As explored in chapter two, displaced populations face a myriad of traumatic events, throughout the migration process. It comes as no surprise than, that two landmark, systematic meta-reviews found prevalence rates among refugee populations of 40% (Turrini et al., 2017) and 30.6% (Steel et al., 2009) respectively. Another meta-review noted that PTSD prevalence rate among first generation migrants in general and refugees/asylum seekers ranged from 9 to 36% compared with reported prevalence rates of 1–2% in the general population (Close et al., 2016). There is evidence that these high prevalence rates of PTSD persist several years after displacement, both in countries of settlement and refugee camp contexts (Bogic et al., 2015; Kaltenbach et al., 2018; Nickerson et al., 2018). Prevalence rates of PTSD reported in displaced populations screened using the Harvard Trauma Questionaire (HTQ) in particular, include 45.5% among earthquake survivors in Wenchuan China (Kun et al., 2009), 37.2% among Cambodian refugees living on the Thai–Cambodian border camps (Cardozo et al., 2004), 29.3% among populations living in conflict-ridden southern Lebanon (Farhood et al., 2006), and 11.8% among displaced Guatemalans living in Chiapas, Mexico (Sabin et al., 2003).

This chapter will present prevalence rates of PTSD noted among displaced populations in three independent studies I conducted in collaboration with colleagues in South Africa, Iraq, and the Philippines respectively.

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

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

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

In the first two case studies, The Harvard Trauma Questionnaire (H.T.Q.) was used as a screening instrument due its recognised cultural sensitivity in assessing highly traumatised populations (Mollica et al., 1992, 1998; Shoeb et al., 2007). PTSD in this case is defined according to a scoring algorithm previously described by the Harvard Refugee Trauma Group on the basis of DSM IV diagnostic criteria (Association, 1980; Mollica et al., 1992). In the third case study, the Posttraumatic Stress Disorder Checklist (PCL-5) was used as a screening instrument to assess the prevalence rate of PTSD Developed in 1990 at the National Center for PTSD, the PCL comprises 17 items corresponding to the PTSD symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (American Psychological Association (APA), 2013), and is one of the most widely used self‐report measures of posttraumatic stress disorder (PTSD) (Blevins et al., 2015). The instrument been revised to include new symptoms and to conform to the DSM’s four-factor conceptualization of PTSD and its corresponding symptom clusters: re-experiencing, avoidance, negative alterations in cognition and mood, and increased arousal and reactivity (Ashbaugh et al., 2016). In all studies, the aim of assessing the prevalence rate of PTSD was to identify and highlight the mental health needs of this particular population, to develop a culturally-appropriate intervention programme as well as to enrich advocacy campaigns for their humane treatment by state and non-governmental organizations alike.

Case Study One: Durban, South Africa

In April 2015, following an upsurge in violent xenophobic attacks throughout the country, displacement camps were set up to house roughly 7,500 foreign nationals seeking refuge in Durban, KwaZulu-Natal. Médecins Sans Frontières (MSF) were among the actors intervening in the camp by providing the population with basic medical care and psychosocial support. The majority if displaced individuals in the camp were refugees and asylum seekers from the Democratic Republic of Congo and Burundi who choose to remain in the camps: stating that they cannot return home to their countries of origin safely due to fear of persecution and that they fear returning to the South African communities from which they fled, in many cases after experiencing significantly violent attacks on themselves and their property. The people remaining in the displacement camps represent a population which has been exposed to multiple traumatic events—both in their countries of origin and more recently in South Africa—and were therefore presumed to be at risk of experiencing symptoms of post-traumatic stress. As part of a package of psychosocial care offered by MSF in the displacement camps, I conducted a study of post-traumatic stress symptoms among a convenience sample of refugees in order to explore the extent of the psychological trauma among this particular population, to reflect on the relevance of a PTSD diagnosis within this particular cultural setting and to offer relevant treatment. The case described here also appears in a chapter of a book entitled “Post-traumatic stress responses among refugees following xenophobic attacks in Durban, South Africa” first published by InScience Press (Womersley et al., 2016).

Method

After obtaining authorization from the local municipality and campsite managers, men and women—all of them foreign nationals from the DRC or Burundi—were approached by myself on site at three displacement camps.

