Psychologists’ Perspectives on the Psychological Suffering of Refugee Patients in Brazil

Worldwide there are 79.5 million displaced people, many of which face war, violence, tragic flights and struggles in host countries. Research shows augmented prevalence rates of mental disorders among refugees internationally, but little is known about refugee mental health in Latin American countries. Furthermore, only a few studies have taken into consideration the knowledge of clinical psychologists who treat refugee patients. The present study examines the experiences of 32 psychologists in Brazil regarding their refugee patients’ psychological suffering and mental disorders. Semi-structured interviews were conducted in various locations in Brazil and analysed following a consensual qualitative research approach. Four clusters of refugee patients’ suffering were synthesised: post-migration stressors, traumatic experiences, flight as life rupture, and the current situation in the country of origin. The most frequently described conditions in patients were anxiety and depression. However, the results also show that the use of manuals for the classification of mental disorders is contested among psychologists in Brazil. Most psychologists stressed patients’ socio-political suffering and saw patients’ symptoms as normal reactions to their experiences. There is a need to acknowledge the socio-political suffering of refugees in Brazil and foster their mental health by tackling current post-migration stressors such as discrimination.

definitions of ''immigrant'', ''emigrant'', ''border resident'', ''visitor'' and ''stateless person'') expresses the persistence of aiming to place migrants closer to the idea of strangers and foreigners, instead of fostering a perception of migrants as mobile subjects in the contemporary world, which was what the commission originally set out to establish. Still, there are various notable aspects in the Brazilian jurisdiction for migrants, such as that asylum seekers are granted a work permit directly after applying for asylum, have the same rights to access education, training and healthcare as Brazilians (Assis 2018) and that there is no deportation in Brazil in general (Jubilut 2006;Leão 2011).
The present study aimed to investigate the experiences of psychologists regarding their refugee patients' psychological suffering. We decided to interview professionals as experts due to our assumption that psychologists who encounter refugees in their daily practise might have special insight into the mental health and suffering of their patients (Meuser and Nagel 2009). Investigating their experiences and knowledge might be a valuable first step for understanding refugee patients' situation in Brazil and develop appropriate mental healthcare services. We focused on professionals in Brazil for two main reasons: Firstly, even though there has been a recent increase in studies investigating various aspects of refuge in Brazil (Duden & Martins-Borges 2021;Barros and Martins-Borges 2018), there is still little information concerning their mental health across several Brazilian states (Braga Bezerra, Martins-Borges and Cunha Pereira 2019; de Moraes Weintraub 2012; da Teixeira, Lotufo Neto and Skokauskas 2013), and even more so, a lack of international attention to this specific field of research. Secondly, gaining the perspectives of experts from a country from the Global South might provide new insights for the discussion on the categorisation of mental disorders (Drodžek 2007;Kirmayer 2001;Summerfield 1999Summerfield , 2008. Our research design addressed participants' perspectives as culturally mediated phenomena located in the Brazilian context, with the aim to understand ''explanatory models'' of practitioners (Kleinman 1980). This concept from medical anthropology stresses the importance of causal attributions and ethnophysiological theories on illness experience, but also on treatment response (Kirmayer and Sartorius 2007;Watters 2001). In other words, how psychologists in Brazil think about the suffering of their refugee patients will influence how they attend to the needs of those patients within the Brazilian context. Specifically, we formulated the following research questions: How do psychologists who work with refugees in Brazil experience the psychological suffering of their patients? (a) How do they describe the suffering? (b) Which mental health disorders and symptoms do they perceive to be most common among their refugee patients?

Method Study Design
This article forms part of a larger study investigating Brazilian approaches to the mental healthcare of refugees. The focus of the present investigation was how psychologists experience the psychological suffering of their refugee patients. In order to allow for an in-depth analysis of psychologists' perspectives located in the Brazilian socio-political and cultural context, the research project used qualitative procedures of inquiry resting on a constructivist ontology and a subjectivist epistemology. The study consisted of semi-structured interviews which were analysed adopting a consensual qualitative research (CQR; Hill et al. 2005) approach.

