Beyond PTSD

PTSD as a disorder was first introduced as a diagnosis by the American Psychiatric Association (American Psychiatric Association (APA), Diagnostic and statistical manual of mental disorders 1980) in the DSM III in 1980, with interest in it booming to such an extent thereafter that it was referred to in mass media as “the disorder of the 1990s” (Marsella et al., Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications, 1996).

It was notably with this work with veterans of the Vietnam combat in the 1960s that the trauma mental health movement can really be said to have begun. These socio-political forces and trends drove the rise in the popularity and salience of discourses of trauma-including the political momentum produced by the Vietnam Veteran's associations and the anti-war movement of the United States who were seeking recognition of the damages of conflict (Eagle, 2014;Herman, 1997). This later expanded to include female survivors of sexual assault (Burgess & Holmstrom, 1974;Foa & Kozak, 1986;Koss & Harvey, 1991). Another significant wave of interest in the category of PTSD similarly occurred in the nineties, where a surge of humanitarian actors drew on the concept. They used it not only to inform their emergency medical interventions but also as a way to testify to the suffering of populations in the developing world. Indeed, this application of PTSD was fundamental in the formation a new language of political denunciation of the dramas humanitarian actors encountered in the field (d' Halluin et al., 2004). The stage was similarly set for the modern era of research into trauma among refugee populations in particular, with the first studies being conducted among South East Asian refugees-for example Cambodian survivors of the Khmer Rouge (Mollica et al., 1992(Mollica et al., , 1998. PTSD thus has been "glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated and represented and by the various interests, institutions, and moral arguments that mobilised these efforts and resources" (Young, 1995, p. 5). Today, the burgeoning interest in PTSD among refugee populations continues to shape the humanitarian field.

Models of Trauma: Conflicting Theoretical Traditions
Since the 1950s, two main positions on trauma have been articulated (Andreasen, 2010;Eagle, 2014). The first position (the "neurobiological school"), represented by thinkers such as Selye (1950Selye ( , 1956, emphasized how environmental stressors set into motion certain physiological reactions mediated through the nervous and the hormonal systems. Selye coined the term "stress" in the 1950s and hypothesized that physiological reactions to stressors within the environment are mediated by the hypothalamic-pituitary-adrenal (HPA) axis. Within this medical model, the HPA axis is generally considered as a healthy and functional system but maladaptive and physically debilitating under continued exposure to extreme stress. The second position (the "psychological school") was rooted in psychodynamic theory. It considered responses to stress from a more subjective and context-specific perspective by emphasizing the role of the unconscious and of repressed childhood memories in how individuals respond to stressors within their environment.
These two conceptual frameworks, the neurobiological and the psychological, continue to set the stage for debates in the field of traumatology regarding the cross-cultural applicability of PTSD as a diagnostic construct. Is PTSD a universal construct? What is the same and what is different across cultures? Scholars falling predominantly into the "neurobiological school" point to the scientific evidence, particularly neurobiological studies, which have documented that affect regulation and right hemisphere alterations in brain functioning are indeed universal (Schore, 2003). They refer to the stable and consistent neurobiological pattern of changes involving the hyper arousal of the sympathetic nervous system such as the augmentation of the acoustic startle reflex, sleep abnormalities and changes in the H-P-A axis (Marsella, 2010;Marsella et al., 1996). This position highlights neurobiological/physical responses to trauma. These are responses not based on conscious or deliberate meaning, but which go directly to the nervous system as an automatic or "primitive" response based on evolutionary tactics for threat detection and survival (Eagle, 2014;Foa & Kozak, 1986).
In contrast to the neurobiological position, many theorists falling into the second "psychological" school of thought have argued that the location of trauma within a psychiatric/neurobiological paradigm neglects the broader socio-political context. They question the applicability of categories that structure Western psychological discourse, arguing that a diagnostic understandings of traumatic symptoms do not give careful attention to the notion that people's ways of seeing the world, their assumptions, and the discourses available to them, inform the meaning which is attributed to trauma. In short, current discourses on trauma are simply inadequate to grasp the complexity of how different human beings in different cultures respond to terrifying events (Bracken, 2001(Bracken, , 2002Fisher, 2014;Janoff-Bulman, 1985;Kirmayer et al., 2010;Staeuble, 2004;Summerfield, 2001;Tummala-Narra, 2007;Wasco, 2003;Young, 1995). According to Eagle (2014), seen from within this psychodynamic perspective: Formulation of trauma impact requires careful exploration of the manner in which the individual describes the traumatic event and their response to it, including for example, the language they deploy, emphases, omissions, affective tone, and fantasy material; with a view to uncovering pre/unconscious associations to the trauma and the way in which intrapsychic constellations have shaped and/or mapped onto the experience. A strongly ideographic approach is maintained in which trauma impact can only be fully appreciated with a careful personal history taking, formulation of personality constellation and dynamics, and attention to unconscious as well as conscious meanings. (p. 9) This relativistic and individualistic model is in clear contradiction of the "biological" model of psychiatry which seeks to re-position psychiatry as a medical specialty replete with well-defined disorders with identifiable symptomatology and treatment protocols (Marsella, 2010).
A third school of thought, based on the cognitive tradition, recognises that PTSD involves specific cognitive and behavioural responses mediated by forms of learning and memory, as well as processes of recall and narrative elaboration that are regulated by the personal as well as socio-cultural meaning of the traumatic events (Kirmayer, 2001). The respective fields of ethnopsychiatry in the French tradition Aroche & Coello, 2004;Georges Devereux, 1967;Fassin, 2000;Moro, 1992;Nathan, 1986;Sironi, 1999), transcultural psychology (Moro & Baubet, 2013), and medical anthropology (Kleinman, 1978) are among the disciplines which have long criticised the use of PTSD as a nosological category-considering it to be the result of dialogue among different actors who create normative models to explain and treat suffering relating to trauma. Much criticism from the field of medical anthropology, for example, calls attention to the exclusion of alternate illness presentations related to trauma and a neglect of the role of contextual factors in the emergence and characteristics of psychopathology (Lewis-Fernández & Aggarwal, 2013). This, they argue, leads to a pathologization of reactions to trauma in part to determine social, cultural, and administrative acknowledgments and consequences.
