Trauma' and the lives of women refugees in resettlement. PhD thesis, London School of Hygiene

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Roche, Brenda Anne (2005) Trauma’ and the lives of women refugees
in resettlement. PhD thesis, London School of Hygiene & Tropical
Medicine. DOI: https://doi.org/10.17037/PUBS.00682339
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DOI: 10.17037/PUBS.00682339
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'Trauma' and the Lives of Women Refugees in Resettlement
Thesis submitted to the University of London
for the Degree of Doctorate of Philosophy
Brenda Anne Roche
July 2005
Health Policy Unit
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
To Pat and Kathleen/or teaching me everything I really needed to know,
supporting me in everything that I do, and encouraging me to learn all
that I could.
ABSTRACT ........................................................................................................................................................ 3
ACKNOWLEDG EMENTS ............................................................................................................................... 5
I. INTRODUCTION ......................................................................................................................................... 7
CONCEPTUALISING TRAUMA ............................................................................................................................ 9
CHARTING DISCOURSE ................................................................................................................................... 13
PRIMARY RESEARCH OBJECTIVE .................................................................................................................... 16
THESIS STRUCTURE ........................................................................................................................................ 17
II. BACKGROUND ......................................................................................................................................... 22
CONFLICT AND FORCED MIGRATION .............................................................................................................. 22
Kosov A AND THE COLLAPSE OF yUGOSLAVIA .............................................................................................. 24
HISTORICAL AND CULTURAL FEATURES OF RELEVANCE IN KosovA ............................................................ 28
SEXUAL VIOLENCE & ETHNIC CLEANSING .................................................................................................... 31
III. ASYLUM IN THE UK .............................................................................................................................. 37
PRACTICAL ISSUES ......................................................................................................................................... 41
CULTURAL ISSUES .......................................................................................................................................... 43
HEALTH ISSUES AND REFUGEES ..................................................................................................................... 48
IV. 'A HISTORY OF TRAUMA' DISCOURSE ........................................................................................... 56
V. RESEARCH DESIGN AND METHODS ................................................................................................ 78
AIMS AND OBJECTIVES .................................................................................................................................. 79
RESEARCH METHODOLOGIES ......................................................................................................................... 81
CHARACTERISTICS OF A COMMUNITY IN EAST LONDON ................................................................................ 92
THE WOMEN .................................................................................................................................................. 94
DATA CODING AND ANALySIS ....................................................................................................................... 99
STUDY LIMITATIONS .................................................................................................................................... 101
REFLEXIVITy ................................................................................................................................................ 103
VI. TRAUMA AND REFUGEES ................................................................................................................. 110
PUBLIC HEALTH AND EPIDEMIOLOGICAL PERSPECTIVES ............................................................................. 110
ANTHROPOLOGICAL PERSPECTIVES ............................................................................................................. 116
VII. ACADEMIC AND CLINICAL DISCOURSE IN THE UK ............................................................... 123
THE NATURE OF DISCOURSE ........................................................................................................................ 125
LOCATING TRAUMA IN REFUGEE HEALTH ................................................................................................... 127
SOCIO-POLITICAL IMPLICATIONS OF TRAUMA .............................................................................................. 145
VIII. MAPPING SERVICES AND PHILOSOPHIES. ............................................................................... 152
MAPPING THE NATURE OF SERVICES ........................................................................................................... 153
PHILOSOPHY AND PRACTICE ........................................................................................................................ 166
IX. ASSESSING HEALTH, DEFINING TRAUMA. .................................................................................. 175
FRAMING POST TRAUMATIC STRESS DISORDER ........................................................................................... 178
THE HORROR STORy .................................................................................................................................... 184
x. LIVES IN RESETTLEMENT ................................................................................................................. 188
A Kosov AR COMMUNITY IN LONDON ......................................................................................................... 18 8
STORIES OF EXILE AND RESETTLEMENT ....................................................................................................... 193
FINDING COMMUNITy .................................................................................................................................. 20 1