Participants and Procedures
Gatekeepers and contacts to local NGOs were used for recruitment, as well as subsequent snowball sampling. The Ethics Committee of the University of Osnabrück gave ethical approval for the study and informed written consent was obtained from all participants. A semi-structured interview guideline was developed with the objective of encouraging participants to speak about their perspectives on their refugee patients' suffering. It included questions on common characteristics of participants' patients, such as patients' country of origin (CoO), questions on patients' psychological suffering, symptoms and mental health disorders as well as on psychologists' use of diagnostic manuals and categorical classification of mental disorders (MDC). The latter was incorporated to allow for a contextualisation of the findings on frequent disorders, as we assumed that usage of MDC, such as for instance the DSM-5, would influence the way psychologists spoke about patients' suffering. The guideline was pilot tested with Brazilian psychologists to ensure the unambiguity of questions. Between November 2018 and May 2019, semi-structured interviews were conducted with participants (N = 32) who held a university degree in psychology and had been working with refugee patients for at least 6 months ( Table 1). 44% of the psychologists were of psychoanalytic orientation, reflecting the often-reported predominance of this approach among general clinical psychologists in Brazil (González 2018;Yamamoto 2012). Eight participants worked with Ethnopsychiatry which is an encounter and complementarism of psychoanalysis and anthropology (Martins-Borges et al. 2019; Nathan 2001). These participants had also taken part in courses of ''cultural psychology'' during their academic studies and trained in university clinics to attend refugee patients psychologically. None of the other participants had received any specific training to work with survivors of trauma, refugees or to work transculturally, but six of the participants had a migrational background. Most of the participants did not exclusively attend refugee patients, but also worked with other immigrants and Brazilians. Interviews lasted between 40 min and 2 h. They were conducted in Portuguese, either face-to-face at participants' workplaces (n = 19) or via skype (n = 13), audio recorded and fully transcribed. To secure the anonymity of participants, all identifying information was removed, the names of participants were replaced for codes and locations of practice were collated into regions.

Data Analysis
Interview transcripts were analysed focusing on the overt meaning in the data, i.e. what is said and by whom. CQR (Hill et al. 2005) was adopted as this approach represents a systematic method to evaluate the representativeness of issues across cases. First, every interview was read thoroughly and sections related to psychological suffering of refugees were highlighted. The first author coded highlighted sections line-by-line and developed a hierarchical coding tree by collating the codes into subthemes, themes and categories. In order to assess the fit of the coding tree, the first author and two further researchers re-applied it to the interview transcripts independently and subsequentially discussed until a consensus about the codes, subthemes, themes, and their hierarchical structure was found.
These steps were carried out in Portuguese (González and Lincoln 2006). The coding tree was then translated into English, using a bilingual committee (Brislin 1970). Next, the whole data set was organised into the English coding tree using the qualitative analysis software MAXQDA (VERBI-Software (2020). MAXQDA 2020[computer software]. Berlin, Germany.: VERBI Software. Retrieved from https://www.maxqda.com 2020) in order to systematically represent the frequencies of participants endorsing each theme and subtheme (Tables 2, 3). The frequency counts enable an overview of the presence of each theme in the data set (Malterud 2001). Themes were labelled ''general'' if they were endorsed by 31-32 participants, ''typical'' if they applied to 16-30 cases, ''variant'' for less than 16 but at least 5 cases, and ''rare'' if endorsed by only 1 to 4 participants (Hill et al. 2005).