On reflecting these different theoretical positions, Eagle (2014) wryly notes that "reading the traumatic stress literature (or at least a substantial proportion of it) it is sometimes difficult to comprehend that writers are describing the same phenomenon" (p. 47). She refers to Laqueur's (2010) observation that trauma is much of a moral as it is a medical category, and to Fassin and Rechtman's (2009) suggestion that trauma is a "floating signifier that denotes any number of ills which have the name" (p. 19). She concludes: "thus on the one hand we have the validity of traumatic stress ultimately tied to its location in neurophysiology or anatomy, and on the other, a suggestion that traumatic stress is to some extent a discursive or epiphenomenal construction with political and strategic effects. It is difficult to see how these positions might be reconciled" (p. 47). Fisher (2014) similarly examines this debate and postulates that both the "biological" and "psychological" interpretations of PTSD may be true. He concludes that biopsychic realities, identified through biomedical knowledge structures, do indeed underlie the PTSD construct while the manner in which the disorder manifests is equally informed and shaped by the cultural meanings and perceptions attached to trauma. In other words, he views the disorder from within a "social diagnosis" framework which presumes that individuals contribute to the creation of a diagnosis which is inextricably linked to political, economic, cultural and social factors. His argument is linked to social constructionist critiques of medical diagnoses in general, as outlined in depth by Brown (1995) and others such as Goguikian Ratcliff and Rossi (2015) and Turner (1992) who have opened up a sociological debate about illness and advocate for attention to be paid to the individual social experience, language and symbols in order to deconstruct politically charged diagnostic categories and definitions. These ideas are based on Foucealdean (Foucault, 1988) principles of social constructionism which emphasize the role of language, definition-making, symbols and structures in psychiatric "illness" experiences and actions regarding the body, necessarily situated within personal, dyadic and group levels. Such a paradigm would imply that a thorough, integrative understanding of the multiple dimensions of each context is needed (Weine et al., 2002). As such, it is rooted in wider Foucauldian critiques of the way in which the production of academic and professional psychology has led to the "governing of the soul"-through a range of "technologies of subjectivity" that regulate human behaviour, often in ways that sustain deeply problematic power relations (Campbell & Cornish, 2014).

What Is "Trauma"?
One particular point of criticism highlighted is the fact that PTSD by its very definition requires a "traumatic" event to have taken place, which in itself relies on the subjective experience of the individual and subsequent cognitive appraisal of the event. The very first criterion required to meet the diagnosis, known as "Criterion A" according to the DSM-V (APA, 2013) is an "exposure to actual or threatened death, serious injury, or sexual violence" (p. 271). Thus, an explicit causal mechanism is built into its very diagnostic criteria. This is inherently related to the socio-political and historical context in which the diagnosis was developed. Indeed, the experience of war has been a central element in the search for relatively delineated traumatic events, such as a robbery, disaster, or traffic accident, mainly stemming from the second half of the twentieth century, when the psychological aftermath of World War II was being explored (ter Heide et al., 2016). As such, it was heavily based on assumptions of an otherwise "benign universe" being disrupted by a concrete isolatable event.
The reality, however, is not as simple. Not all trauma experiences relate solely to isolated events in the context of an otherwise stable environment. There are many ethical and clinical challenges associated with being able to identify a clear and discrete event as being "traumatic" required by its very definition for PTSD to be diagnosed. According to Maier and Straub (2011), the causal attribution of symptoms to a single traumatic event inherent to diagnosing PTSD represents the prevailing biomedical concept of illness, yet is certainly also one of the most significant shortcomings of psychotraumatology. Are the same events necessarily experienced as "traumatic" by everyone? What components determine whether an event is subjectively perceived as "traumatic" or not? Questions remain about the common elements underlying the diverse experiences of people across the world, and critics of a unifying model of PTSD therefore challenge the assumption that the same responses to a stressor would manifest across a multiplicity of events and contexts Momartin et al., 2003;Tummala-Narra, 2007). These critics view the context of trauma as shaping and in turn being shaped by worldview, cultural norms and constructions of society and individual victims. Trauma is therefore not a disembodied construct linked to a discrete event but a cultural and historical construction . As Silove (1999) notes, it is possible that the significance and meanings underlying trauma experiences are more important than the concrete details of discrete events in determining risk to PTSD Considered from this perspective, PTSD is not a consequence of trauma but of the interaction between trauma and culture, specifically trauma experienced within an individualized western context (Bracken, 2002).
Recent research has highlighted substantial differences in the ways in which people experience ongoing trauma as opposed to those who have experienced a discrete traumatic event (Nicolas et al., 2015). PTSD, however, does not take into account the nature of the trauma-the near dead, horror, fear, the unthinkable, the unspeakable-in other words, the "trauma story" which may be experienced both singularly and collectively (Maqueda, 2005). For people whose lives are characterized by ongoing hardship, often shaped by discrimination, poverty and other current and future dangers, traumatic events may fall within a continuum of suffering and may not be singled out or experienced with the same precision as the definition of PTSD appears to demand (Eagle, 2014). Furthermore, individuals with a trauma history rarely experience only a single traumatic event but rather are likely to have experienced several episodes of traumatic exposure (Cloitre et al., 2009). In many countries around the world, conflict is not an abnormal situation of short duration but rather a "fait connu" (Summerfield, 1996, p. 33), influencing all aspects of political, socio-economic and cultural relations in a society. As such, extreme trauma owing to torture and war is both an individual and collective process that refers to and is dependent on a given social context, marked by its intensity, extremely long duration and interdependency between the social and the psychological dimensions (Becker et al., 1990).
In a study conducted by Maier and Straub (2011) among a sample of refugee patients in a health clinic in Zurich, they noted that many of their patients complained more about their current living conditions than they did about earlier trauma: Many patients perceived their (then) current suffering not as a consequence of identifiable traumatic events, but as a delayed consequence of their earlier lives under inhuman conditions. This concept is much broader than just the impact of a torture experience or war scene, and it comprises the impact of longer periods of life characterized by a constant threat, a general and complete negation of the values of humanity, and permanent feelings of helplessness (p. 235).

They continue:
No participant mentioned a mono-causal concept of illness; none of the patients believed that a single traumatic event, or even a single experience of torture, was an adequate cause to provoke his or her symptoms. Therefore, the academic concept of PTSD (i.e., identifiable traumatic events directly provoking pathological symptoms) seems to have had limited explanatory value for these patients. However, many of the interviewees gave meaningful testimonies regarding how they lived over long periods of time under inhuman conditions of war and oppression… If their explanatory models had to be situated in the area between biological, psychological, and social concepts, they tended to relate mainly to social and psychological categories (p. 244).
