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

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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 Downloaded from: http://researchonline.lshtm.ac.uk/682339/ DOI: 10.17037/PUBS.00682339 Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact '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 2 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 3 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. 4 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 5 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. 6 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. 7

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