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Working with traumatized refugees on the Balkan route
Abstract
In the past several years Serbia has been in the center of the so‐called “Balkan route”, a pathway for refugees from the Middle East and Central Asia. In March 2016 the Balkan route was closed and this measure reduced the number of daily arrivals and prolonged the stay of refugees in Serbia. A brief overview of the current situation is given, together with some previous experiences in psychosocial programs for the displaced population during wars in former Yugoslavia and current psychosocial programs and interventions. Several short examples are presented to point out some aspects of those experiences that might have relevance to our understanding of the psychological trauma and possible ways of treatment.
... In March 2016, the EU and Turkey signed an agreement to reduce the number of refugees entering Europe by sending migrants crossing from Turkey into Greece back to Turkey and by increasing border security (Weber, 2016). The endeavor to close the Balkan route has only been partly successful, but it has made the flight more difficult and dangerous (Weber, 2017;Jovic, 2018). ...
... Mobile teams were organized comprising a medical doctor and a nurse to attend to refugees' physical and medical needs using a set of interventions known as medical first aid (MFA). The teams also comprised a psychologist, responsible for providing psychosocial first aid (PFA), and a translator (Jovic, 2018). Guidelines for brief psychosocial interventions for refugees were developed that included: 3 The Inter-Agency Standing Committee is an inter-agency forum for coordination, policy development and decision-making involving the key UN and non-UN humanitarian partners. ...
Most studies on refugee populations are organized around trauma-related issues and focus on explaining pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence how developmental tasks are negotiated. This study is part of a larger mixed method study seeking to identify resilience-promoting and resilience-inhibiting factors, on individual and contextual levels, among asylum seekers and refugees on the move (passing through Serbia) and settled in reception centers in Norway. A strategic sample of 20 adolescent and young adult refugees/asylum seekers during flight in Serbia (10) and after arrival in Norway (10) was chosen from a sample of 178 refugees interviewed in depth in Serbia and at receptions centers in Norway. The sample reflects the focus of this paper, which is to explore adolescent and young adult refugees/asylum seekers’ psychological and social needs and resources during flight to and after arrival in the host country, including how developmental tasks are negotiated. Through qualitative analysis, experiences associated with the developmental changes the participants experienced before, during, and after flight are contextualized. Their sense of self, their relationships with their families and their perceptions of their situation as adolescents or young adults in a highly unpredictable situation are presented in the light of relevant theory and findings from similar refugee studies. All the participants have fled from dangerous and intolerable situations in their home countries. They describe extreme dangers during flight in contexts that are unpredictable and where they feel lonely and unsupported. Most have unmet psychosocial needs and have received little support or help for their mental health issues during flight or after arrival in Norway. Suggestions for interventions and resilience-promoting actions are given based on the findings of the study.
... Life situations that are so difficult that one cannot manage without psychotropic or sleep medication, and where one considers "salvation" through ending one's life, are manifestations of the severity of these violations. Based on our study, as well as on others (Chavez, 2012;Jovic, 2018), it seems legitimate to argue that living under such conditions is equivalent to severe and long-lasting social suffering due to avoidable violence imposed by external others (Galtung, 1969). ...
Asylum seekers are in an extraordinary situation as their future life depend on decisions made by authorities in a bewildering, bureaucratic system, with excessive waiting and unpredictable timeframes. Those that are not granted asylum, and not able to return to their country of origin, can neither spatially nor temporally visualize if, when or how a potential change is going to occur. This paper is part of a larger study based on narrative interviews with asylum seekers and refugees in asylum centers in Norway, exploring their experiences before, during, and after flight. As we found that the life circumstances for those being refused asylum, were highly different from other participants in the project, we chose to address this particular group in a separate paper. The participants in this part of the study consisted of 21 individuals (of a total of 78 participants) in the age range 18–44, of whom eight were female and 13 males. Trough qualitative interviews and participant observation the aim of this study was to explore and describe the life condition and mental health situation of rejected asylum seekers in Norway. We found that the gradual loss of rights, opportunities and finances are experienced as a form of violence that leads to extreme mental and social suffering. This policy clearly conflicts with Human Rights incorporated in the Norwegian constitution, and we argue that it legitimizes treating asylum seekers as a group of undesirable and underserving political bodies, with serious consequences for their mental health and wellbeing.
