Lecture 8: Problems and treatment of traumatized refugees in Western countries 


ARQ: organization helping people after traumas.

Who are refugees? Because conflict or persecution they have to flee their country. No longer in their own country, having to cross borders and it is not possible to go back home safely. Countries have a legal obligation to help refugees and are not allowed to send them back if it is not safe. When do you stop being a refugee: when they can go back? When they integrate in their new country?

2017: 14.716 new asylum application. Mostly from Syria (2.202) and Eritrea (1.095). 14.490 people reunited with their families in the Netherlands. 

Problems

Syrians are the largest group of refugees in the Netherlands. 40% of male and 45% of female recognised refugees have psychological complaints (anxiety, depression, PTSD).  

The refugee (mental) burden:

  • War, organized crime, persecution 
  • Leaving everything behind
  • Fleeing
  • Asylum procedure: very stressful
  • Integration 
  • Loss of status: for example, when you were a doctor in your home country and have to be a cleaner in the new country. 
  • Takes a long time to be reunited with your family 
  • Conflict in the home country is ongoing, they keep checking the news, very stressful. 

Posttraumatic stress disorder 

  1. Exposure to actual or threatened death, serious injury, or sexual violence
  2. Intrusion symptoms(need 1 for diagnosis) 
    1. Intrusive memories: the memory keeps the same vividness. 
    2. Destressing dreams
    3. Dissociative reactions 
    4. Cued psychological distress
    5. Cued physiological reactions
  3. Avoidance symptoms(need 1 for diagnosis) 
    1. Avoidance of memories, thoughts, feeling 
    2. Avoidance of external reminders
  4.  Cognitions and mood symptoms(need 2 for diagnosis)
    1. Inability to recall important aspect of event
    2. Exaggerated negative beliefs or expectations
    3. Distorted cognitions leading to blame 
    4. Persistent negative emotional state
    5. Diminished interest or participation in activities
    6. Detachment or estrangement from others
    7. Persistent inability to experience positive emotions
  5. Arousal and reactivity symptoms(need 2 for diagnosis) 
    1. Irritable behaviour and angry outburst
    2. Reckless or self-destructive behaviour
    3. Hypervigilance (extremely alert) 
    4. Exaggerated startle response
    5. Problems with concentration 
    6. Sleep disturbance
  6. Dissociative symptoms
    1. Depersonalization
    2. Derealization 

Complicated grief (persistent complicated bereavement disorder)

Complicated grief is unusually severe and prolonged, and it impairs function in important domains. Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased. Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means. 

PTSD prevalence

  • Dutch general population: 7,4% 
  • Displaced people worldwide: 30,6%
  • Refugees in Western countries: 9%, 5% major depression 
  • Treatment seeking refugees: 14-95%

Predicting PTSD in refugees

Elements that predict PTSD: 

  • 23,6% torture
  • 10% cumulative number of traumatic experiences
  • 10% time since conflict 
  • 3,5% level of political terror in country of origin 
  • I.e. 1/3 predicted by traumatic experiences 

Prediction depression in refugees

  • 22% cumulative number of traumatic experiences
  • 21.9% time since conflict
  • 11.4% torture
  • 5.0% residency status

Treatment

Guideline for PTSD treatment in adults

  • Trauma-focused cognitive-behavioural treatment (TF-CBT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

Discussion in refugees: should we follow the treatment guidelines in refugees? We have to stabilise them instead of focusing on the PTSD, but now a lot of research is done, and we know it is not true. There is no reason to wait.  

TFT in refugees

  • Narrative Exposure Therapy (NET) is effective 
  • Culturally-Adapted Cognitive Behavioural Therapy (CA-CBT) is effective 
  • TFT is more effective than multimodal treatment
  • TFT reduces PTSD severity and depression

Narrative Exposure Therapy: 

  • Protocol with 10-12 sessions 
  • Laying a lifeline (rope) on the floor, for different memories they put a rock or a flower down. 
  • The other sessions are used for narrative (imaginary) exposure, reliving the memories. 
  • The narrative is also written document, in this way they can give it to someone (children, lawyers). 

EMDR - helps to lose information and boil it down. 

  1. Activating memory, putting it in the working memory
  2. Focus on the event 
  3. Rapidly moving the fingers across the eyes (burden the working memory)
  4. A lot of information has to be processed by the working memory
  5. The memory will become blurry, fewer emotions

If the memory is in the working memory, then it can be changed. 