Several studies on refugees and asylum seekers have confirmed this clinical impression (Silove, 1999;Silove et al., 1998;Van Ommeren et al., 2001). In their intriguingly titled paper, 'Is life stress more traumatic than traumatic stress?, ' Gold et al. (2005) studied traumatic events among four hundred and fifty-four college undergraduates and found that those who reported a traumatic event which met the diagnostic criteria for DSM displayed fewer symptoms of PTSD then those who had not been exposed to a traumatic event meeting diagnostic criteria. This finding highlights the current debate regarding whether or not to remove "Criterion A" from the diagnosis of PTSD, a criterion which appears to reflect political or moral imperative alongside scientific/diagnostic considerations (Eagle, 2014). In a seminal paper on the topic, Brewin et al. (2009) argue that PTSD's "dependence on the etiological criterion is now more of historical interest rather than practical importance." The notion of prolonged exposure to trauma as potentially resulting in a "complex PTSD" pathology was first developed by -and has since become an integral concept in the literature examining the complex and prolonged traumatic experiences of refugee communities (Droždek et al., 2003;Mollica et al., 1998;Momartin et al., 2003;Schweitzer et al., 2006). The notions of "cumulative trauma" first developed by Khan (1977), "complex PTSD" developed by Herman ( , 1997, "extreme trauma" developed by Becker (1990) and 'Continuous Traumatic Stress' introduced by those offering psychological services to political activists during the repressive apartheid years in South Africa (Eagle, 2014;Eagle & Kaminer, 2013), were all constructs developed to conceptualize trauma as having been accumulated over time through exposure to repeated stressors within the environment.
Becker (2004) defines extreme trauma thus: Extreme traumatisation is an individual and collective process that refers to and is dependent on a given social context; a process that is marked by its intensity, its extremely long duration and the interdependency between the social and the psychological dimensions. It exceeds the capacity of the individual and of social structures to respond adequately to this process. Its aim is the destruction of the individual, of his sense of belonging to society and of his social activities. Extreme traumatisation is characterized by a structure of power within the society that is based on the elimination of some of its members by other members of the same society. The process of extreme traumatisation is not limited in time and develops sequentially. (p. 5).
Considering trauma thus as a process, elements of temporality are highlighted, as is the continual interaction of the person with their environment in a given social and historical context. What is particularly interesting in these conceptualisations is the highlighting of the socio-political context and power dynamics at play in influencing the mental health of whole populations. Indeed, considering the 'elimination of some of its members by other members of the same society' referred to in the definition is pertinent both to situations of conflict as well as to societal dynamics at play for refugee communities attempting to integrate into host societies and facing possible discrimination.
The concept of cumulative trauma similarly incorporates dimensions of time and the interactive relationship between an individual and his/her ecological surroundings into the discussion regarding trauma, thereby transforming the event (traumatic experience) into a process over the individual's entire life trajectory (Droždek et al., 2020;Khan, 1977). The concept of continuous traumatic stress (Eagle & Kaminer, 2013) likewise developed in opposition to existing conceptualizations of traumatic stress which retained the assumption that traumatic experiences have occurred in the past. This is due to the fact that many patients living in apartheid South Africa faced the realistic prospect of future victimization and were often living under precarious circumstances, including moving from one potential place of refuge to another. As such, the concept is intended to more accurately capture the "experiences and impact of living in contexts of realistic current and ongoing danger" (Eagle & Kaminer, 2013, p. 85). It does this by taking into account the context of the stressor conditions, the temporal location of the stressor conditions, the complexity of discriminating between real and perceived or imagined threat, and the absence of current external protective systems by the state.
Complex PTSD, in comparison, refers not to trauma having accumulated over time specifically, but is used more to describe severe cases PTSD with comorbidity (dissociation, depression, substance abuse, personality disorders etc.). It is not recognized as a discrete disorder in psychiatric classifications (Droždek, 2015b). However, the topic has gained new impetus in recent years, with an official complex PTSD diagnosis has been proposed for inclusion in the 11th version of the International Classification of Diseases (Maercker et al., 2013;Nickerson et al., 2016;Silove et al., 2017;ter Heide et al., 2016). The clinical definition of complex trauma 1 has gone virtually unchanged since its conception, with the ISTSS guidelines for complex PTSD speaking of "exposure to repeated or prolonged instances or multiple forms of interpersonal trauma, often occurring under circumstances where escape is not possible due to physical, psychological, maturational, family/environmental, or social constraints" (Cloitre et al., 2012, p. 4). Many refugees, almost by definition, meet these definitions. They have left their country of origin because of persecution, war, or organised violence. There is some preliminary evidence for the validity of Complex PTSD as a diagnostic construct among highly traumatised refugees emerging in the literature (Nickerson et al., 2016;Silove et al., 2017)-yet a plethora of research shows that refugees are more likely to meet a regular PTSD diagnosis or no diagnosis than a complex PTSD diagnosis, and that prevalence of complex PTSD in refugees is relatively low compared to that in survivors of childhood trauma (ter Heide et al., 2016). As such, the literature raises many questions regarding the clinical relevance and utility of both a simple and complex PTSD diagnosis among refugee communities.

Conflicting Concepts of Trauma
If PTSD were to exist between individuals and not only in them, the construct not only would be incapable of understanding the phenomenon but would also influence the appearance of the illness, treatment strategies (Becker, 1995). We need to see beyond narrow western constructs illness at the level of the individual (Nickerson et al., 2011). This is particularly true of researchers and clinicians working within collectivist 2 communities wherein individuals rely more heavily on larger family systems and where mental health is typically seen to be more linked to a broader socio-cultural context Tang, 2007). As Tang (2007) notes: "cultures differ regarding their dominant ideas about the ontology of self as well as relationship between self and others, between self and the universe, and between life and death." (p. 129).
From an historical perspective, cultures have been conceptualized as falling into two categories: the individualistic (guilt) and the collectivist (shame) cultures . In other words, in more typically Westernized societies, the emphasis is on guilt. Self-esteem, and the general moral judgement of behaviour, is based on individual competition. In more collectivist societies, the emphasis is on shame linked to (a lack of) cooperative behaviour. In simplistic terms, shame is based on the judgement of the other, guilt is based on our own moral judgement of our behaviour. Shame is external (located interpersonally), guilt is internal (located intrapersonally). Shame affects our entire sense of self, guilt is a judgement on specific behaviour. Tankink and Richters (2007), for example, refer to communities in South Sudan. Here, they noticed that research participants were framing their sense of identity from a collective perspective. In other words, they were presenting a more "family self"-an identity inherently based on relational models. Even the experiences of the self were described as being located on an intersubjective plane, rather than an intrapersonal one.
Bracken (2001) reflects on this individualistic versus collectivist cultural debate in the field of traumatology, similarly arguing that PTSD as a diagnosis is too heavily focused on a western understanding of illness as situated within an individual, neglecting the social or familial context. He quotes the reflection of Jenkins (1996) in her work with Salvadorian refugees: Because traumatic experience can also be conceptualized collectively, person-centred accounts alone are insufficient to an understanding of traumatic reactions. In addition to the social and psycho-cultural dynamics surrounding any traumatic response, the collective nature of trauma may be related to what was ... referred to as the political ethos characterizing an entire society (Jenkins, 1996, p. 177). and Summerfield's work with Nicaraguan refugees: Western diagnostic classifications are problematic when applied to diverse non-Western survivor populations. The view of trauma as an individual-centred event bound to soma or psyche is in line with the tradition in this century for both Western bio-medicine and psychoanalysis to regard the singular human being as the basic unit of study" (Summerfield, 1997, p. 150).
