships. They seemed only to reinforce his solitude. Here, it is worth returning once more to his stated reason for attending consultations with the psychologist and psychiatrist as highlighted above. It is not because he seems himself as a patient. It is for visibility and recognition.

It is so that “they will know that I am also here.”

As illustrated by the case of this particular individual, post-migration factors encountered in Europe, including delayed asylum trials and poor living conditions, had a substantial impact on post-traumatic symptoms among the refugee victims of torture in the study. These symptoms were never static but in a continual state of flux, in dynamic interaction with the socio-cultural environment.

Case Study Two: Self-immolation Among an Asylum Seeker in Switzerland

In April 2016, Armin,² an asylum seeker in a village of Switzerland, set himself alight in the public square of the town, one of a few cases reported across Europe. He performed the act following a denied request for asylum and was saved by bystanders. Here, I present the results of two qualitative interviews which I conducted with Armin, his translator and his roommate following the incident. The case study also appears in a scientific article published in Frontiers in Psychiatry (Womersley & Kloetzer, 2018a).

The Self-immolation of Armin

Armin is an asylum seeker from North Africa who arrived in Switzerland in September 2014. He had been imprisoned in his country of origin in 2008 after having physically attacked a judge in an attempt to gauge out his eyes. This incident occurred during a court case involving a land dispute wherein the judge ruled against his favour. In prison, he began engaging in hunger strikes to protest against the conditions. After serving six years out of a 20-year sentence, he managed to escape and make his way to Europe.

Upon his arrival in Switzerland, he was transferred to multiple reception centres where he would go on hunger strike for eight days at a time to protest against the reception conditions. He describes, “sleeping on the sofa with eight people living and breathing in the same room.” The situation become unbearable for him to such an extent that he began sleeping in the bathroom. He was subsequently transferred to a private apartment with he shared with an Eritrean refugee. He began using marijuana and cocaine “because it helped me to forget my problems,” and was arrested by the police for shoplifting whilst intoxicated. He also started grinding up paracetamol and selling it as cocaine—using the money to send back to his mother. In November 2015, he heard news of his eleven-year old daughter drowning to death in his country of origin.

After having waited for 23 months for the results of his second asylum application, he attempted to leave Switzerland by asking to annul his asylum application. He boarded a train heading for Germany. However, due to the fact that his fingerprints were already registered, he was prevented from leaving the country. In November 2015, he heard news of his sole remaining child, his 12-year old son, being killed. It was during the same time that he heard of the fact that his application for asylum had been refused, a decision which he decided to appeal. According to his personal file, he attempted suicide in February 2016 following an argument with his doctor and was sent to a psychiatric hospital. Upon returning to his apartment, he received the second negative response to his request for asylum, with a deadline to leave Switzerland by the 7th of July.

On April 20th, the morning of the self-immolation, his roommate reports that the police came to his apartment at five o’clock in the morning looking for drugs. According to his roommate, he was detained at the police station until 11:00 a.m., whereupon he was released and returned home for lunch. His roommate describes his mood as being “calm and quiet” during the meal. Thereafter, he headed to the town’s biggest public square with a can of petrol in his bag. In his words, “I was very very angry and very… I poured the petrol onto myself and the people stopped me…I found that there was no other solution but death and that’s why I took the petrol and a lighter and set myself alight.” According to newspaper reports, passers-by heard him screaming incoherently in Arabic and rushed to pour water over him to extinguish the flames.

The incident was poorly reported in the media and few if any public statements were made on behalf of any of the institutions working with asylum seekers. The little that was reported focused mainly on applauding the quick-thinking actions of the citizens and local fire brigade in putting out the fire. One newspaper report concluded that the act did not seem to have been of a political nature. Little was said by the community of asylum seekers and refugees themselves living in the town. The following day, roughly 70 people congregated in a demonstration in solidarity. There was no report of this demonstration in the local media. It was as though a veil of silence shrouded the incident. Armin ended up in intensive care for a month with severe burn injuries, and seven weeks later was subsequently transferred to a psychiatric hospital.

Analysis

The first interview I conducted with him was at this psychiatric hospital, with the assistance of a translator. Upon meeting him, the first words he said were, “We find ourselves in a country where we are considered terrorists …we need to unite.” He stated that he planned to go to Geneva the following day to visit the head office of Al Jazeera, the international news network. He wanted to be interviewed to tell people that “the prison of my people in Africa is better than the prison here…I want to explain to my people what Switzerland actually is.” From the first interview, what Armin immediately highlights is wanting to “show” and “explain” to people the dire reality of his situation, for his suffering to be seen. It is the need for social recognition.