... 2 Referencial teórico 2.1 Refugiado: conceito e caracterização Ao tentar definir-se o que vem a ser um refugiado, geralmente, recai-se na tentativa de pensar em sentidos opostos às tipologias empregadas para categorizar experiências individuais ou grupais, como qualificados ou não qualificados; permanentes ou temporários; voluntários ou forçados, dentre outros (Erdal & Oeppen, 2017). Muitas vezes, seu conceito também se confunde com diversas modalidades de migração, não levando-se em conta o seu ponto de partida, que é amplamente debatido, mas que se fundamenta a partir da transgressão das fronteiras internacionais e o pedido formal de asilo em outra nação, por causas das ameaças de insegurança e pobreza existentes que levam milhares de indivíduos a começar sua jornada incerta e perigosa (Hynie, 2018;Jović, 2018). A fim de orientar a discussão sobre a temática do refúgio, a Tabela 1 caracteriza as variantes envolvidas nos debates acerca do contexto da migração forçada no mundo: ...
O presente artigo tem por objetivo compreender os desafios da integração de refugiados em suas experiências de trabalho nas organizações brasileiras. Por meio do paradigma
interpretativo e utilizando-se de uma pesquisa descritiva, com abordagem qualitativa, o
estudo foi aplicado a oito refugiados, de origem síria e africana, residentes na cidade de São Paulo, SP. Os resultados apontaram para barreiras de nível individual, como idioma, cultura e gênero; já a nível nacional, fatores como a crise econômica, o não reconhecimento de qualificações e as políticas governamentais ficaram em evidência; por fim, no nível organizacional o desconhecimento e a discriminação por parte de muitas empresas foram considerados. A pesquisa trouxe contribuições teóricas e práticas importantes para a integração ao dar voz aos refugiados presentes no Brasil e compreender, a partir dos seus relatos, quais as suas maiores dificuldades enfrentadas no mercado de trabalho e nas organizações locais, visando, assim, proporcionar uma reflexão ao governo, entidades sociais, organizações e sociedade em geral, sobre que medidas podem ser impostas para reduzir as barreiras que impedem o sucesso de permanência desses grupos no território brasileiro.
A theory of traumatic memory was developed by Breuer and Freud in “Studies on Hysteria” based on Charcot’s theory on the traumatic origin of mental disorders. This was again developed in DSM-III in 1980 with the introduction of posttraumatic stress disorder (PTSD), where traumatic memory was conceptualized as a core of the syndrome and set in causal relationship with its manifestations. This implied that “trauma” tended to be seen as something static and reified, like a “thing” in the mind. It is shown that this conceptualisation diverts attention from the dynamic and reorganizing processes in the traumatized person’s mind, body and relations to others. The psychoanalytic conceptualization includes a wider spectre of the manifestations in posttraumatic conditions and it differs in the understanding of underlying processes. What is common for both childhood and adult trauma and their posttraumatic manifestations are deficiencies in symbolization processes related to the traumatic experiences. The signal anxiety function fails and the ego is overwhelmed by automatic or annihilation anxiety. The ability to distinguish between real danger and neutral stimuli which function as triggers fails. As anxiety related to trauma cannot be mentalized, fragments of the self are split off and evacuated. These experiences remain as fragmented bits and pieces that can express themselves in bodily pain, dissociated states of mind, nightmares and relational disturbances. Thus, the consequences of psychological trauma may be conceptualised as processes characterised by splitting off of not mentalized inner objects/introjects and parts of the mental apparatus. These processes are illustrated with a short clinical vignette.
Measuring of stressors related to war experiences, especially the experiences of torture, as well as systematic collection and analysis of such data, are the indispensable part of a comprehensive evaluation of psychological consequences of torture. The methodological problem of measuring types of torture in the IAN Centre for Rehabilitation of Torture Victims (CRTV) has been overcome through the attempt to create a special questionnaire covering 81 different forms of psychological, physical and sexual abuse and ill treatment. This paper explains the constructing principles of the instrument and its basic metric characteristics, done on a sample of 322 individuals, IAN CRTV clients since December 2002. We have obtained a tri-factor structure of the questionnaire, which according to our opinion can clarify to some extent the complex phenomenon such as torture in the situation of war in former Yugoslavia. In the appendix we have included an analysis on frequency of types of torture in the surveyed sample, showing that the clients of our centre have frequently been subjected to extreme forms of torture.