Current thinking around responses to trauma shares the same fundamental assumptions with mainstream psychiatry in remaining too focused on an individualistic and positivist agenda, based on a split between 'inner' mind, which can be investigated scientifically, and the "outside" world (Bracken, 2001). This "reductionist discourse" locates the experience of distress solely within the intrapsychic realm of the individual, defining subjective experiences of trauma in terms of "illness, recovery, and broken brains"-a master narrative arguably unrepresentative of each individual's lived subjective experience (Adame & Knudson, 2007, p. 157).
Thus, it is evident that an individual's response to trauma necessarily be embedded within a socio-cultural context. Furthermore, one could further problematize this individual versus collectivist dichotomous split by acknowledging the fact that it is not only individuals themselves who face traumatic events, but indeed entire communities. Eagle (2014) refers to notions of collective or historical trauma whereby whole groups of people carry a sense of common persecution or victimization: The idea of historical trauma is associated most strongly with the history of first nation people in America and the genocidal violence to which they were subjected. Collective trauma is the term that tends to be used about the response of groups of South Africans subject to a brutal apartheid and colonial history, as well as about the response of groups of Jewish people to the Holocaust. Such trauma may be understood to be transmitted intergenerationally via both conscious and unconscious mechanisms, such that those of generations post those directly victimized nevertheless carry the experience of trauma within themselves. In some respects identity and collective trauma come to be intertwined. Such conceptualizations of trauma may encompass a somewhat broader definition of traumatic stressors including not only relations of oppression that threaten actual survival of the group, but also more ideological forces that threaten the eradication of cultural or group identity. In this framework racism, xenophobia or fundamentalisms based on oppression may be understood to produce collective traumatisation. (p. 13) She suggests that persons may be traumatised at multiple levels including collective/social, personal/physical and role identity levels, and that which of these levels is most salient at a particular point in time will be dependent both on life history and current environment. This point is no more pertinent to bear in mind than in the case of refugee populations, often faced with a plethora of traumatic events on a collective level.

The Problem of Pathologization
In a recent paper, Droždek and colleagues (2020) have highlighted the "hidden" longterm impact of war and violence, including "dissociative states, attachment problems, personality changes, guilt, shame, rage, identity issues, moral injury, substances abuse, damaged core beliefs, and bodily sensations linked to stress activation." (pg. 1)-difficulties not adequately captured by a PTSD diagnosis. The PTSD diagnosis has been criticized for its failure fully to account for all of the changes and comorbid clinical presentations that are common among people who have experienced prolonged exposure to potentially traumatizing events Kirmayer et al., 2010;Steel, 2001;Wilson & Droždek, 2004). The existence of the stressor criterion (Criterion A) implies a unique relationship between trauma and PTSD, yet trauma is also associated with an increased prevalence of other disorders, most commonly depression, generalized anxiety disorder (GAD), panic disorder, and increased substance use (Brewin et al., 2009). Not only is it "too little" in accounting for all responses to trauma, it also "too much" in prescribing symptomatic responses which are not necessarily found among different populations across the world. In a meta-review of the literature, Hinton and Lewis-Fernandez (2011) found significant cross-cultural variability which cannot be ignored, including the salience of avoidance/numbing symptoms (far more common among western populations and which Bracken (2001) argues is a specifically westernized postmodern construct), the role of the interpretation of trauma-caused symptoms in shaping symptomatology, and the prevalence of somatic symptoms which were generally found to be more common among culturally diverse samples. Maier and Straub (2011) observed the following among a sample of refugee patients diagnosed with PTSD: Whether they suffered from flashbacks and nightmares, general anxiety, sleeplessness, irritability, chronic pain, or depression, the participants considered the symptoms to not be specific indications of any particular disorder, but merely general expressions of distress. The symptoms, although very discomforting, did not seem to be sufficiently mysterious or confusing to the participants to make them repeatedly search for (medical) explanations and clarification. (p. 239). Wilson (2004Wilson ( , 2005 as cited in Drož - dek  has discussed the unique nature of trauma archetypes and trauma complexes and suggests that the experience of trauma is both universal and archetypal for the human species yet with specific manifestations of trauma complexes informed by culture. According to him, PTSD does not take into account the whole spectrum of the post-traumatic change, including core belief changes, dissociative moments, ruptures in the growth and development of the personality or other comorbid disorders such as depression, substance use and somatization, a view endorsed by many others in the field (Drož - dek Kirmayer et al., 2010;Marsella, 2010;Marsella et al., 1996).
According to Wilson and Droždek (2007): Posttraumatic syndromes involve a broad array of phenomena that include trauma complexes, trauma archetypes, posttraumatic self-disorders and posttraumatic alterations in core personality processes (e.g. the five factor model), identity alterations (e.g. identity confusion) and alterations in systems of morality, beliefs, attitudes, ideology and values. The experience of psychological trauma can have differential effects to personality, self, and developmental processes, including the epigenesis of identity within culturally-shaped parameters …given the capacity of traumatic events to impact adaptive functioning, including the inner and outer world of psychic activity, it is critically important to look beyond simple diagnostic criteria such as PTSD to identify both pathogenic and salutogenic outcomes as individuals cope with the effects of trauma on their lives. (p. 371) It would seem that the diagnosis of PTSD is simply inadequate to capture this vast range of responses. As Lewis-Fernández (2010, 2011) note, even within the strict frame of the DSM, traumatic exposure can lead to multiple syndromes, including acute stress disorder and adjustment disorder, as well as major depression, panic disorder, and dissociative identity disorder. Such criticisms raise legitimate concerns surrounding the shortcomings of the diagnosis in capturing the full range of human experiences in the aftermath of trauma. These criticisms hold true if viewed from the more narrow perspective of a clinical or "medical diagnosis" paradigm even before one widens the frame to consider broader social-constructionist criticisms of diagnoses in general.