Researchers' Positionality
The study's principal investigator who conducted the interviews and served as the primary coder is a PhD candidate in cultural psychology. Being of German origin, she gained awareness for challenges in post-migration settings through her own experiences of migration and academic interests in refugee studies. The fact that she is of German nationality might have, in regard to the history of colonisation (González and Lincoln 2006), impacted the extent to which participants felt at ease to articulate their perspectives. Yet, the principal investigator had worked for an extended period of time among psychologists in Brazil and was, thus, familiar with styles of communication and interaction in this context. Moreover, the other two coders of the study were Brazilian clinical psychologists which improves the likelihood that the manner in which psychologists in Brazil speak about psychological suffering was captured accurately. All three researchers have extensive experience using qualitative methods of inquiry. Informed by the literature on refugee mental health, the researchers expected participants to highlight PTSD, depression and anxiety as common mental health problems in their patients.

Refugee Patients' Backgrounds
In order to contextualise the findings on patients' suffering, psychologists were asked to name the country of origin (CoO) of their patients as well as additional characteristics they deemed important. In doing so, participants did not distinguish between patients' official immigration or asylum status. Thus, the CoOs reported here are of diverse immigrants, including refugees and asylum seekers. In sum, participants named 42 different CoOs (see Figs. 1). Most frequently mentioned CoOs were Venezuela, Haiti, Syria, and Colombia. Other frequently mentioned characteristics of patients were pregnant women or single mothers, lesbian, gay, bisexual, transgender, and queer people.
How Do Psychologists Describe the Suffering of Their Refugee Patients?
The following section synthesises in four categories what psychologists perceived to constitute the psychological suffering in their refugee patients (Table 2).

Post Migration Situation
All participants stressed how the post-migration context causes substantial suffering in refugee patients. This category took up the most considerable portion of all interview transcripts. The following factors were perceived as particularly impactful for patients:

Hostile Attitudes, Intolerance and Rights Violations
There is suffering for not being recognized by the other. We have many refugees here in Brazil who are black, who come from African countries or Haiti. Blacks suffer a lot from racism. Racism is very strong here. They tell me: ''What do I do if I walk on the street, people start walking very fast, they don't stay on my side.'' That creates suffering. (P15, psychoanalytic, Age: 41, South) All participants mentioned that their patients were suffering from experiencing hostile attitudes and intolerance, in particular by being subject to xenophobia, discrimination, racism, LGBTQ-phobia, as well as not feeling recognised by society or objectified as a refugee. Variant participants also described the human rights violations their patients were experiencing in Brazil, including physical mistreatment, (sexual) abuse and slavery work. Discrimination and xenophobia have been described as major obstacles for the integration of refugees in Brazil and as strongly related to the struggle of finding employment (Moreira and Baeninger 2010). Internationally, experiencing discrimination in host countries has been found to greatly impact the mental health of refugees (Bogic et al. 2012), sometimes even more than pre-migratory trauma (Beiser and Hou 2016).

Isolation
Isolation was another factor participants typically saw as part of the suffering of patients: ''[…] a state of complete loneliness. She feels disconnected from people. She feels that no one will understand her. And she feels that she won't understand anyone'' (P9, ethnopsychiatric, Age: 28, South). Psychologists described patients' feelings of loneliness and not-belonging and highlighted the fact that patients often suffered due to being separated from their families. Two participants mentioned that refugee patients had very fragile networks in their new context. Social isolation has been described as a major stressor in post-migration settings (Miller and Rasmussen 2011). Eisenbruch (1991) integrated the loss of social networks and of a sense of belonging in the concept of ''cultural bereavement'' which he considered characteristic of forced displacement (e.g. Bhugra and Becker 2005). Reinforcing this, others have found associations between the wellbeing of displaced people and the reconstruction of social networks and a feeling of community (Summerfield 1999).