XI. LOSS, TRAUMA AND IDIOMS OF DISTRESS ................................................................................. 206
XII. THE POWER OF 'TALK' .................................................................................................................... 219
TALK AS 'THERAPY' .................................................................................................................................... 219
TALK IN RESETTLEMENT .............................................................................................................................. 231
XIII. DISCUSSION ........................................................................................................................................ 240
PROVIDER UNDERSTANDINGS OF TRAUMA .................................................................................................. 241
TRAUMA AND WOMEN REFUGEES IN RESETTLEMENT.. ................................................................................ 249
INTERPRETATIONS OF 'TALK' ...................................................................................................................... 253
XIV. CONCLUSION ..................................................................................................................................... 266
XV. BIBLIOGRAPHY .................................................................................................................................. 275
XVI. APPENDIXES ....................................................................................................................................... 300
APPENDIX 1: UNHCR DEFINITION OF THE TERM "REFUGEE" ...................................................................... 301
APPENDIX 2: ASYLUM PROCEDURES AND STATUS CATEGORIES .................................................................. 303
APPENDIX 3: SUMMARY OF IMMIGRATION POLICIES IN THE UK 1993-2004 ................................................ 305
APPENDIX 4: FINANCIAL SUPPORT FOR ASYLUM SEEKERS (2004) ............................................................... 307
APPENDIX 5: DIAGNOSTIC CLASSIFICATIONS FOR PTSD (DSM AND ICD) ................................................. 309
ApPENDIX 6: ETHICS COMMITTEE APPLICATION TO CONDUCT A STUDY INVOLVING HUMAN SUBJECTS .... 314
APPENDIX 7: INTERVIEW GUIDE, HEALTH AND SOCIAL CARE PROVIDERS .................................................. 325
APPENDIX 8: INTERVIEW GUIDE, WOMEN RESPONDENTS ............................................................................. 326
ApPENDIX 9: SUMMARY OF HEALTH AND SOCIAL CARE PROVIDERS ........................................................... 328
ApPENDIX 10: SUMMARY OF WOMEN RESPONDENTS .................................................................................. 329
APPENDIX 11: MENTAL HEALTH TREATMENTS OFFERED TO THE WOMEN .................................................. 330
ApPENDIX 12: CONSENT FORM .................................................................................................................... 331
APPENDIX 13: PARTICIPANT INFORMATION SHEET ...................................................................................... 332
APPENDIX 14: CODES FOR ANALYSIS, PROVIDER INTERVIEWS .................................................................... 334
APPENDIX 15: CODES FOR ANALYSIS, INTERVIEWS WITH WOMEN .............................................................. 336
APPENDIX 16: STRUCTURE OF THENHS ...................................................................................................... 337
APPENDIX 17: UK ACADEMIC AND CLINICAL DISCOURSE, SELECTED TEXTS .............................................. 338
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ABSTRACf
'Trauma' has emerged as a central defining construct within professional and popular
discussions on refugee health. Refugees are considered to be at risk for psychological
distress due to traumatic events experienced in the context of conflict and natural disasters
in their countries of origin as well as in the context of exile. Following migration, life in
resettlement is often an unstable process marked by poverty, social exclusion, as well as
poor health status.
The importance of 'trauma' in the discussions on refugee health has left health professionals
struggling to make sense of and react to groups of people now defined as 'traumatised'.
However, we have little understanding of how trauma is understood, experienced and
addressed by individuals, their advocates and the service provider's impacts upon the
experiences of refugees in resettlement. Juxtaposing information from three distinct
sources, I examine the discourse(s) surrounding refugees and health in resettlement,
focusing upon the definitions and meanings attached to the issue of 'trauma'. The analysis
draws on 16 qualitative interviews with health and social care professionals, qualitative
'resettlement history' interviews with 25 women refugees, as well as an examination of a
selected body of authoritative knowledge (academic articles and conference reports) in the
UK.
At the heart of this analysis are contrasting perspectives in relation to the dominant
paradigms of psychiatry, the metes and bounds of localised frameworks of distress, and the
margins of socio-political action and interpretation. Definitions of trauma as a psychiatric
disorder have implications for the clinical and social care responses of health professionals.
In turn, women refugees are encouraged to engage with psychiatric systems of care and to
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learn a new language of distress that is psychologically informed, and may be distant from
the socio-cultural context of their lives in resettlement.
At the same time, the construct of 'trauma' has significance in the context of political
asylum, where a diagnosis of , traumat is ed' may be perceived as evidence supporting
asylum claims. The highly politicised context of resettlement raises issues of social justice,
which are interspersed with notions of trauma, as professionals seek to reconcile ideas of
testimony and therapeutic interventions. These ways of seeing trauma rely upon the use of
conventional Western notions of mental health and well-being that are grounded in a
psychiatric paradigm and make use of related clinical strategies. Particular emphasis is
placed upon the value of 'talk' as a means of achieving recovery. The women interact with
popular and professional discourses on trauma in their daily lives. How they perceive and
respond to these discourses (whether accepting it in whole, in part or rejecting it) offers
insights into the meaning of trauma in resettlement and the coping strategies they employ in
response to a psychological framing of their experiences.