Looking beyond the frame of the DSM, Young (Young, 1995) suggests that the diagnosis is just one part of a dynamic process of individual adaptation to adversities in life and shouldn't be considered as merely a diagnostic entity in and of itself. In his interactive model of individual reaction to trauma within a socio-cultural context, Chemtob , as cited in Droždek & Wilson, 2007 also describes responses to trauma as an inevitable interaction of the universal aspects of reactions to trauma and violence with the culture-bound reactions and the personal history of the trauma victim. Scientific research on PTSD, however, has been criticized for remaining badly skewed towards the study of psychopathology rather than on the growth, selftransformation, and resilience often observed among survivors of trauma (Roberto & Moleiro, 2016;Tummala-Narra, 2007;. Papadopoulos (2002b) notes how the predominant way in which refugees are viewed today is in terms of trauma theories, stating that "although there are numerous and varied theories about the related themes of conflict, violence, power, identity, ethnicity, trauma, etc., it seems that there is unanimity about one prevailing belief that according to which almost everybody affected by war experiences and political oppression is traumatised." (p.26). Despite this prevailing belief, the relevance of diagnosing PTSD among refugee populations has been criticized by scholars such as Summerfield (1996), Haans et al. (2007), Mattar (2011) and Sturm (2010). They highlight the limitations of western clinicians attempting to apply this medicalized construct among ethnically diverse populations with questionable relevance, as a result of having fallen into the "myth of sameness" (Young, 2004as cited in Lindy et al., 2007. According to Papadopoulos (Papadopoulos, 2002b), the "refugee trauma" discourse (p. 26), is a linear concept which implies a clear causal relationship between external events and intrapsychic consequences. As such, it ignores systematic complexities such as the relational nature of the event's impact among family, community, and ethnic group members, as well as the effects of the wider societal discourses which colour the meaning, emphasis and quality of events and experiences. Kirmayer (in introducing Droždek & Wilson, 2007), similarly notes that:

Criticism of the Use of PTSD as a Diagnosis Among Refugee Communities
PTSD is a limited construct which captures only part of the construct of violence, ignoring issues of loss, injustice, meaning and identity that may be of greater concern to the traumatised individuals and to their families. A clinical focus on the symptoms of distress that presented by the refugee, survivor or victim may draw away from contexts that define their identities and possibilities. As time wears on, the salient concerns for survivors become less focused on the meaning of the past than the realities of the present, and possibilities for the future. For refugees, this shift in temporal perspective underscores the crucial importance of their place in host societies. (p.vi) A significant criticism of the PTSD diagnosis noted by Hinton and Lewis-Fernández (2011) involves its dangerous potential for medicalizing human suffering; that is, for reducing the social and moral implications of traumatizing events, such as war or genocide, to a strictly professional, even biological, set of consequences. Thus, by emphasizing the "reality" of PTSD as a universal biopsychological category, a focus on PTSD may have unintentionally and paradoxically helped decrease social and moral responsiveness to these events. As Herman (1997) argues, this is another way for the political and social reality causing traumatic events to be denied or pushed out of our collective conscious. This would be particularly true, for example, in cases of war, which typically terrorizes and destroys entire communities, including social networks and collective identities. In such instances, it is likely that even those who have survived personal atrocities would deem their injuries to be social and political rather than psychological (Summerfield, 1996).
A very obvious but often neglected point is that not all refugees are traumatised. Recent research suggests that, despite a substantially higher prevalence rate of mental health disorders noted among the population, most refugees are not suffering from mental disorders and most appear recover to recover from distress related to experiences of migration within a year of arrival in the host country (Hynie, 2018). As stated by Summerfield (1996Summerfield ( , 1999 in his extensive critique of trauma programmes and other psychosocial interventions of international NGOs: all refugees need social justice, and just some need psychological treatment. He criticizes the assumptions underpinning much humanitarian work informed by western models of trauma. These assumptions, he argues, reflect "a globalization of western cultural trends towards the medicalization of distress" (p. 1449). Marsella (2010), another ardent critic of the use of PTSD in humanitarian settings, quotes Wessels: In emergency situations, psychologists hired by NGOs or UN agencies often play a lead role in defining the situation, identifying the psychological dimensions of the problems, and suggesting interventions. . . . Viewed as experts, they tacitly carry the imprimatur of Western science and Western psychology, regarded globally as embodying the highest standards of research, education, training, and practice. … Unfortunately, the dynamics of the situation invite a tyranny of Western expertise. The multitude of problems involved usually stems not from any conspiracy or conscious intent but rather from hidden power dynamics and the tacit assumption that Western knowledge trumps local knowledge. … Local communities have specific methods and tools for healing such as rituals, ceremonies, and practices of remembrance. Since they are grounded in the beliefs, values, and traditions of the local culture, they are both culturally appropriate and more sustainable than methods brought in from the outside (Wessells, 1999, pp. 274-275).
Refugees are thus placed in the role of passive victims, their own choices, traditions, survival strategies and competencies ignored, and the role of Western "experts" and their technology in the field of mental health exaggerated (Summerfield, 1996).
To illustrate the cultural imperialism inherent in the imposition of psychological knowledge, Summerfield (1996), provides the example of the conflict in Rwanda in the 1990s which lead to many international NGOs implementing "psychosocial interventions." One of these interventions included an evaluation of the "knowledge learnt" about trauma by refugees-raising the interesting question of whose knowledge is being prioritised in a context where the local language, Kinyarwanda, does not include a direct translation of the word for "stress." He has been vociferous in his condemnation of this approach which, in his view, pigeonholes refugees as suffering from PTSD but pays scant attention to their own perceptions and interpretations of distress and their choices in terms of treatment (Summerfield, 1996(Summerfield, , 1999Watters, 2001). Losi (2002) is another ardent critic of humanitarian interventions focused on PTSD, arguing that it leads to a reductive assessment of the refugees plight, victimization and a shift in the interpretation (and understanding) of the refugees' experiences, where the reasons for their exile are no longer socio-political but belong to a more neutral, "technical" dimensions. He demonstrates how this de-contextualization of the lived experience of refugees leads to languages and concepts being lost and replaced by medical jargon and obscure terms. Simply put, imposing pre-packaged "universal" interpretations, definitions, tools, and approaches to human psychological suffering does not bring them the help they need. According to Watters (2001) a useful way of conceptualising the needs of refugees may be through the construction of a Maslowian hierarchy of needs wherein humanitarian interventions attend initially to needs relating to physical well-being, such as food and shelter and safety, before "higher-level" needs relating to psychological wellbeing are attended to.
In short, diagnosing an individual with PTSD may serve as a form of western cultural imperialism (Steel, 2001). The act denies the resilience of survivors (Marlowe, 2010) and serves to reinforce existing imbalances of power between Western "expert" and "victim-patient" (Summerfield, 1996). As stated by Pupavac (2002): Internationalization and professionalization of adversity, indigenous coping strategies are thus not merely demeaned and disempowered. The community itself is pathologized as dysfunctional and politically delegitimized (pg. 493).