Results

27 participants completed the Harvard Trauma Questionnaire. The results of questions 1–16 of part 4 of the HTQ were subsequently noted and scored. The mean score was 2.87. Participants included 12 women, out of which all 12 (100%) met diagnostic criteria and 15 men, out of which 12 (80%) met diagnostic criteria. When questioned about the traumatic event which participants had either experienced, witnessed or heard about, the majority referred to events which had taken place in their country of origin, as well as the recent xenophobic attacks. 22 participants (81%) reported experiencing or witnessing conflict, murder, torture and/or sexual violence. All participants had been in the camp for at least 7 weeks after the xenophobic violence. For all participants, the traumatic symptoms reported were related to events which had happened in their countries of origin, exacerbated by the xenophobic violence and experiences of being in a refugee camp.

Participants rated the items of the HTQ on a scale of 1–4. A score of 1 indicates ‘not at all’, 2 indicates ‘a little,’ 3 indicates ‘quite a bit’ and 4 indicates ‘extremely.’ The mean results of these scores are indicated below:

 

Item

Mean score

Standard deviation

1.

Recurrent thoughts or memories of the most hurtful or terrifying events

3.11

0.89

2.

Feeling as though the event is happening again

3.41

0.75

3.

Recurrent nightmares

2.37

1.21

4.

Feeling detached or withdrawn from people

3.00

1.11

5.

Unable to feel emotions

2.48

1.25

 

Feeling jumpy, easily startled

3.00

0.92

7.

Difficulty concentrating

2.78

0.93

8.

Trouble sleeping

3.04

0.94

9.

Feeling on guard

3.19

0.89

10.

Feeling irritable or having outbursts of anger

3.07

0.87

11.

Avoiding activities that remind you of the traumatic or hurtful event

2.85

1.67

12.

Inability to remember parts of the most traumatic or hurtful events

1.93

1.11

13.

Less interest in daily activities

2.96

1.06

14.

Feeling as if you don't have a future

3.15

1.06

15.

Avoiding thoughts or feelings associated with the traumatic or hurtful experience

2.41

1.15

16.

Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events

3.34

0.83

Total mean

 

3.34

 

There were no statistically significant outliers in terms of the mean response to individual items (p < 0.05). However, it must be noted that the mean response of items 3, 5, 12 and 15 fell below 2.5. This suggests that participants reported not being strongly affected by recurrent nightmares, an inability to feel emotions, an inability to remember part of the most traumatic or hurtful event in their lives or a sense of avoiding thoughts or feelings associated with the traumatic or hurtful experience. In general, participants reported being fully aware and emotionally responsive to the traumatic events which they had experienced or witnessed. The highest mean response to an individual item was to item number 2 (mean score = 3.4). This item refers to a feeling that the event is happening again. When questioned, the majority of participants explained that the recent xenophobic attacks which they had experienced or witnessed in South Africa had triggered traumatic memories or flashbacks of events from which they had had to flee in their country of origin. The greatest standard deviations were for item 3 (‘recurrent nightmares,’ std dev = 1.21), 5 (‘unable to feel emotions,’ std dev = 1.25) and 11 (‘avoiding activities that remind you of the hurtful or traumatic event,’ std dev = 1.67).

Case Study Two: Yezidis in Iraq

Yezidism arguably remains one of the most oppressed religions in Iraq, with the population historically confronted by many attempts at genocide. In the summer of 2014, fighters tore into Kurdish northern Iraq and committed attacks against the Yezidi under the black banner of Islamic State. They took more than 7000 people hostage, killing around 5000, mainly men (Mohammadi, 2016). Although men were mostly killed, women and girls were kidnapped, taken a hostage, raped and used or traded as sex slaves. For many, these catastrophic events lasted for years. These atrocities have left many survivors displaced and affected by trauma. Furthermore, the deep-rooted trauma is collective: 3500 women and 1200 children are still held captive by Islamic State. Indeed, recent research on socioecological mental health and psychosocial support (MHPSS) interventions suggests that individuals may suffer from posttraumatic stress through the impact of the disaster on their community, even if not directly exposed (Wind & Komproe, 2018). Little research has been conducted on experiences of trauma among this population. The detrimental effect of the torture, sexual abuse and genocide of this population remains largely unaddressed (Hoffman et al., 2018). One study estimates the prevalence of post-traumatic stress disorder (PTSD) among Yezidis seeking refuge in Turkey at 43% (Tekin et al., 2016), with women being more frequently affected than men. Another preliminary study assessed both PTSD and complex post-traumatic stress disorder (CPTSD) among female Yazidi former captives residing in post-ISIS camps. The results indicated that 50.9% women had probable CPTSD, while 20.0% had probable PTSD (Hoffman et al., 2018). A few more studies confirm this alarmingly high prevalence of trauma among the Yezidi population (Ceri et al., 2016; Gerdau et al., 2017; Nasıroğlu & Çeri, 2016).