Six years of the IAN Trauma Centre work and three years of work in the IAN Centre for Rehabilitation of Torture Victims have been marked with socio-political and professional challenges, as well as with challenges common to the work of humanitarian organisations in emergencies. The predominantly psychological and psychiatric profile of the organisation and its core programmes was gradually supplemented with an orientation towards a wider psychosocial context of assistance to victims of torture and war-related trauma, inlcuding not only psychological aid, but also classical humanitarian programmes of emergency material aid distribution, repatriation and integration programmes, skills training and economic self-reliance programmes, medical aid and forensic expertise. This paper provides an overview of key principles underpinning the work of various segments of the comprehensive programme of assisance for torture and trauma victims as the basic operational framework in which specific project activities have been implemented.
Research on the psychological well-being of refugees has focused on deficiencies within individuals either in terms of psychiatric symptoms or feelings of distress. To achieve a more holistic view of the life experiences of refugees, we need to look at the limitations of our current theoretical models. This article critically examines some of the major theoretical approaches that have guided research on the psychological well-being of refugees: the medical model, the psychosocial stress model and Berry's (1997) ‘acculturation framework’. It goes on to examine Hobfoll's ( 2001 ) Conservation of Resources stress theory, a model which has important implications for refugee research. Drawing upon the models reviewed, the last section outlines a conceptual framework for adaptation among refugees. At the heart of it lies the concept of resources . However, resources must be understood in terms of the individual's needs , personal goals and the demands he or she encounters. Each of these concepts must be examined in the context of the pre-migration, flight and post-migration phases. The additional concept of constraints on the use of or access to resources is particularly relevant to the post-migration phase. Such a conceptual toolkit could prove especially useful in going beyond quantitative data to present the human stories of refugees. It could also sensitize researchers to the impact of host societies on the well-being of refugees.
The authors of this paper use the term 'mentalisation' as a supra-ordinate concept that encompasses processes of representation, symbolisation and abstraction. Mentalisation is defined as a preconscious or ego function that transforms basic somatic sensations and motor patterns through a linking activity (Freud's notion of Bindung). This binding proceeds from initial associations of somatic/motoric substrata with mental representations, on to the multiplication and organisation of these representations, thus allowing the emergence of mental contents and structures of higher levels of complexity (symbolism and abstraction). Inspired by the contributions of Marty, Luquet and Bion, the authors propose a conceptual model of formal levels of mental elaboration. Mentalisation is defined as consisting of two theoretically separate and independent dimensions. Each presents levels of a hypothesised and gradually increasing mental elaboration. The first dimension considers different channels of drive-affect expression: somatic and motor activity, imagery and verbalisation. The second specifies five descriptive levels of affect tolerance and abstraction: disruptive impulsion (acting out), modulated impulsion (catharsis), externalisation, appropriation and abstract-reflexive meaning association. A clinical case illustrates how the two dimensions may influence listening and interpreting. Some metapsychological aspects of the process of mentalisation are discussed.
Using the DSM-IV diagnostic criteria for acute stress disorder, the authors examined whether the acute psychological effects of being a bystander to violence involving mass shootings in an office building predicted later posttraumatic stress symptoms.
The participants in this study were 36 employees working in an office building where a gunman shot 14 persons (eight fatally). The acute stress symptoms were assessed within 8 days of the event, and posttraumatic stress symptoms of 32 employees were assessed 7 to 10 months later.
According to the Stanford Acute Stress Reaction Questionnaire, 12 (33%) of the employees met criteria for the diagnosis of acute stress disorder. Acute stress symptoms were found to be an excellent predictor of the subjects' posttraumatic stress symptoms 7-10 months after the traumatic event.
These results suggest not only that being a bystander to violence is highly stressful in the short run, but that acute stress reactions to such an event further predict later posttraumatic stress symptoms.