Cultural Adaptation
As a further variant factor of suffering in the post-migration situation, processes of cultural adaptation were described. Participants mentioned the patients' struggles with integrating into Brazilian society, experiencing cultural shocks and finding it hard to build relationships with Brazilians: ''They report a lot of difficulty in establishing ties with people here'' (P23, psychoanalytic, Age: 60, Southeast). Together with feelings of homesickness these struggles contributed to the sense of isolation in patients. Furthermore, psychologists saw some of their patients as coming into conflict with their culture of origin.
The latter may, as research suggests, be particularly impactful in individuals with families and cause intergenerational conflicts since family members can differ in their speed and way of acculturating (Droždek 2007;Leyendecker et al. 2018). There have been inconsistent results in the literature regarding the relationship of acculturation and mental health (Kartal and Kiropoulos 2016), but often cultural adaption is viewed as a cause of substantial distress in immigrants (Knipscheer and Kleber 2006;Martins-Borges 2013.

Precarious Situation
The precarious nature of the patients' context was typically perceived as a further aspect of refugees' suffering: ''the precariousness of his life made him feel Cult Med Psychiatry (2022) 46:364-390 375 paralyzed and unable to act'' (P10, community/social, Age: 27, South). Variant participants described patients fearing for basic needs, experiencing hunger or living on the street. Furthermore, participants typically highlighted the economic instability and financial troubles of patients due to a lack of stable employment and financial support structures. Variant psychologists mentioned that the precarious situation evoked feelings of helplessness and humiliation in many refugees. Participants also stressed the impact of future insecurity on patients: The greatest suffering is the uncertainty. They are not ''refugees'' when they arrive. They are 'asylum seekers', a totally preliminary and provisional situation that can last three to five years. This reinforces the liminal character of migration... being in and out... which makes it impossible to build long-term plans. (P3, community/social, Age: 61, Southeast) Even though there is no detention and deportation in Brazil (Jubilut 2006;Leão 2011) and these two aspects have been most strongly associated with future insecurities (Davidson, Murray and Schweitzer 2008;Momartin et al. 2006), participants described strong feeling of insecurity in their refugee patients. These feelings can be understood in light of a context in which refugee applications are only processed slowly, in which high rates of extreme poverty and social inequality are common (de Barros, Henriques and Mendonça 2001) and in which refugees struggle with unmet basic needs and a lack of integration structures (Knobloch 2015; Moreira and Baeninger 2010). For instance, Aydos, Baeninger and Dominguez (2008) reported that about 37% of displaced people lived on the street after arrival in Brazil. A strong association between social inequality, poverty and mental health disorders has been stressed for the general population in Brazil (Silva and Santana Santana 2012). Concerning refugees, employment and economic stability have been found highly important for good health outcomes (Bogic et al. 2012;Lindert et al. 2009;Knipscheer and Kleber 2006). The effect of future instability due to tedious asylum procedures and temporary visa on the mental health of asylum seekers is an issue of international concern (Comtesse and Rosner 2019; Davidson, Murray and Schweitzer 2008).

Traumatic Experiences
Most participants talked in some form about traumatic experiences in relation to the suffering of their patients. Patients' traumas included experiences of war, surviving an earthquake, violence and human trafficking, seeing people dying, being persecuted, robbed, and crossing the Amazon forest: She entered the Amazon forest and spent days on a boat in a river with crocodiles and with others who assaulted her. In this country, on her first stop after Cuba, she worked in slavery-like conditions, she was even locked-in at her work, and she had to escape. (P12, ethnopsychiatric, Age: 27, South) The types of trauma experienced depended on patients' trajectories and their CoO. For instance, psychologists who attended mainly Haitians often described the impacts of surviving an earthquake.

Flight as Life Rupture
A common issue is grief. Grief in relation to the country, to the culture, to the recognition of identity. To their life project, that was abruptly interrupted. (P24, ethnopsychiatric, Age: 33, South).
Most psychologists perceived a life rupture due to the involuntary flight as part of the suffering of their patients. The flight came with many losses that sometimes lead to the experience of existential crisis.
Leaving one's home involuntarily without preparation for the ruptures that this flight will cause has been described as a risk factor for mental health (Martins- Borges 2013). Research has shown that experiencing loss, such as of one's home and the sense of social belonging and connection to a land and its symbols is associated with refugees' mental health outcomes (Davidson, Murray and Schweitzer 2008). The loss of social belonging also forms an essential element of the concept of cultural bereavement (Droždek 2007;Eisenbruch 1991).