The Free Yezidi Foundation (FYF) women’s centre is situated in the Duhok province of the Kurdistan Region of Iraq. This centre offers psychological interventions for women who suffered in captivity and eventually escaped, as well as those who were never captured but were displaced by attacks and whose entire families are now homeless and jobless. The centre, inside the Khange IDP camp, serves all the women in the camp, including women who have escaped ISIS captivity. The facility at present features a counselling/recreation room, an art corner, a computer lab, a classroom area (for teaching English, Arabic, Women’s Rights, Kurdish and Yezidi culture and history), a sewing room and an outdoor garden. The project collaborates with over 20 non-governmental and governmental actors in Kurdistan to coordinate MHPSS responses. Furthermore, FYF is also active in global advocacy for genocide recognition and more resources to Yezidi survivors. An essential part of the programme focuses on addressing the significantly high levels of trauma in the community.

This specific MHPSS intervention, informed by the mental health pyramid alluded to in the Inter-Agency Standing Committee (IASC) guidelines,Footnote 1 targets three levels of interventions—the level of the individual, the level of the group (of service users) and the level of the wider community. Broadly, the intervention is informed by empirically validated trauma treatment interventions, which include principles of psychoeducation, and stabilisation techniques based on trauma processing therapies such as Eye Movement Desensitization and Reprocessing (EMDR) Therapy (Eichfeld et al., 2018). This includes pilot projects implementing group EMDR Group Traumatic Episode Protocol (GTEP) therapy under the clinical supervision of international experts. Individual and group therapy is offered by the project psychologists. Intake interviews are held with each service user to allocate them to appropriate groups or to refer them to individual therapy according to their specific mental health needs. Group sessions draw on techniques of emotional regulation, grounding and stabilisation tools and skills—and are complemented by further extra activities, such as art, exercises, games, role playing, singing and dancing. Furthermore, 13 service users have been trained as lay counsellors to provide psychological first and second aid, and work under the supervision of the project psychologist. Part of this community work includes facilitating psychoeducation workshops to raise the community's awareness on trauma and its impact on psychological wellbeing, and conducting community sensitisation/awareness sessions. For example, with the input of the lay counsellors, cultural mediators and the art teacher, a toolbox was created, which included pictures and text (in Arabic and Kurdish), demonstrating reactions to trauma and loss as well as basic stabilisation techniques. The case described here also appears in a scientific article published in Intervention (Womersley & Arikut-Treece, 2019).

Method

In the context of an internal evaluation, Yezidi women, service users of the FYF, were screened before starting and after completing the programme using the WHO-5 well-being scale—among the most widely used questionnaires assessing subjective psychological well-being with demonstrated clinimetric validity (Topp et al., 2015). For further quantitative data on the prevalence of trauma among the population, the Harvard Trauma Questionnaire (HTQ) was used due its recognised cultural sensitivity in assessing highly traumatised populations (Mollica et al., 1992, 1998; Shoeb et al., 2007). It has been validated for assessing PTSD in Iraqi refugees in particular (Shoeb et al., 2007). PTSD was defined according to a scoring algorithm previously described by the Harvard Refugee Trauma Group on the basis of DSM-IV diagnostic criteria (APA, 1980; Mollica et al., 1992). A client satisfaction questionnaire was completed by service users in individual psychotherapy upon completion of the programme in June.

Results: Topline Findings

  • 37 out of 54 individuals from a convenience sample of displaced Yezidi community in Khanke (69%) met the diagnostic criteria for PTSD

  • This suggests a substantially high prevalence rate of PTSD among the Yezidi community in general, compared to other displaced populations exposed to conflict globally (estimated at 31%).