Survival-related clinical reports are abundantly found in the works of classical, object-relational, and self psychological writers, but are underrepresented in major theoretical formulations on anxiety. Fears of being overwhelmed, merged, penetrated, fragmented, and destroyed, as contents of unconscious and conscious fantasies, are regularly interrelated with the typical dangers. Fifteen preliminary propositions invite closer study of such apprehensions and provide definitional components. Annihilation anxieties are triggered by survival threat; are found early but can be engendered throughout the life cycle; constitute a basic danger; are residuals of psychic trauma; have specifiable subdimensions; may occur in presymbolic form or be associated with fantasies in conflict/compromise formation; may arise with or without anticipation; may be accompanied by controlled or uncontrolled anxiety; are motives for defense; and may be associated with particularly recalcitrant resistances. The study of annihilation anxieties in relation to the basic danger series has both theoretical and clinical advantages, especially for understanding traumatic, anxiety, phobic, psychosomatic, addictive, narcissistic, borderline, and psychotic manifestations, as well as sexual problems (including perversions), nightmares, dissociative and panic states, and especially difficult resistances.
This paper describes a Bosnian refugee, a survivor of war and ethnic cleansing, during a 3-year follow-up in a psychiatry clinic.
This case throws light on the tension between medicotherapeutic and sociomoral ways of understanding the effects of such experiences, and of the limitations of morally and politically neutral psychiatric categories and technologies. Suffering always invokes questions of values: in this case the clinical picture represented a moral protest at what had been done with such impunity, and a refusal to accommodate to a world which now seemed unintelligible. The clinical picture also embodied the collective outrage, and sense of unfinished business, which many back in Bosnia itself were carrying in the wake of the 1995 Dayton peace accords which effectively legitimised the lines of ethnic cleansing.
DSM or ICD diagnoses of depressive disorder or post-traumatic stress disorder turned out to lack validity and explanatory power. Claims that victims of war and atrocity typically have an unmet need for mental health services are overstated. Recovery from the effects of war may depend on reestablishing a sense of intelligibility, a task that must primarily go on in social space rather than mental space.
About 13 million people are classified as refugees worldwide, and many more former refugees have been granted citizenship in their new countries. However, the prevalence of post-traumatic stress disorder, major depression, or psychotic illnesses in these individuals is not known. We did a systematic review of surveys about these disorders in general refugee populations in western countries.
We searched for psychiatric surveys that were based on interviews of unselected refugee populations and that included current diagnoses of post-traumatic stress disorder, major depression, psychotic illnesses, or generalised anxiety disorder. We did computer-assisted searches, scanned reference lists, searched journals, and corresponded with authors to determine prevalence rates of these mental disorders and to explore potential sources of heterogeneity, such as diagnostic criteria, sampling methods, and other characteristics.
20 eligible surveys provided results for 6743 adult refugees from seven countries, with substantial variation in assessment and sampling methods. In the larger studies, 9% (99% CI 8-10%) were diagnosed with post-traumatic stress disorder and 5% (4-6%) with major depression, with evidence of much psychiatric comorbidity. Five surveys of 260 refugee children from three countries yielded a prevalence of 11% (7-17%) for post-traumatic stress disorder. Larger and more rigorous surveys reported lower prevalence rates than did studies with less optimum designs, but heterogeneity persisted even in findings from the larger studies.
Refugees resettled in western countries could be about ten times more likely to have post-traumatic stress disorder than age-matched general populations in those countries. Worldwide, tens of thousands of refugees and former refugees resettled in western countries probably have post-traumatic stress disorder.
After the so-called refugee crisis of 2015–2016 European reactions to foreigners had come to the fore and we are seeing xenophobic political and populist movements become increasingly mainstream. The massive rejection of refugees/asylum seekers taking place has made their conditions before, during and after flight, increasingly difficult and dangerous. This paper relates current xenophobia to historical attitudinal trends in Europe regarding Islam, and claims that a much more basic conflict is at work: the one between anti-modernism/traditionalism and modernism/globalization. Narratives on refugees often relate them to both the foreign (Islam) and to “trauma”. In an environment of insecurity and collective anxiety, refugees may represent something alien and frightening but also fascinating. I will argue that current concepts and theories about “trauma” or “the person with trauma” are insufficient to understand the complexity of the refugee predicament. Due to individual and collective countertransference reactions, the word “trauma” tends to lose its theoretical anchoring and becomes an object of projection for un-nameable anxieties. This disturbs relations to refugees at both societal and clinical levels and lays the groundwork for the poor conditions that they are currently experiencing. Historically, attitudes towards refugees fall somewhere along a continuum between compassion and rejection/dehumanization. At the moment, they seem much closer to the latter. I would argue that today’s xenophobia and/or xeno-racism reflect the fact that, both for individuals and for society, refugees have come to represent the Freudian Uncanny/das Unheimliche.