Current Situation in Country of Origin (CoO)
Finally, psychologists suggested patients' suffering was dependent on what was happening in their CoO. First, they linked patients' distress to the expectations from relatives that remained in the CoO. Second, patients suffered when the situation in their CoO was still unstable, dangerous and difficult for those who had stayed: ''First of all there is the family left behind in Venezuela. I hear a lot that it's like a type of guilt: 'I am here eating, I am here sleeping, and my family is starving on the street''' (P22, psychoanalytic, Age: 43, Southeast). Some patients were described to be constantly worrying about the well-being of their relatives in the CoO and to be feeling guilty for surviving and leaving people behind. Furthermore, two psychologists saw the fact that patients did not receive reparations from their CoO for violations they had experienced as impeding the healing process.
Many of the CoOs of participants' patients, such as Venezuela and Haiti, continue in precarious situation of violence, famine and misery (de Oliveira, Yazdani and Gomes 2019). The literature shows that refugees from countries whose conflicts are still unresolved have worse mental health outcomes (Porter and Haslam 2005) and a sort of ''survivor guilt'' has been reported as a common phenomenon among refugees (Eisenbruch 1991;Martins-Borges 2013).

Which Mental Health Disorders and Symptoms Do Psychologists Perceive to Be Most Common Among Their Refugee Patients?
The following section focuses on the mental disorders and symptoms participants most commonly perceived in their patients (see Table 3; Fig. 3). However, and in order to contextualise these results, we first report on whether and in which way participants made use of mental disorder classifications (MDC).  The term ''generic'' is indicated to show the number of psychologists mentioning general symptoms of a disorder (e.g. ''depressive symptoms'') rather than specifying them further c ''Specific'' refers to the specific symptoms of a disorder described by participants d Categories and Symptoms which are either not listed in the DSM-5, but were highlighted by participants, or which were not mentioned uniquely in relation to one specific disorder e The total refers to the sum of participants who referred to specific symptoms and/or the diagnostic category itself Certainly, these opinions might also reflect the fact that of the participants 44% followed psychoanalytic/-dynamic, 25% ethnopsychiatry and 16% community, social or systemic approaches (Table 1)-therapeutic orientations which do not place their emphasis on diagnostic categories (e.g. Guzder 2014;Wolitzky 2020). Some psychologists indicated the use of diagnostic strategies, but rather than applying categorical manuals such as the DSM-5, they were oriented towards psychoanalytic structural diagnostic or the axis of DSM-IV. These approaches seemed more flexible, continuous and more appropriate to them. The participants who made use of manuals such as the DSM-5 (n = 14), indicated employing them carefully and mostly in order to communicate with other professionals. Participants showed themselves aware of cultural and languages differences that might cause wrongful diagnosis, but they did not see this as a difficulty. Rather participants stressed that these differences made the careful and flexible use of diagnostic manuals even more important. This finding was especially pronounced in the  The number indicates the total of psychologists who referred to the respective symptom or state participants who had studied cultural psychology and worked with ethnopsychiatry; meanwhile it was also represented among other participants.
A critical use of Western psychiatric diagnostic manuals is not uncommon in Latin American countries (Parra 2013). Internationally, critiques of these manuals have been made, especially concerning their universal applicability (Droždek 2007;Summerfield 1999), since the manuals themselves represent cultural products (Gone and Kirmayer 2010) and their use can lead to miss-interpretation of suffering (Kizilhan 2006;Wohlfahrt and Zaumseil 2006). Some have also posed the more general question if MDC necessarily leads to an improvement in our understanding of effective interventions (Kirmayer and Sartorius 2007). In line with many of the participants of the present study, Aveline (2005:158) argues, that the categorical perspective of psychological suffering often does not fit the ''problems in living'' of patients. To a large extent the interviewed psychologists embraced the idea that the focus on classified disorders was insufficient to guide their practice, as patients struggled with the ''social suffering'' discussed in the previous section, i.e. contextual predicaments stemming e.g. from experiencing racism, not necessarily from psychiatric disorders (Guzder 2014;Kleinman, Das and Lock 1997).
I haven't identified depressive cases. The point is, there are cases of sadness, but if you do a little more analysis, you realize that it's a sadness of the whole process they are experiencing in their lives at the moment. (P16, community/social, Age: 29, South).
Alternative strategies for making sense of the suffering of patients in transcultural encounters have been proposed in the literature, such as the DSM-5 Cultural Formulation Interview (APA 2013) or the McGill Illness Narrative Interview (Groleau, Young and Kirmayer 2006). This latter interview aims to elicit patients' own narratives of their suffering in order to find pathways to care that are in line with their experience (Groleau, Young and Kirmayer 2006).

