Trauma and Resiliency: A Tale of a Syrian Refugee

One of the most controversial topics in refugee mental health is the diagnosis and management of posttraumatic stress disorder (PTSD) and psychological trauma, for several reasons. Applying diagnostic checklists too broadly, or too early, after a mass trauma event may generate artificially high estimates of PTSD (1) while underestimating the mental health needs of the rest of the population (2). Other concerns include whether the diagnosis itself truly captures the psychological suffering of refugees on the one hand or pathologizes normal reactions to disaster on the other (3).

The authors’ clinical experience concurs with evidence in the literature that a classic PTSD diagnosis has many limitations in this context and does not accord with the clinical picture of many of the refugees we have treated (4). This is hardly surprising, as van der Kolk and colleagues (5) have shown that the diagnosis does not encompass the variety of clinical manifestations among treatment-seeking “complex trauma” patients in the United States. We therefore believe that the issue is not the legitimacy of the application of the PTSD diagnosis to refugees, but rather whether such a diagnosis is sufficient in itself. It has been demonstrated that “pure” PTSD, which presents mainly with intrusive thoughts and avoidance symptoms, is “the exception rather than the rule” (6). This is particularly important in the refugee context, for refugees are exposed to both repeated and ongoing traumatic triggers (fear from the past, current uncertainties, new traumas).

As has been shown with victims of natural disasters, the prognosis of classic PTSD has as much to do with events that occur after the trauma as with the trauma itself. For example, the onset and duration of PTSD among survivors of hurricane Katrina was largely explained by gender, financial situation, level of social support, and postdisaster events, such as physical and sexual assault (7). Other studies have shown the importance of social context by highlighting lack of social support as a primary risk factor in developing PTSD (8). Being in constant touch with family and hearing news from home continued to trigger symptoms for Ms. A. Yet it has been shown that it is essential to maintain a connection with extended family, despite how painful it is, in order to maintain a sense of their own “moral dignity” and to reduce the sense of isolation while in exile (9). The definition by Suarez (10) captures all of these elements: “Trauma is a multidimensional experience of mostly targeted rather than random occurrences, which is situated within a social context and a temporal sequence.”

Another factor in working with refugees is to identify the stage in their journey (premigration, migration, postmigration, or resettlement), for their symptoms may differ with each phase’s related risks and stressors (11). One large meta-analysis concluded that mental health problems among refugees are not always a direct consequence of their acute traumatic stress but may also be a reflection of their contextual factors after displacement (12).

In refugee populations, there are close associations between somatization, dissociation, and PTSD (13). It is often the case that patients who are referred to a mental health provider will initially want to discuss their somatization and current stressors and not necessarily their memories and trauma stories. A diagnosis of PTSD by definition will emphasize the memory’s impact on a traumatic experience and then focus treatment on dealing with the consequences of this specific trauma and the impact of memory processing. When presented with not only PTSD symptoms but also somatization and dissociation, it may be more important for the patient to address the latter symptoms, since they cause more functional impairment (14). Episodes of fainting, dizziness, or weakness (15) and chronic pain (16) are particularly common in this context, and they warrant a thorough medical examination before determining that they are “psychosomatic” in nature (16). In regard to the syncopal episodes described in this case of Ms. A, there is good evidence for the important role of vagal tone in emotion regulatory functions (17). In particular, excessive sympathetic stimulation and vagal withdrawal seem to be related to the emotional lability of one’s fight-or-flight response (18). A syncopal episode could be the result of a parasympathetically dominated “shutdown” in the face of an overwhelming traumatic event, and subsequently it may be a reaction to any reminder or activation of the trauma (19). From an evolutionary perspective, then, fainting would be viewed as the last defense mechanism in a cascade of responses, from freezing to fight or flight, becoming frightened, and then finally total system shutdown or fainting (19). In this view, the fight-or-flight response is mainly activated via the sympathetic branch, whereas fright and fainting are activated by the parasympathetic system (19).