A narrow preconception of refugees as invariably damaged, weak or scarred, manifest through the use of a diagnosis of PTSD, may have unintended negative consequences for refugee populations by minimizing strengths and positive adaptation mechanisms Marlowe, 2010;Papadopoulos, 2002b;Sturm et al., 2010). Tummala-Nara (2007) explores the notion of "collective resilience" and post-traumatic growth and adaptation among various culturally diverse populations, noting that the research continues to be defined by predominantly middle-class North American and European values based on individualistic principles which "fail to consider the interdependence of individual capacities, salient attributes of family and community, and/or larger cultural belief systems" (p. 34). In response to this criticism, it must be noted that the notion of Post-Traumatic Growth (PTG) has begun to grow into a burgeoning field in the literature on cross-cultural responses to trauma (Calhoun & Tedeschi, 2014;Copping et al., 2010;Knaevelsrud et al., 2010;Marsella, 2010;Tankink & Richters, 2007;Tedeschi & Calhoun, 2004;Tummala-Narra, 2007;Wagner et al., 2007), defined as significant beneficial change in psychosocial well-being, beyond previous levels of adaptation, psychological functioning, or life awareness. This growth includes changes in selfperception, interpersonal relationships and life philosophy (Wagner et al., 2007). More recently, key authors in the field have added the notion of sociocultural influences in their model of PTG-including both proximal family and community as well as the wider (distal) sociocultural environment in general (Calhoun & Tedeschi, 2014;Copping et al., 2010).
The diagnosis of PTSD also neglects to consider the fact that different reactions or non-reactions to trauma-not matching those prescribed by PTSD-may indeed serve as a defensive and adaptive survival mechanism for individuals who may not have the "luxury" of allowing the experience of psychological distress to impede the urgent and daily task of surviving. Refugees from Mozambique and Ethiopia, for example, have been reported in the literature as saying that an active process of forgetting is a culturally normative method used to overcome difficulties (Summerfield, 1996). In such a context, judging individuals according to a predetermined list of symptoms which are either "present" or "absent" is strikingly simplistic.

The Instrumentalisation of the Diagnosis Among Asylum Seekers
As succinctly highlighted by Droždek (Droždek et al., 2020), Nowadays, the PTSD diagnosis is often a prerequisite for the survivor's access to specialized treatment services and for obtaining legal recognition or financial compensation when exposed to violence. However, some survivors do not meet all necessary criteria for the PTSD diagnosis, particularly not in the long term. Therefore, they run the risk of being misdiagnosed, inadequately helped or undertreated, and may remain legally unrecognized and unprotected (p. 1).
A significant criticism of PTSD as a diagnostic construct highlighted within the literature relates to its political use as a tool providing evidence of "damage" in order for individuals to claim quite concrete benefits. Fisher (2014), for example, explores the skewed and often confusing incentive structure for soldiers in the American military to claim a diagnosis of PTSD for obvious secondary gain. Among refugee populations more specifically, such a diagnosis may open the door for access to care (Brown, 1995) or assist the asylum-seeking process. However, this political use brings significant risk as well as potential benefits. d 'Halluin (2009) convincingly demonstrates the dangers inherent in this contentious relationship between immigrant, medicine and social security by arguing that multiple investigations and abundant political discourses relating to the 'safety' of welcoming refugees into Europe or not began with psychiatrists in the 1970s and continues to this day. The result, she concludes, is that the diagnosis has ultimately become a 'pre-requisite' for validating the experiences of migrants, reifying and reducing these experiences by placing them within an exclusively psychiatric paradigm. Furthermore, she argues, by pathologizing asylum seekers, mental health damages inherent to this population have been used in anti-immigration public discourse to highlight security issues related to refugees as a damaged, diseased 'other'. As such, PTSD as a political tool has indeed been used to limit and control the influx of migrants. A worrying trend she observes by using the example of France is the way in which the supposedly poor mental health of refugees has similarly been used to justify limiting their right to work in host countries, adding further fuel to a disempowering, victimizing fire. It also serves to detract attention away from the structural violence inherent in the asylum seeking procedure of host countries to which many asylum seekers are exposed-a colonization of intimate psychic spaces in a manner of speaking.
For asylum seekers and their lawyers, the medical certificate, including evidence of PTSD, is an "open sesame" (Fassin & d'Halluin, 2005, p. 600); for officials and judges it is a piece of evidence among others; and for both it is an innovation in governmentality. This labelling of asylum seekers is supported by a system in which tabulation of numbers with psychiatric labels forms a crucial basis for the mobilisation of broader social supports (Watters, 2001) and a new form of the transnational administration of people (Fassin & d'Halluin, 2005). It risks tearing individuals away from the potential protection of their own resilience as well as from their community's traditional means of coping with trauma (Losi, 2002). As Papadopoulos (2002b) argues, in our efforts to express our justified condemnation of the individuals, groups and policies that lead to political oppression and crimes against humanity, we offer as 'proof' the fact that people have been 'traumatised' by these despicable actions. In doing so, we ignore all psychological considerations of how people process experiences and, unwittingly, we end up doing violence to the very people we want to help through psychologizing the political dimensions of human suffering.
In terms of Article 1, Chapter 1 of the Geneva Convention of 1951, a refugee is defined as being someone with a "well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion." The word "fear" here is of particular interest as it implies that a refugee is defined by his or her psychological response to events, not to the events themselves. This discursive shift away from a wider understanding of the political context from which refugees may be fleeing, towards a narrower and more medicalized concept of such refugees as suffering from PTSD, may also lead to the moral disqualification and criminalization of unsuccessful asylum seekers who are not found to be "traumatized" (Sturm et al., 2010). According to Summerfield (1996) such a politically loaded use of PTSD indeed leads to "absurd" (p. 14) situations whereby victims of torture and other atrocities fear not being believed unless they can 'check off the tick list of symptoms' required to be diagnosed with PTSD He notes that it would be terribly ironic if the survivors of trauma felt that their best chance of getting any help was to position themselves in the role of victim and diminish their knowledge, their anger at injustice and their resilience.
This poses a dilemma for health professionals working with asylum seekers. They may in fact be seen as agents of de-culturalisation and de-politicisation in that they transfigure the refugees' accounts of atrocities into individualised pathologya process refugees themselves may not be averse to as it may be the only avenue available to secure wider legal and welfare benefits. Fassin and d'Halluin (2005) quote the June 2002 newsletter of the organization Primo Levi which aptly asks, "does one need a paper to prove torture?" The authors state: For immigrants, the poor, and more generally, the dominated -all of whom have to prove their eligibility to certain social rights -[the individual body and mind] has also become the place that displays the evidence of truth…asylum seekers are more and more submitted to the evaluation of their physical sequels and psychic traumas, as if their autobiographical accounts were not sufficient… Medical authority progressively substitutes itself for the asylum seekers' word. In this process of objectification, it is the experience of the victims as political subjects that is progressively erased (p. 597).
They argue that the medical certificate is detached from the lived experience of the victims of persecution, attempting a process of objectification through expert's words and thus desubjectifying individual narratives. A health professional they interviewed is quoted as saying that "by issuing certificates, we're busy judging who's guilty and who's innocent. What situation are we in? We're neither experts nor jurists" (p. 601). Another explains: "it is part of a programme designed to destructure and depersonalize the individual" (p. 602). This highlights the multitude of challenges often posed to health professionals, torn between the "moral demand" for PTSD to be diagnosed at the risk of influencing the therapeutic relationship, which by definition is less based on 'truth funding' and more on an exploration of the subjective experience of the individual. For many professionals who find themselves on the horn of this dilemma: "it is their burden and their duty to testify" (p. 604). The other health professionals interviewed by the authors similarly perceived the gap between the meaning that potentially traumatic acts can have for the people who were subjected to them and the "semantic reduction" (p. 603) of the clinical examination and medical report.