Mental Health Disorders and Symptoms
Despite critiques of MDCs, all psychologists participated in a description of the most common symptoms and disorders of their refugee patients. The descriptions are elaborated here and represented in Fig. 3 and Table 3.

Depressive Disorders and Symptoms
Typically, psychologists mentioned depressive disorders and symptoms as common among their patients. Described depressive symptoms included constant crying, sadness and apathy. Three participants also referred to a deep despair in patients which they perceived as an existential hopelessness. Furthermore, suicidal ideation was often mentioned in combination with depression.
Internationally, depression has been reported with high prevalence rates among refugees (Lindert et al. 2009). In Brazil, a study of Haitian immigrants yielded that depressive symptoms were in the clinical range in 10.6% of participants (Brunnet et al. 2018). A study of Bolivian immigrants in São Paulo indicated the high probability of a mental disorder in more than half of the participants, with depressive and anxiety symptoms having the highest prevalence (Bustamante Ugarte et al. 2019).
However, many participants of the present study questioned the distinction between depressive disorder and grief. 12 of the interviewed psychologists explicitly stated they preferred to talk in terms of grief as opposed to depressive disorder and to consider their patients' mental states, which resembled depressive phases, to be normal reactions to the many losses the refugees had faced.
The refugee suffers from grief. From a succession of bereavements. The refugee's suffering revolves around loss. The loss of a known place, the loss of a group of people, of relationships, the loss of a social function. So, I think in terms of psychic suffering the most striking one is loss and grief. (P9,ethnopsychiatric,28 years,South) In the literature there has been a resurgence of interest in the construct of grief, especially concerning refugee patients (Comtesse and Rosner 2019; Momartin et al. 2004;Silove, Ventevogel and Rees 2017), since loss is such a common experience among refugees and linked to their mental health outcomes (Davidson, Murray and Schweitzer 2008).

Anxiety Disorders and Symptoms
Typically, psychologists also described anxiety symptoms and disorders as common in their refugee patients: The most common psychological suffering.... Very high anxiety. Depression. Absurd. Panic attacks.
[…] Anxiety and panic because they find themselves in a dangerous situation and are always alert. And that means stress as well. They are always afraid that somebody could rob them, the family is starving and in need of them in Venezuela. (P1,existential/humanistic,Age: 31,North) Research has found heightened levels of anxiety in asylum seekers (Silove et al. 1997). Lindert, et al.'s (2009) meta-analysis showed a combined anxiety prevalence rate of 40% in refugees and more recently, Turrini et al. (2017) reported that anxiety and depression in refugees were at least as frequent as PTSD and affected on average one out of three refugees. Presumably, anxiety states result from refugees' past experience, but also from the insecurity and instability in their postmigration situation: ''Anxiety disorders are very present. But for complex reasons, not for certain permanent core beliefs, but due to the external stress that is permanent'' (P20, cognitive-behavioural, 43 years, South). In the case of Brazil, one might question if heightened anxiety is specific to refugees or also common in the general population and a reflection of a widespread sense of political, economic and personal insecurity. For instance, in São Paulo anxiety disorders were found to affect almost 20% of the general population . Meanwhile, the study by Andrade et al. used criteria of the DSM-IV which were criticized by many participants in the present study. Furthermore, it is likely that there are enormous differences in the anxiety rates of the general Brazilian population depending of the location of research-São Paulo, the most populous city of Brazil and South America might differ considerably in this aspect compared to a rural region in Minas Gerais, for instance.