  • Average score among 16 service users of 2.81 in February (81% of service users met diagnostic criteria for PTSD)

  • Average score among 19 service users of 2.4 in June (45% of service users met diagnostic criteria for PTSD)

  • A 15% decrease in post-traumatic symptoms

  • A 44% decrease in service users meeting diagnostic criteria for PTSD

  • The cohort started with a rate of PTSD higher than the general Yezidi population of Khanke (69%), yet dropped below this average after having completed the programme

WHO-5

Service users of the FYF were screened pre- and post-programme using the WHO-5. Out of 200 women attending the programme, 170 completed the pre-test and 113 the post-test. The lower number of women completing the post-test was due to the logistical challenges of having all participants available for testing in the particular week of evaluation. The average pre-test score was 12.35 (49%, n = 170), and the average post-test score was 22.56 (90.24%, n = 113). This represents an 83% increase in self-reported wellbeing among service users who have completed the programme. The pre-test score was found to be lower in comparison to general population studies conducted in Denmark, where the mean score was found to be 14 (Bech et al., 2003; Ellervik et al., 2014), yet substantially higher upon completion of the programme.

When WHO-5 is used for the screening of depression, a cut-off score of ≤ 10 is used (Topp et al., 2015). At baseline, 45% of participants in this sample fell below this cut-off score, meeting diagnostic criteria for depression upon entering the programme. Service users of the project were screened using the HTQ upon entering the project and again upon graduating from the programme. The baseline prevalence rate of PTSD was 81.25%, with an average score of 2.81. Upon completing the programme, the prevalence rate of PTSD was 45%, with an average score of 2.4. This represents a decrease in service users meeting diagnostic criteria for PTSD of 45%. Despite this, the symptoms decreased on average by only 15%. This suggests that there may be a sub-population who continued to meet the diagnostic criteria for PTSD (without any reduction in symptoms) and who continued to need psychotherapeutic support.

Harvard Trauma Questionnaire

 

Item

Mean score: February 2018

Mean score: June 2018

Percentage increase/decrease

1.

Recurrent thoughts or memories of the most hurtful or terrifying events

2.8

3.2

2.

Feeling as though the event is happening again

2.6

2.5

3.

Recurrent nightmares

3

2.4

4.

Feeling detached or withdrawn from people

2.7

2.4

5.

Unable to feel emotions

2.4

1.9

6.

Feeling jumpy, easily startled

3.4

3.1

7.

Difficulty concentrating

3

2

8.

Trouble sleeping

2.8

1.6

9.

Feeling on guard

2.5

2.1

10.

Feeling irritable or having outbursts of anger

3

2.6

11.

Avoiding activities that remind you of the traumatic or hurtful event

3.3

2.7

12.

Inability to remember parts of the most traumatic or hurtful events

2.5

2.2

13.

Less interest in daily activities

2.7

2.1

14.

Feeling as if you don't have a future

2.3

2.7

15.

Avoiding thoughts or feelings associated with the traumatic or hurtful experience

3.1

2.7

16.

Sudden emotional or physical reaction when reminded of the most hurtful or traumatic events

2.9

2.2

Total mean

 

2.8

2.4

It is interesting to note that, despite a clear reduction in symptoms of trauma globally, there was an increase in symptoms related to question 14 of 19% (feeling as if you don’t have a future). This may not necessarily relate directly to symptoms of PTSD but could be more related to the ongoing sociopolitical and economic environment in which the population finds themselves, including poor material living conditions and prospects for the future.

There was similarly a 12% increase in self-reported “recurrent thoughts or memories of the most hurtful or terrifying events.” Given the overall reduction in post-traumatic symptoms, this is an anomaly. A full understanding of the reason for this increase is beyond the scope of this paper. It would be interesting to explore the reason behind this through qualitative interviews. As has been suggested in literature on refugee mental health (Steel et al., 2016), one hypothesis could be the reduction in dissociative symptoms associated with trauma leading to service users being more able to think about or remember the events—the relatively safer space of the camp in general, and the project in particular, allowing them to confront these thoughts and memories.

The most significant improvement in symptoms was a 41% decrease in having trouble sleeping, and a 33% decrease in having difficulty concentrating. The overall decrease in symptoms may be attributed to a variety of factors—including as a reflection of the efficacy of the MHPSS intervention in reducing symptoms, as well as the simple fact of time having passed because the traumatic events experienced by the population as they were forced to flee their homes.