He went on to describe a life without meaning: an endless and empty repetition, a wordless nothing:

There’s nothing to do in the apartment. You eat, you drink, you sleep, you eat, you drink, you sleep, you eat, you drink, you sleep. There is nothing.

There appears to be a striking absence of connection to Others mentioned in his speech. The endlessness is repetitive; past and future are circular, not linear. He continues the conversation by reflecting on his initial arrival to Switzerland, where he was housed in a reception centre for asylum seekers staying:

for 8 months sleeping on the sofa and not on my bed where 8 people lived and breathed in the same room

Armin found the physical proximity to the other living, breathing people unbearable, resulting in him leaving the communal room and isolating himself. He continued the interview by explaining this:

Armin: I slept in the toilets. I slept in the toilets! 15 nights I slept in the toilets!

Translator: Why?

Armin: I took my mattress and went to sleep in the toilets!

Translator: Why?

[silence]

His silence is striking. There are no words to describe this disconnection, this descent into nothingness. He explained that the centre for him had been.

An open prison. It’s the place where you return to no matter in which direction you go. So long as there are no offers of work, no internship for mutual benefit, there is no future here

Once again, time is represented in a circular fashion, not a linear one. No matter the direction, there is a return to this same place of nothingness. Any hope for a future is linked to “mutual benefits”—in other words, a dialogue with an Other who could serve to recognise him, to assist him in creating future plans. In the absence of this Other, Armin remains disconnected not only from society but from his own future; “there are inexplicable events, life is unendurable, and … justice is a mirage” (Geertz, 1993, p. 108 as cited in Tankink & Richters, 2007).

He continued.

I set myself on fire because I didn’t have any will to live. I found myself in a situation without future, without anything and therefore a worthless person, like this cup...without future, without anything, like this cup. I am like this cup. No future for me, no work, no marriage, no learning.

In this discussion, Armin asserts that there is no future here for him, which he relates to the lack of work or professional training. This seems to be for him both an “entry ticket” to normal life, and a way to overcome suffering. It is not only the economic security of a job which he has lost, but the social security of connection to Others and the recognition of himself as a valued member of society—without which he is “worthless,” something less than human.

He believes there to be no possible life for himself in Europe, there is “no work,” “no school,” “no marriage,” “no future.” He states the reason for having committed suicide as being “I need to have work, to do something.” Elsewhere, it has been argued that the process of forced migration risks creating an “a-temporal space,” a transitional and disconnected period wherein experiences, skills, connections acquired and built in the past are rendered inaccessible (Métraux, 1999), as are any clear perspectives on the future. A consequence of such overwhelming episodes is that the experience seems dissociated—isolated in one’s consciousness (Zittoun & Sato, 2018).

Poignantly, he concludes this interview by saying:

Yes, I went to death³

The second interview, similarly conducted in the presence of a translator, occurred once Armin had been released from the psychiatric hospital. He began by saying:

I came to Switzerland, but Switzerland wasn’t my destination. In my mind, there were other destinations like France, Italy, England, but I was stopped.

His words imply a sense of being stuck, of thwarted dreams and ambitions for the future. He is overwhelmed by the reality of the situation, in rude contrast to what he imagined for his life:

Armin’s words (spoken by his interpreter): After 9 days, I went back home but I encountered the same problems of solitude, there is nothing to do, there is no solution but death. I thought there was no solution but death, and for this reason, I brought petrol and a lighter and I set myself fire.

Interpreter: Why did you choose that way?

Armin: So that people know. I did it so that people could be made aware, to stop despising people like me, to know that all people are equal.

And so far, nothing happens. I stay home, I… I eat, I drink, I sleep. There is nothing. There is no future in Switzerland. No future. I got married, my wife died, my two children died. There is nothing. (translation and exchange in Arabic)

Interpreter: I told him that we were here with him. He told me there is nothing. The dog here is better treated than me.”

Armin: In this case, is it not better to die?

Further on in the interview, he continued:

I’m not happy with my life, I do this and that, I do some terrible things, I sell drugs, I take cannabis, things like that and I’m unable to find a solution - not for me nor for my family …I want to live like other people. I don’t consider what I have to be a life. I am not living. (…) I am a shirt and walking trousers, not a human being.

An underlying sentiment of shame pervades his speech: he is ashamed of being someone who sells drugs, ashamed of not being able to support his family and make them proud. The mystifying dualism of this shame is that it is at once an isolating, intimately intra-psychic phenomenon seeking concealment, yet remains deeply embedded in a visual and public interpersonal space where the self is violently and unexpectedly exposed to the critical gaze of the Other (Womersley et al., 2011). The source of shame can therefore never be completely in the self or in the Other, but is a rupture of what Kaufman (1989) calls the “interpersonal bridge” (p. 22) binding the two. It is a disconnection and consequent lack of social recognition which underlies this shame.