Posttraumatic Stress Disorder (PTSD)
Ten participants spoke of PTSD or related symptoms among their patients: ''There's posttraumatic stress which we end up working with a lot. You see a lot of it. Posttraumatic stress due to displacement, due to violence'' (P1, existential/ humanistic, Age: 31, North). At the same time, 29 psychologists used the word ''traumatic'' when describing their patients' experiences: ''Many were raped and robbed on their way. They got here only with their cloths on their body -the experience from there to here is traumatic for almost everybody'' (P29, psychoanalytic, Age: 23, North).
The finding that most participants described refugees' traumas but relatively few mentioned PTSD might, firstly, be due to an epistemological difference in participants' concepts of trauma and the concept underlying the PTSD diagnosis. When participants were invited to explain their understanding of trauma, most psychologists defined it as an event that did not have a psychic representation and was ''unbearable to tell''. This demonstrates a psychoanalytic understanding of trauma (Levine 2014). A second explanation might be that, even though, robust associations have been made between pre-flight trauma and the mental health of refugees (Davidson, Murray and Schweitzer 2008;Silove et al. 1997) and refugees show higher rates of PTSD than the general population (Fazel, Wheeler and Danesh 2005), most people who have survived traumas do not develop PTSD (Bisson et al. 2015). Furthermore, traumas linked to profound losses might, in the long term, rather evoke depressive than PTSD symptoms (Momartin et al. 2004). Finally, a closer analysis of the transcripts showed that, in relation to the aforementioned critical attitude towards MDC, many participants were reluctant to use the PTSD category as they worried that this would reduce patients' suffering to past events and turn it into an individualised and ''medical'' problem, thus neglecting its sociopolitical dimension: ''Of course, trauma means that the subject has experienced a terrible traumatic scene. I'm not saying otherwise. I am saying that the sociopolitical situation promotes trauma and is something that stifles the subject in various ways'' (P27, psychoanalytic, Age: 33, Southeast).
As with most diagnostic categories, the concept of PTSD is a product of Euro-North-American culture, context and history (Kirmayer et al. 2015), but the discourse around it has reached diverse cultural realties globally (Argenti-Pillen 2000). One might wonder if participants' critique of the concept of PTSD, i.e. implying an individualisation of trauma, could be related to the recent history of dictatorship in Brazil which involved experiences of collective traumas (Kevers et al. 2016). However, the argument, that PTSD is too much focused on past traumas and disregards the socio-political context in which traumas occur, has been used internationally, too, as one aspect of the considerable critique of PTSD (Droždek 2007;Kevers et al. 2016;Summerfield 1999Summerfield , 2008. Some authors state this focus implies neglecting the complexity of the refugee situation and missing out on the Cult Med Psychiatry (2022) 46:364-390 383 opportunity to better mental health outcomes in refugees by changing present conditions in host countries (Watters 2001). This was also stressed by the participants in the current study who, in line with Cleveland, Rousseau and Guzder (2014), consistently brought up the present post-migration situation as interplaying and exacerbating past traumas: In the case of the Syrians, we think that we will work with war traumas. But none of them ask for trauma care in the sense we imagine. All of them have other challenges, especially the daily challenge of living as a refugee here in Brazil. (P19, systemic, Age: 30, South)