Case Study Three: Marawi, Philippines

On 23 May 2017, affiliated militants of the Islamic State (IS), including the Maute and Abu Sayyaf Salafi jihadist groups, launched an attack on the Philippine government security forces in Marawi, Mindanao, the country’s largest Muslim-majority city. It was a planned effort to establish an ‘IS province’ in the Philippines. Government troops took an unexpected five months to liberate Marawi, at a cost of near-total destruction of the old city and displacement of some 350,000 citizens (who became ‘internally displaced persons’, or IDPs), plus more than 1,000 dead. Then, on 22 December 2017, tropical storm Tembin (known as Vinta in the Philippines) struck Mindanao Island and turned another 100,000 people, already living in the IDP reception areas following the violence, into new IDPs, and also added several hundred dead.

The recent Marawi crisis is not an isolated traumatic incident or event. Rather, it reveals a context and pattern of deeply engrained complex trauma dating back generations, related to:

  • Historical and intergenerational trauma

  • Intra-familial trauma, including Rido

  • Endemic political violence

  • Violent extremism

  • Sexual Gender-Based Violence (SGBV)

  • Natural disasters

  • History of forced evacuations/displacement.

Furthermore, the current context is characterised by long waiting lists for resettlement, the impossibility for many to return to their homes, increased reports of SGBV and of young women sent away to Manila and elsewhere to earn money as commercial sex workers, rising tension among IDPs and host communities, and a risk of compassion fatigue among host communities and even engaged humanitarian actors. All of this increases the risk of polarisation and violent extremism. This is a critical consideration for the mental health of this community, given the role that exposure to complex trauma may play in the cycle of violence, abuse and aggression.

Method

In response to these events, I was part of a five-member team from the Global Initiative for Stress and Trauma Treatment (GIST-T), in consultation with EMDR Philippines, Philippines Psychiatric Association, Nonviolent Peaceforce (NP) and World Bank Manila, conducted a needs assessment to understand the psychosocial impact of the recent crises in Marawi on the affected population—individuals, families, and local communities. The team was composed of Rolf Carriere, Dr. Derek Farrell, Fr. Cornelio Jaranilla, Dr. Sushma Mehrotra, and myself. The aim was to gather first-hand information from IDPs, review the state of current psychological services available, identify unmet mental health needs, and propose immediate and medium-term ways to strengthen capacity of mental health professionals and paraprofessionals to provide appropriate treatment.

The team interviewed some 120 people, including 80 IDPs for psychometric screening using eight standardized instruments (in four Evacuation Centres and as ‘Homestays’). Others interviewed were 20 humanitarian workers, eight teachers, three psychiatrists and two military commanders. Focus Group Discussions were held with an additional 30 local actors closely associated with the events. The rapid assessment, conducted over a five-day period with the help of four interpreters speaking English, Maranao, Bisaya, and Tagalog, limited itself to parts of the two Lanao provinces. Given these cultural/linguistic challenges, time restrictions and geographical limitations, the results cannot claim to be representative of the whole community. Even so, involvement of local partners allowed the mission access to a wide range of key stakeholders and to a surprising depth of people’s emotions and experiences of violence, abuse and aggression.

Results

  • Nearly half (49%) of the IDPs screened for anxiety with the GAD-7 could be diagnosed with severe anxiety warranting a specialist referral to a psychiatrist.

  • Nearly half (46%) of the IDPs screened for depression with the PHQ9 could be diagnosed with severe depression warranting initiation of pharmacotherapy and psychological treatment.

  • The population of adults who were screened have been exposed to a high number of adverse events in childhood, such as abuse, neglect, violence, and poverty. The average individual screened had been exposed to around three different adverse events in their childhood.

  • 78% of the IDPs screened for PTSD with the PCL-5 meet the criteria for PTSD.