EMDR study - Discussion

Acceptability 

Acceptability of EMDR significantly lower than of stabilisation → For a subgroup of refugees, acceptability needs to be a focus of treatment.  

Safety 

EMDR and stabilisation equally safe → EMDR may be offered earlier in treatment and to a broader range of refugee patients. 

Efficacy 

EMDR and stabilisation equally efficacious → Efficacy of EMDR with refugees needs to be increased. 

  • With a subgroup of refugee patients?
  • Greater number of sessions?
  • More attention to match in explanatory models? 
  • Phased or multimodal treatment?  

Explanatory model: culturally adapted psychotherapy is more effective than unadapted, bona fide psychotherapy for primary measures of psychological functioning. Adaptation of the illness myth was the sole moderator of superior outcomes via culturally adapted psychotherapy. 

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Lecture 7: Case study: Understanding HIV risk in the aids Pandemic's Epicentre

Lecture 7: Case study: Understanding HIV risk in the aids Pandemic's Epicentre


The epicentre: eastern/southern Afrika. 10% of the world population lives there. 75% of all people infected with HIV and 75% of newly infected people live there. 

Differences between psychology and anthropology

Anthropology: how individuals’ behaviour is shaped more by group norms and values, but they have been too focused on group norms. They studied only the cultures and took themselves as the norm and the other as needed of explanation. We still see this today. But, our own point of view needs explanation too. The individual perspective of a culture lacked, not everyone in a culture is the same. The lay people still see their own culture as the norm and that everyone within a culture thinks the same. 

  • The cultural difference within nations and cultural similarity across nations. 
  • People think that the way they learned it, is the way it should be/ it ought to be. 

Cultural relativism: becoming aware that we are also trained to see the world a certain way. The opposite of ethnocentrism. Differences between groups of people are not biological but cultural (‘man-made’/ taught). Franz Boas: "civilization is not something absolute, but is relative, and our ideas and conceptions are true only so far as our civilization goes”. cultural relativism has consequences for data collection. 

Cross-cultural research (speciality of anthropologists) 

Data collection: it suggests that the data is out there, has a form/shape, regardless of who finds it. That's not true, data is not easy to find. A lot of the time people just ask what they want to know, but when asked sensitive questions (about HIV for example), people don't always answer honestly. Also, our concepts of things/situations aren't always the same. For example, marriage is very different in the West, then in Afrika. 

Ethnographic research: a qualitative research method centred upon direct and sustained, naturalistic interaction with people in the context of their daily lives in an attempt to grasp the world from their perspective.

  • Etic/outsiders’ perspective: e.g. In ‘experience-distant’, biomedical concepts 
  • Emic/insiders’ perspective: ‘experience-near’, locally meaningful concepts and classifications

How to gain the trust of a culture: participate in the daily lives, activities. Trying to bond with the people. Bodily experiencing helps to understand the people.  

Differences in world views: Gender

Malawi: you squat down when talking to someone older. Social hierarchy is much more related to age/seniority than gender. Gender not a universal social stratifier in that society. In Malawi, you have words for a younger and older sibling, instead of brother or sister. 

Cultural differences in health

Everywhere people try to make sense of health problems and seek ways to prevent and cure these. So many profound differences about what health attains and how you can achieve this. 

  • When is a body alive/dead/healthy/ill?
  • Body-mind division
  • Individual vs social body
  • Naturalistic vs personalistic causes of illness 

Health & illness explanations worldwide 

Naturalistic 

Personalistic

Illness explained as caused by natural elements

Cause located in individual body or natural environment 

Explanatory models are restricted to illnesses 

Illness explained as caused by a purposeful act of an agent 

‘Real’ cause located in social or spiritual world 

Part of larger explanatory models of misfortune 

Prevention: Avoid natural forces or conditions that may directly disrupt bodily functions 

 

Prevention: Follow moral, social, religious guidelines.

NB Prevention at other levels may be considered futile! 

Treatment: Find out WHAT caused illness 

Treatment: Finding out WHO caused illness and WHY 

NB Treating the body without addressing ‘real cause’ is senseless... 

 

Biomedical ‘belief’ system is very superficial. The biomedical doctor says take this pill and your body will be restored. This system is a belief system too. Have you seen a virus? We have been told that it works like that, and believe it. 

HIV/aids in the pandemic’s epicentre southern Africa 

Telling people is not enough.