Despite the potential damage caused to the individual by the use of a PTSD diagnosis, there are instances where it can be used in the service of marginalized individuals or groups. Drawing up a certificate is a way of validating the violent acts and traumatic events to which the individual has been subjected-not only are people listened to, it is a recognition that the suffering has been seen. It thus carries a deeply symbolic value. Eagle (2014) refers to research conducted by Foster, Davis andSandler (1987, as cited in Eagle, 2014) on the impact of torture and detention of political activists in apartheid South Africa which was used to substantiate that individuals have been subject to terror or traumatizing conditions, thereby placing moral pressure on the Nationalist government; as well as the mental health evaluations of political refugees that corroborate their need to escape ongoing brutality from repressive regimes (Steel et al., 2009). Furthermore, within the asylum seeking procedure itself, a recognition of trauma may assist judges and other decision makers in recognizing and being more attentive to the difficulties asylum seekers may have in verbalising and constructing their case as a result of a compromised mental state which "may impede the applicant's ability to testify in a manner that appears direct, specific, and emotionally appropriate" (Linton, 2015(Linton, , p. 1085. As Steel (2001) notes, making use of the PTSD diagnosis may present a doubleedged sword. On the one hand, it may serve as an acknowledgement of the deep pain experienced by survivors of trauma and assist in getting the required help. On the other, it risks becoming a trendy 'catch-all' diagnosis open to various forms of political abuse or manipulation. What is needed is not a complete throwing of the metaphorical baby out with the bathwater, but a more nuanced and sophisticated appreciation of trauma in its various forms, an understanding which is less politically motivated and which more accurately reflects the lived experiences of individual survivors of traumatic events-including diagnostic constructs and tools which serve the best interests of those genuinely in need.

Conclusion
One could deconstruct the very notion of "PTSD" by breaking it up into its various linguistic constituents (Post, Traumatic, Stress and Disorder) in order to summarize some of the major criticisms cited above which have been levelled against it. The first word, "Post," refers to a discrete event of the past, thus denying the mental health impact of any ongoing factors of stress based on current economic, political and social hardships faced by refugee populations. The second word, "Traumatic," is problematic insofar as whether an event is perceived to be 'traumatic' or not is in part influenced by the individual's subjective perception of the event, in turn significantly informed by socio-cultural and historical context. The third word, "Stress" implies a specific reaction to the event based on a pre-determined range of psychological symptoms, thereby neglecting the wide variety of possible reactions an individual may have to a traumatic event. The fourth word, "Disorder," necessarily pathologises this reaction, placing it at the level of the individual and squarely within the framework of a Westernised medical discourse.
By framing trauma in clinical and psychiatric terms, PTSD has the power to legitimise certain forms of victimhood, victimization and suffering. It is not a politically nor socially neutral construct. Rather, notions of who exactly qualifies as a "victim of trauma" are structurally, ideologically, and discursively located (Eagle, 2014). Such a conceptualisation of trauma, than, situates suffering within specific social and historical context. Through creating "victims" or "survivors," it has the power to direct attention away from sociopolitical sources of suffering, towards a sense of damage and entitlement. By ignoring the quintessential soiocultural and political dimensions of this suffering, we restrict the individual to the role of patient-victim, rather than recognising them as an active participant in their recovery, and an active participant within their community (Van Der Kolk, 2015). Briefly put, PTSD risks pathologising responses to situations (including armed conflict and torture) which are primordially sociopolitical in nature-rather than a normal reaction to abormal events (Métraux, 1999). Yet, in general, psychometric scales measuring prevalence rates of PTSD based on self-reported symptoms tend to give inflated prevalence estimates, particular in post-conflict or crisis settings, because of the risk of conflating adaptive distress reactions with psychopathology (Ventevogel & Faiz, 2018).
What these critiques highlight, then, is an awareness of the social construction of this diagnostic category, which necessarily needs to be understood within a particular historical and cultural context, including administrative dimensions implying certain rights and treatment (d 'Halluin, 2009). As argued by Brinkmann (2017), The most powerful tool to mediate our understanding of suffering today has arguably become the psychiatric diagnoses, serving as a widespread "language of suffering." ...to the extent that psychiatry's "language of suffering" permeates different parts of modern life, this specific understanding of mental illness and distress is likely to affect the ways we approach, treat and think about our problems. (pp. 1-2).
There is therefore a strong ethical case for taking a cautious approach to the application of PTSD as a psychiatric category among refugee populations, who come with a plethora of diverse histories, cultural traditions, definitions and understandings of self, economic priorities and health seeking behaviours (Bracken et al., 2016).
In summary: research identifies that refugees often meet the criteria for diagnoses such as PTSD, but that symptoms present as part of complicated constellations of problems for which there is no consensus regarding treatment approaches. Diagnostic labels may well be useful in drawing attention to problems and the need for support and intervention. However, confusion about the suitability of psychosocial interventions indicates that the kinds of problems experienced by people from refugee backgrounds are not necessarily well understood within the current mental health diagnostic nomenclature of universalized individualistic labels. As d' Halluin (2009) demonstrates in her analysis of psychiatric models used among migrant populations in France in the twentieth century, such universalist models of mental health developed after the second World War have rejected a priori any notion of singularity, or of ethnic or cultural differences in the manifestation of pathologies.
A more sophisticated, nuanced and culturally sensitive understanding of refugee trauma, merging clinical, psychological, anthropological, and epidemiological perspectives, is needed. As argued by Neace et al. (2020), "anything less than this level of nuance should be treated with suspicion, especially when the dialogue is focused around creating a special class of people, a trend which seems to dominate public and partisan political discourse" (p. 9). Therefore, in the following chapter, I continue these reflections by reviewing the literature exploring how cultural variations in ways of life and social contexts shape the embodied experience of trauma.

Case Study
To explore diverse representations of trauma (and PTSD in particular), I compare the way in which trauma is understood and described by refugees (in interviews with victims of torture in Athens) to how it is understood and described by health professionals (in 43 interviews I conducted among psychiatrists and psychologists from thirteen different countries across the E.U., all of whom work with refugee populations). A specific focus will be on the ways in which a diagnosis of PTSD is contested, appropriated, and used strategically for different purposes.
The transcriptions of these interviews were analysed by noting all the references made to PTSD or representations of trauma. An average of 3.7 of these representations was identified for each participant, 65% of them being spontaneous representations formulated by the participants during the interview, and 35% being direct answers to the researcher's question. These representations were collected, and a thematic analysis conducted on the content. Three major themes emerged which highlighted participants' statements falling along a continuum between (1) a complete, noncritical acceptance of a PTSD diagnosis, (2) making use of a nuanced, individualized and context-dependent diagnosis of PTSD, and (3) criticizing and problematizing the diagnosis.