Other Mental Disorders and Symptoms
Other mental health conditions described by more than one psychologist included somatic symptoms, psychotic disorders and symptoms, severe stress, sleep disturbances and substance abuse: ''There are a lot of cases of alcoholism, in women too'' (P30, existential/humanistic, Age: 40, North). Most of these disorders and symptoms have been described in previous studies concerning the mental health of refugee patients (Silove, Ventevogel and Rees 2017). For instance, a number of studies has linked PTSD symptoms to psychotic symptoms in refugees (Nygaard, Sonne and Carlsson 2017) and reports of somatic symptoms are common among immigrant, but also among most general patients suffering from depression or anxiety (Kirmayer 2001).

Limitations and Suggestions for Future Research
The results of the present study have to be considered in light of certain limitations. Firstly, it is important to note that participants reported not on refugees in general, but on their refugee patients, i.e. people who seek psychological help as they find themselves in troubling states. To obtain a broader picture of the mental health of refugees in Brazil, future studies are needed that focus on refugees outside of clinical settings.
Secondly, findings represent the subjective evaluations of psychologists who treat refugees in Brazil and do not represent quantifiable or generalisable data. For instance, participants might have been more likely to report on extreme cases when asked to describe their patients' psychological suffering. However, as the first study investigating the suffering of refugee patients across Brazilian states, the results provide valuable insights into common social and mental health problems faced by this group and a base for further epidemiological and quantitative studies. Potentially lower rates of PTSD diagnosis in Brazil for example, might also result from professionals' critical attitude towards mental health categorisation and the PTSD concept.
Finally, this study focused on psychologists' experiences in treating heterogenous patients from various countries with diverse reasons for migration, heterogenous experiences of flight and post-migration stressors, and varying lengths of stay in Brazil. These factors and their complex interaction may play a crucial role in shaping patients' mental health (Turrini et al. 2017). Also, even though participants were asked to report on their refugee patients, it is unclear if their descriptions only related to people with the respective official asylum status. Many of the psychologists also treated general immigrants and may not have differentiated between patients in relation to their immigration status when reporting on their suffering. This, as well as the diverse interview settings ranging from the South to the extreme North of Brazil, is likely to have impacted participants' descriptions of their patients' suffering . However, the analysis of the data did not show any major differences in perspectives on patients' suffering related to location of practise (Table 2), except for traumatic war experiences which were only described by psychologists in the South and Southeast. This might be explained by the fact that there are more Syrians applying for asylum in these regions (CONARE 2020). Patients in the North came almost exclusively from Venezuela, where there is a humanitarian crisis (CONARE 2020), but not a situation of war as in Syria. Further studies could explore the differences in suffering related to diverging asylum status and psychologists' location of work in more detail.

Conclusion
To our knowledge, this study is the first to investigate psychologists' perspectives on the suffering of their refugee patients in diverse Brazilian states. It confirms previous findings highlighting depression and anxiety as common conditions among refugee patients (Lindert et al. 2009), but also supports concepts such as prolonged grief (Comtesse and Rosner 2019; Momartin et al. 2004) and cultural bereavement (Eisenbruch 1991) as valuable alternatives to common mental disorder classifications in refugees. Additionally, the present study provides evidence for a prevailing critical perspective on mental disorder classifications, such as the DSM-5, among psychologists in Brazil. Many of the participants thought of the suffering of refugee patients in relation to their social and political context and post-migration situation, rather than in relation to specific diagnostic categories. This reinforces the call to acknowledge the socio-political suffering of refugees (Droždek 2007;da Silva Machado, Barros and Martins-Borges 2019) and increases the importance of strategies that, in order to foster the mental health of refugees, address current stressors in post-migration settings, such as discrimination (Duden and Martins-Borges, 2021).
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