Armin comments on the act of self-immolation in relation to his negative evaluation of his own life and thwarted expectations of living a normal life, a “human” life. The feelings expressed seem to be the same: injustice, solitude, sadness, emptiness, uselessness, all worsened by a perceived lack of hope in a better future. Here, time is a circular, wordless nothing. His act is defined explicitly as communicative, a direct call for social recognition:

I did it so that people could be made aware, to stop despising people like me, to know that all people are equal.

Continuing the interview, he paused and stated, “I don’t know. Maybe I’m mad.” It is impossible to grasp the full meaning behind these words. At face value, Armin seems to be considering whether or not he is indeed suffering from a psychiatric disorder, as stated by the many professionals with whom he has been in contact in Switzerland. However, throughout the two interviews we conducted with him, we are left with the impression that, for the most part, he appears to be contesting this very idea. Indeed, his words seem to reflect a resistance to the fact that he is a psychiatric patient in the face of others telling him that he is “mad.”

Concluding Remarks

Although he finds himself cast out of the networks of humanity—having lost his family, his friends, his cultural homeland, his work, he justifies his act as a will to communicate his situation and humanity to other human beings. For Stolorow (2011), being plunged into such singularity and solitude may paradoxically bring about an enhancement of “resoluteness” (p. 45). In such a state, the individual returns from the publicness of “they” to a more authentic and steadfast sense of self and purpose, which may lead to authentic “Being-toward-death.” In his own words, “Yes, I went to death.” However, on analysing his motives for committing the act, it is evident that it goes beyond a simple desire to commit suicide. The self-stated reasons for him having committed the act highlight both the socio-political conditions in which he finds himself, as well as an internal psychological state of despair. This echoes the work of Biggs (2008), who highlights the paradox that, in many cases, the act serves as both an escape and a protest.

Based on this hypothesis, considering the act “as escape” would arguably be indicative of suicidal ideation possibly linked to psychological factors of depression including a sense of helplessness and despair—in his own words “having no will to live.” Armin continues this reflection on his “situation without future” in which he finds himself. Not only does he perceive a life without future, he perceives a life where “dogs are treated better than me” and he is no better than “a cup”. He sees himself without a future and, most significantly, he connects this state to the lack of relationship with a social Other—in other words, his relationship to the network of human society which places him in the position of less-than-human, outside of social recognition.

In the apparent absence of social recognition, Armin found himself “a worthless human.” Cast outside of the containment of human plurality as a result of a myriad of political and social mechanisms of exclusions, we hypothesize that his act of self-immolation serves as both an escape and a protest, both a “relational striving” for “being‑in‑the‑world,”—profoundly embedded in an intersubjectively constitutive context, and a “being-toward-death” (Stolorow, 2011). Is the act both a significant indicator of deep psychological distress and despair, as well as an attempt to restore a connection to the world of the living? We argue that the utterance is at once disruptive and engaging, destructive and constructive, a conflict and a collaboration, a death instinct towards destruction but a “destruction as the cause of coming into being” (Spielrein, 1994). To quote Armin himself, it is at once a “yes, I went to death” as well as an “I want to live like other people.”

When he placed himself in the most public space of a Swiss town and set himself alight “to show that all men are equal,” it was an attempt to overcome trauma, social isolation and lack of social recognition, a co-constructed inquiry to begin to try and put symbolic expression to experience (Rosenbaum, 2016). A “social interaction in its own right” (Rasool & Payton, 2014), it represents an attempt to restore interaction. As such, it is a way of metaphorically construing and narrating experience; a compelling narrative enjoining others to take action (Kirmayer & Ramstead, 2016). This is an utterance, a communicative act with the consequent potential to promote agency and civic engagement (Yang, 2011) which demands a response from the addressee, the Other. It demands and forces social recognition.

The brutality of such acts leave the public with little choice but to be disrupted and engaged as an “addressee”—whether voluntarily or not. In such moments, ‘the public sphere can no longer turn a blind eye to its privileged bodies’ (Habermas, as cited in Cho, 2016), “the audience is not allowed to simply demonstrate ‘distant compassion’ but rather they are encouraged to engage and self-reflect about local injustices and activism within their own vicinities.” (Bhimji, 2015, p. 100). This self-immolation was a powerful communicative act that utilized self-inflicted violence as a means of forcing social recognition, both a personal and political action.