Representations of Trauma Among Refugee Victims of Torture in Athens
The majority of refugee beneficiaries interviewed appeared to contest the medicalised notion of PTSD with which they had been diagnosed. When referring to their subjective experiences of trauma, they drew upon a variety of diverse cultural representations of suffering (explanatory models) and idioms of distress to explain their subjective experiences of trauma. To analyse this, I examined every instance in the interview transcripts that these individuals referred to PTSD and what it meant for them. Four main themes emerge: ( This is when your morale is not at a 100% In this case, the morale is not good The first participant describes torture as something one "has." This is in direct contradiction to the idea that trauma is an event one has experienced. It is rather metaphorically represented as being internalized: the event has become part of him and what he is. The immediate consequence is the constant fear is feels. He absolutely rejects the idea that he is sick-his fear is related to the torture he experienced. According to him, it is clearly not a medical condition. For one refugee, the trauma he experiences is not only his but related to the "shock" of the entire family. This contradicts the inherently individual narrative of PTSD The idea is similarly reflected in the words of participant 5, who feels "the pain of my families." This more collectivist representation of trauma has similarly been noted researchers and clinicians working within collectivist communities wherein individuals rely more heavily on larger family systems; here, mental health is typically seen to be more linked to a broader socio-cultural context (Adame & Knudson, 2007;Bracken, 2001;Maercker & Hecker, 2016;Tang, 2007). As Tang (2007) notes, "cultures differ regarding their dominant ideas about the ontology of self as well as relationship between self and others, between self and the universe, and between life and death" (p. 129). Tankink and Richers (2007) give the example of South-Sudanese research participants who did not experience themselves so much as an individual in the Western sense of the term, but more as having a "family self" based on relational models where experiences are considered more within the intersubjective realm of the group rather than on an individual, intrapsychic level.
Another refugee's representation of trauma as "I'm sick because I think a lot. It also affects my body" reflects the idea of the mind and body being connected. However, inherent to his model appears to be the separation of a "medical" illness (the body being sick) and a psychiatric diagnosis or mental illness (the mind being sick) of which he makes no mention. In other words, according to his explanatory model, "too much thinking" lead to physical suffering. He refers to an illness in the body-which somehow bypasses any mention of a mental or psychiatric illness.

Representations of Trauma Among Medical Professionals Across Europe
The above representations of trauma emerging in interviews with refugee victims of torture often seem to be in contradiction with those emerging in interviews with health professionals working with refugee populations across Europe. In reflecting on the use of a PTSD diagnosis for refugees, many health professionals stated, for example: They don't understand that they have it, let's say. They do not realise that something is wrong with them, umm, but we're trying to show them how, show them how they can realise that they, they will suffer from that sometimes they say, uh, you know, um, magic, like spell, like 'somebody put a spell on me and they want to destroy my life' or 'they want to, because they don't like me so they put a spell on me and they want my money so they put a spell on me and because of that that I have this thinking and this insomnia and many many of things.' They don't understand the psychology, that they have a, because of some event that happened before or some stress or something Somebody who comes and is experiencing what we might consider an 'obvious' case of post traumatic stress... I try to explain [it] to them Most of them suffer from [PTSD] The words "they don't understand" reflect a recurring discourse among professionals that PTSD was something to be "understood." Refugees need it to be "explained" to them. Implicit therein is an unequal distribution of power related to western knowledge: it is the victim of torture diagnosed with PTSD who needs to "understand" the diagnosis from the perspective of a westernised, medical model of distress. The medical team ultimately hold the "true" knowledge. A diagnosis of PTSD was "obvious." "Most" had it. This "internationalisation and professionalisation of adversity" (Pupavac, 2002) enforcing "the asymmetry of the therapeutic relationship" (Wang, 2016) has been criticised in the literature as a form of "cultural imperialism" (Steel, 2001a) serving to reinforce existing imbalances of power between Western 'expert' and 'victim-patient' (Bracken et al., 2016;Summerfield, 1996;Watters, 2001).
However, the privileging of western psychiatric knowledge was not necessarily always the case. The majority of health professional's discourse reflects a certain ambivalence in the face of such contradictions, which appear to range on a continuum from complete and unproblematic acceptance of the category of PTSD to a nuanced, individualised and context dependant use: PTSD as a diagnosis maybe varies for people, it's a category that we can use and it will be helpful for people. PTSD, it's a category that will help you to predict what he wants, to predict what he will do, and to understand what he has gone through.
Many health professionals refer to a PTSD diagnosis as an instrument: useful in certain contexts, for certain purposes, for a certain audience. For some, it's a useful clinical tool which serves to further their own understanding of a patient's experience, guiding treatment pathways. It provides a common language of understanding for themselves and other health professionals. For others, the clinical use lies in helping the patient themselves make sense of this experience. In chapter eleven, for example, I explore how both refugees and professionals use it for the asylum tribunal.
A smaller percentage of health professionals, 11 out of the 43 interviewed, appear openly critical of the diagnosis: I am very critical of PTSD It's difficult to define [trauma] in, um, such a rigid, uh, diagnostic configuration. There's the, the category of PTSD and there's each individual patient or different ways to express them.
PTSD is a social control construction which has a certain history in medical anthropology field -there were a lot of critique.
Looking at the elements which organize these positions, several factors seem to play one role. Firstly, this type of professional training is followed by a factor influencing the acceptance or not of the PTSD On the one hand, we have pure a biomedical model with some medical doctors and psychiatrists, and on the other, a model that is rather psychoanalytic, which takes into account a subjective and individual perspective. Secondly, professionals having more work experience with refugee populations seem, for the most part, more conscious of the cultural influencing factors with which these individuals express their distress or suffering and face them. The scientific literature reveals that, when facing culturally foreign contexts, health professionals oscillate between "normalization" processes (based on the dominant western medical models, by imposing symptomatically and explanatory norms related to the PTSD, for instance), and the "customization" (taking into account the singularity of each individual, including their socio-cultural context, for instance) (Bourassa-Dansereau, 2013;Leanza, 2011).
Health professionals are constantly juggling these two positions. The majority of those interviewed seem to have representations of trauma in refugee populations which serves as an attempt to reconcile the "normalised" with the "customised" position: The individual is never just a trauma.
Someone may have PTSD, but that doesn't define them.
There is no one size fits all.
Above all else, what is highlighted is the need to see the individual beyond the trauma. It is not about accepting the diagnosis or not, but about being conscious of the limitations and concrete social, political, and legal implications of using it, as well as the need to recognize the unique complexities of individual experiences of trauma. We need to go beyond PTSD.
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