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ACKNOWLEDGEMENTS
This work relied upon the kindness, encouragement and cooperation of many individuals. I
would like to thank the women from the Albanian speaking community in London for
taking the time to participate in interviews. Beyond the formal interviews, they welcomed
me into their homes and their community as a friend. This is something I remain grateful
for. All of the providers who took part in this research also gave freely of their time. I thank
them for their assistance, for taking the time to meet with me and to share their opinions and
experiences with me, and for sharing an enthusiasm for this work.
Luljeta Nuzi and Alketa Krasniqi donated their time as Albanian interpreters on this project,
without their help the interviews with Kosovar women could not have taken place. A
special thanks to Luljeta Nuzi, whose tireless dedication, humour and friendship made the
research a pleasure to conduct.
I would like to thank my supervisor Karina Kielmann, for her incredible support, wisdom,
and editorial skills above and beyond the call of duty. Her commitment and enthusiasm for
the research made the difficult times easier to get through and the inspiring moments all the
more joyful. Thanks also to Charlotte Watts, Jessica Ogden and Cathy Zimmerman all of
whom provided guidance, support and tireless cheerleading throughout the research study.
I would like to thank Maureen Miller for her unofficial mentoring and her unflappable faith
in my ability to do this. Thanks to Paul Colson, Kostas Gounis, Kim Hopper, Bob and
Mindy Fullilove for encouraging me to do this for a very long time. A special thanks to
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Miceal Campbell for his support and generosity, and for giving me the final push to pursue
doctoral studies.
In London, my friends at the London School of Hygiene & Tropical Medicine have made
the journey a much nicer one to take, especially Salim Vohra, Najibullah Habib, Chris
Wallace & Jan Mac, Eric & Shana Tongren, Juraci Cesar, Rosanne Rushing, Maria
Bakaroudis, Val Percival, Miguel Betancourt, Eleonore Bachinger, Molly Fitzgerald, Sylvia
Struck, Pornthip Chompook, Jolly Kamwanga, Alvaro Alonso, Meenakshi Gautham and
Oscar Arteaga-Herrara.
Thanks to friends near and far for their encouragement throughout the process, especially:
Deborah Borne, Quintin Clough, Jennifer Fuld, Laura Schalk, John Moraitis, Jessica Glass,
Janine Tramontana, Sarah Hunt, Peter Holleran, Antonia Swann & James Kreppner, Amy
Scammell, Ed Parkes, Nicola Markham, Jo O'Rourke, Mary Flower and Tarig Hilal. Very
special thanks to Bernie O'Connell for her enthusiastic support and friendship throughout
the doctorate.
Finally none of this work would have been possible if not for the unconditional love and
encouragement of my family, who have helped me through the difficult moments and urged
me on in all the small victories. Love and thanks to Kathleen and Patrick Roche, Michael
and Carmen Roche, Patrick Roche Jr, Mary Summers & Leigh Craney, Karen Roche, Brian
Roche & Frances Wright, James & Elise Roche. Special thanks to nieces & nephews for
their emails and video messages of support: Bernadette, Kimberly & Thomas Summers,
Concetta & Patrick Roche, Catriona & Dec1an Roche.
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I. INTRODUCTION
l
Life in resettlement following forced migration is often an unstable process marked by
poverty, social exclusion, as well as poor health status. Refugees are considered to be at
additional risk for psychological distress due to the events experienced in the context of
conflict and forced migration. Extreme events may transpire across the phases of conflict
and into the process of exile with varying degrees of intensity. These can range from
economic deprivation to profound social disruption (persecution, fragmentation of social
and family networks, as well as the more extreme situations of violence) (Ager 1999).
The concept of 'trauma' has come to encapsulate the core elements related to such
experiences; referring to the nature and intensity of the event(s) itself through to the
psychological after-math for individuals and communities. The struggle to comprehend the
nature of 'trauma' and suffering has coincided with the rise of particular forms of traumatic
response. Post-Traumatic Stress Disorder (PTSD), a formally defined psychiatric disorder,
has emerged as a particular framework for understanding the psychological impact of
extreme events upon individuals.
For many refugees, PTSD has become the particular lens with which their experiences are
viewed (Clinton-Davis and Fassil 1992, Friedman and Jaranson 1994, WHO 1996). The
war in Yugoslavia, for example, came to be viewed through a popularised prism of
'trauma', one heavily ingrained with the markings of PTSD.
I The term 'resettlement' is used in the broad sense of the word, and does not refer to specific programmes of
support for refugees, unless otherwise specified.
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