In terms of prevalence rates of PTSD in particular, the focus of this chapter, the more detailed results of the PCL-5 was as follows:

PCL-5 Scores per Cluster ( N  = 80)

PCL-5

Mean

Criterion A

100%

Cluster B (1)

2.5

Cluster C (1)

2.54

Cluster D (2)

2.06

Cluster E (2)

2.29

Total mean

45.19

μ

15.66

Cut-off score

33

Meeting DSM-5 criteria for PTSD

77.5%

The results indicate that 100% of participants reported being exposed to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence through direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to a trauma—diagnostic criterion A of a PTSD diagnosis according to the DSM-5 (Association, 2013). 77.5% met the diagnostic criteria for PTSD.

Conclusion

Significant limitations of all three case studies include the convenience sampling and the small sample size taken by convenience. Meta-analyses of prevalence studies have indicated that small studies have much higher prevalence than the apparent true prevalence (Terhakopian et al., 2008). Another limitation is potential self-reporting bias. Perceived secondary gain for being considered psychologically impacted by the events may have included, for example, the perceived hope of improved access to social, medical, psychological and legal services in all three cases. To minimise the impact of this bias, all participants were clearly informed of the fact that responses to the questionnaire would in no way impact treatment by state mechanisms or NGOs.

Despite this, the prevalence rates of 85, 82 and 78% across these three vastly different contexts are remarkably similar. This is even more remarkable given the fact that they are significantly more than those reported in other long-term refugee populations screened using the HTQ noted above—typically noted as being somewhere between 11.8% (Sabin et al., 2003) and 45.5% (Kun et al., 2009). The results of these case studies indeed attest to the alarmingly high rates of trauma among the displaced populations. Furthermore, they highlight the substantial impact of the political, legal and sociocultural environment on both the prevalence of trauma as well as processes of psychosocial rehabilitation.

It is possible that the high prevalence rate of traumatic stress response symptoms reported could be partly attributed to the current significant levels of environmental stress and insecurity. All three contexts were that of ongoing displacement in a situation of crisis. In all three communities—the trauma was not necessarily linked to one specific catastrophe, but a series of traumatic incidents facing the population collectively. In all three cases, the situation remained unstable—communities often living in appalling conditions, meeting a hostile reception by host communities, and remaining unsure as to whether or not they’d be able to return home. In all three cases, the trauma linked to the precarious nature of this ongoing displacement was not the only trauma affecting the community. It was on the back of multiple traumas dating back generations. Trauma was related to not only direct exposure to human rights violations and other atrocities leading to the displacement itself (in other words, the “headline events”) but compounded variables related to.

  • Multiple losses (home, family members, possessions, socioeconomic status)

  • Fear of ongoing attacks

  • Breakdown of the family unit (due to loss, separation and family members seeking refuge abroad)

  • Poverty

  • Gender roles being threatened due to men losing employment opportunities

  • Poor living conditions in the camps (including cramped living quarters)

  • Feeling “trapped” in the camps

  • Uncertain futures

  • Ethnic discrimination.

Trauma across all three contexts was shown to be related to collective and historic trauma experienced on a community level. For many, the uncertainty as to whether or not their loved ones were alive or dead appears to have complicated the mourning process. Many individuals across all contexts reported feeling as though they are “frozen” in the liminal space of displacement, unable to start on the important and necessary work of grieving. Furthermore, hope that loved ones may still be alive is a double-edged sword—keeping many stuck on a perpetual loop of acute and intense pain, unable to proceed along the emotional journey of mourning.

The prevalence rates of trauma is presented here in this chapter in terms of percentages, in neat figures. Yet trauma is irrevocably collective, symbolic, and deeply political. Can this “dynamic” nature of trauma—the complex inter-relation of factors across multiple levels—truly be measured by instruments such as the HTQ and PCL-5? Is PTSD a valid diagnostic entity? Can it adequately capture the economic, social, and political landscape? Is it culturally relevant? Is it useful—for whom and for what? Yes—high prevalence rates of PTSD were noted among displaced populations in the case studies explored here in this chapter. Yes, we need to be shocked by these figures. They bear witness to deep suffering. Yes, it is important that we take stock of the real challenges people report facing. Yes, the trauma is real, it is there. However, I would argue that we also need to look “beyond” this diagnosis—which in the contexts noted above seemed to have little or no meaning for the communities affected. In the following chapter, I explore some of these questions by providing examining the politicized history of PTSD, the criticisms levelled against it, and the way in which it is understood and used by various actors—including health professionals working with displaced populations across the E.U.