HIV is not a very contagious virus; you need a lot of the virus and it should be released in the bloodstream. Probabilities of getting HIV when having unprotected sex: women: 1 in 500; men: 1 in 1000. Only when semen can get in the bloodstream (wound). Not everyone gets it. The campaigns say: everybody can get HIV, but it is not the reality that people see. 

Problem: HIV continues to spread despite the high levels of awareness. 

What makes this epidemic so extraordinary, why so many people there and not here, so demographically different?

Biological explanations: were there any biological difference, no. 

Cultural explanations: the claimed: stimulation of sex, uncontrolled sexual drive of African women/man. Lineage family. More freedom, not only sex with the husband.

--> it was a comfort for other people: it's them, not us. 

--> then, more epidemics. The cultural explanation did not hold anymore. 

Dr. Paul Farmer: vulnerability approach: “Real cause of most diseases is not in the biological body, but in the social context.” If people have structural deficiencies, it will affect people's health. = ’Structural violence’: social/political/economic structures or institutions which harm people by preventing them from meeting their basic needs. 

Structural vulnerabilities approach to HIV infection (paper Parker 2001)

Marginalization & impoverishment: Malnourished bodies are more susceptible to any kind of infection, including HIV. Also, low-quality living circumstance, health care services, education, infrastructure etc. If you don't have access to medication/healthcare, that will also increase the infection rates. High-risk survival strategies (migration, transactional sex) - pushing men to migrate, which leads to more short-term sexual relationships, when they migrate back, they spread the disease. 

Gender inequality: “women most disadvantaged!” -  the only thing that women have, is their body to survive. Women are especially disadvantaged in poverty. Women receive something for sex, in the West we interpret that as prostitution, but it is not like that. 

The ‘Transactional Sex’ paradigm: Assumption that low social and economic status forces women to direct exchanges of sex for resources needed for survival. It underlies much of the current thinking on African women’s persistent engagement in risky sexual practices. It leads to the conclusion that women must be economically empowered to halt AIDS pandemic. --> focus right now: Women, make them independent. Give them the choices that we think they want to make. 

The sexual and partnership choices are very risky: 

  • Quick acceptance of proposals, even from unknown men, they form relationships extremely quick (for example within one day); 
  • Both men and women have extramarital relationships, relationships are quite short (frequent partner change); 
  • Low condom use, the use of condoms is connected to HIV/Aids, so if someone suggests the use of condoms, it is directly connected to HIV. 
  • Also, people with HIV will die soon and cannot reciprocate help she gets. Or she will not get help because she will die soon. 

Men and women really need each other. Men do all the work (build houses, get food, get soap etc.). Women can’t do it; it is looked down on. A single woman is seen as strange, people will not help them, especially if she declined a husband. 

Sexual norms & values in southern Malawi:

  • Elaborate initiation rites for sexual instruction, especially of girls 
  • Sex is almost a sacred undertaking, to be performed with the utmost care, very powerful forces come with it. There are a lot of sexual rituals (for example the death of a partner). 
  • Vital for personal health, relationship stability, and community survival 
  • Should be enjoyable for both partners, there is a very positive attitude towards sex. 

But what is ’safe’ sex? What do professionals think of sex?

“Risky” sex in Mudzi (Malawi)?

Physical risk 

Social risk

    • HIV infection 
    • Losing a ‘good’ husband (e.g. best are those working abroad...) 
    • Losing community support (e.g. being single, not accepting proposal) 
    • Remaining childless 

In the social risk perspective, condom use and abstinence are risky. 

Intersecting forces that causes HIV to spread. 

  • Biological vulnerability - women are more at risk (vaginal skin tears easily)
  • Structural economic deprivation
  • Cultural sex & gender & health/illness constructs 

--> Individual perceptions of risk and efficacy (etc) shaped by these wider societal, cultural and material factors! None of these can be meaningfully disentangled from the others. 

Reasons for sexual relationship: Gendered division of tasks: men provide extra’s, build house etc / Conformation to ideal of being married = respectable status, community inclusion, safety net / Sex is vital for good health & community survival (only through children can one become a real woman) / Lust & love  

So... Women’s decision to engage in (high-risk) sexual relationships partly instigated by the desire for direct material benefit. But that is rather a result of cultural constructs than the difference between male wealth/female poverty. Additional motivations are not directly related to material support that a man might provide.