Issues of somatization and dissociation could be addressed by shifting the focus from the traumatic past to the present, using sensory stimulation and motor activation (20), or by encouraging patients to evaluate their different affective states, label them, and establish a connection between these states and their somatic complaints (e.g., “I get headaches whenever I am angry” or “when I hear bad news I faint”) (20). It is of great importance to understand emotions as signals of current affective states, rather than only as a trigger for flight-or-fight responses. These “mindfulness” approaches are becoming more popular in dealing with trauma issues, and they have shown moderate effects in reducing PTSD symptoms among both veterans (21) and refugees (22). An advantage to these approaches is that they may provide improvement in domains of general health and wellness beyond the narrow focus of PTSD symptomatology (23).

In the end, therapeutic approaches must be considered judiciously. An intervention that focuses on the present while avoiding past trauma may exacerbate the dissociation symptoms and relived intrusive memories, while an approach that explores the trauma prematurely may worsen rather than relieve affective and somatic symptoms (24). These two approaches can be complementary and tailored to patient progress. In addition, as we learned from our work (and as reported by others), this improved capacity to name and manage somatic symptoms and related intense affective states may be a necessary preliminary step to the exploration of the trauma from the past (25). Regardless of the modality used, it must always take into consideration the preexisting cultural views of mental health in the target population (26). However, we are reminded that, as Bou Khalil has observed (27), the tragic stories that refugees present, in addition to their ongoing trauma, sometimes make clinicians’ efforts appear minimal in the bigger picture.

Educating refugees on how their somatic symptoms may represent psychological reactions to trauma may help answer their questions as to why they are being referred to a mental health provider (15). The principle of self-management highlights the individual’s belief that one can successfully learn and perform specific tasks using one’s own resources and skills (28). Strong self-efficacy leads the individual to feel in control and therefore feel confident about his or her own ability to achieve goals and understand the role such confidence plays in posttraumatic recovery (29). Attempts to reappraise one’s own situation, share it, and reconsider how one arrived at one’s current state can lead to finding some resolution to presenting problems. Health care providers can help refugees in building social “mastery” by strengthening family ties and social networks in the new environment. Social supports, including interactions with family, friends, and caring professionals, play a particularly important role during major transition periods by enhancing coping, moderating the impact of stressors, and promoting health (30). One promising intervention is a World Health Organization–sponsored transdiagnostic approach called “problem management plus” (PM+). It is a cognitive-behavioral therapy–based intervention that could be delivered by specialists and nonspecialists alike. This intervention helps clients manage stress and problems through positive reinforcement and strengthening social support (31). The intervention was studied in Pakistan (32), where it exhibited remarkable success, and there are efforts to apply it more broadly in the Middle East region.

Mental health professionals working with refugees tend naturally to focus on the “trauma story,” often at the expense of what allowed these people to survive—their resilience—which results in their strengths being overshadowed by a “deficit model” that depicts refugees as traumatized victims (33). Overemphasizing refugees’ trauma at the expense of their strengths may affect how practitioners view their therapeutic task, and it could prevent full recovery by denying their patients’ ability to survive adversity (34). A strength-based perspective draws on the “power” within the client and sees the client as an expert on his or her current situation (35). One way to implement a strength-based approach is to focus on solutions, to allow people to rediscover their ability to solve problems and overcome adversity. This approach helps separate the person from the problem, alleviate judgment or blame, and see the problem for what it is, and not the person as the problem (36).

Limiting our view to the psychological aspects of the traumatic event—while essential to our work—could overlook how, in these protracted conflict situations, distress is also mediated by “political and religious convictions, cultural beliefs, social circumstances, and previous experiences with adversity, and not simply by the distressing events themselves” (37). The term “humanitarian emergency” (38) carries a certain danger with it, since it implies that the solution lies largely within the “humanitarian assistance” domain while overshadowing the underlying structural issues at hand. Ultimately, psychological recovery comes from improvements in the overall circumstances (political, economic, and societal) and the meanings people find in their lives, and not simply from resolving their traumatic stories (37).

The authors acknowledge the helpful comments made by Mohammad Hussein and Haitham Zammou, both with the Mental Health and Psychosocial Support unit at the Union of Medical Care and Relief Organizations in Turkey.