Analyse des cinq principaux arguments (institutionnel, belliqueux, informationnel, relatif a la securite de l'Etat, philosophique) developpes en faveur d'une justification de la pratique de la torture sous ses formes modernes (interrogatoire, force de dissuasion, deshumanisation) dans des etats democratiques ou non-democratiques tels que l'Irlande du Nord, la Chine, la Birmanie, l'ile de Timor
This chapter is based on two propositions. The first is that if we are ever to de-medicalize misery, then both the impact of people’s environments and their life experiences, as major causes of emotional distress, and the social significance of these connections will have to be made more prominent. The second proposition is that both psychiatry and clinical psychology so avoid giving prominence to people’s contexts in their theory, research and practice that we might reasonably ask why. Are they acting in accordance with evidence, has research demonstrated that life experience is not very important or, given what we know of the links between avoidance and fear, are psychiatry and clinical psychology actually rather fearful of context? This matter can be settled quickly. The evidence that what has happened and is happening to people in their lives plays a major role in creating various forms of emotional distress and behavioural problems – including psychosis – is very strong (Bentall, 2003; Read et al., 2005; Stoppard, 2000; Tew, 2005; Wilkinson & Pickett, 2009). As Bentall (2003) and Falloon (2000) have pointed out, this evidence is stronger than any we have for genetic or biological causes. So, if context is not at the forefront of psychiatric and clinical psychological theory and practice, then the avoidance is likely to be associated with something other than neutral presentation of evidence.
The skin-ego is a metaphor created by the French psychoanalyst Didier Anzieu to describe the process by which the infant's emerging ego develops a container for psychic contents and achieves a secure feeling of well-being. The ego encloses the psychic apparatus as the skin encloses the body. The ego becomes able to fix barriers protecting the internal world and to screen exchanges with the id, the superego, and the outside world. The skin-ego is an envelope that contains thoughts and gives to thinking activity some limits, continuity, and a protection against the instincts. The functions of the skin-ego are to maintain thoughts, to contain ideas and affects, to provide a protective shield, to register traces of primary communication with the outside world, to manage inter-sensorial correspondences, to individuate, to support sexual excitation, and to recharge the libido. The skin-ego is the foundation of the container-contained relationship. An important part of psychoanalytic work with borderline patients is the reconstruction of the earliest phases of the skin-ego and their consequences for mental organization.
It is well known that infants as soon as they are born tend to use fist, fingers, thumbs in stimulation of the oral erotogenic zone, in satisfaction of the instincts at that zone, and also in quiet union. It is also well known that after a few months infants of either sex become fond of playing with dolls, and that most mothers allow their infants some special object and expect them to become, as it were, addicted to such objects. There is a relationship between these two sets of phenomena that are separated by a time interval, and a study of the development from the earlier into the later can be profitable, and can make use of important clinical material that has been somewhat neglected. Those who happen to be in close touch with mothers' interests and problems will be already aware of the very rich patterns ordinarily displayed by babies in their use of the first 'not-me' possession. These patterns, being displayed, can be subjected to direct observation. There is a wide variation to be found in a sequence of events that starts with the newborn infant's fist-in-mouth activities, and leads eventually on to an attachment to a teddy, a doll or soft toy, or to a hard toy. It is clear that something is important here other than oral excitement and satisfaction, although this may be the basis of everything else. Many other important things can be studied, and they include: 1. The nature of the object. 2. The infant's capacity to recognize the object as 'not-me'. 3. The place of the object – outside, inside, at the border. 4. The infant's capacity to create, think up, devise, originate, produce an object. 5. The initiation of an affectionate type of object-relationship.
In this contribution the author seeks to examine the theological and psychoanalytic concepts in order to cast light on terrorism and religious bigotry. He suggest that the suicidal terrorist is moved by unconscious sources within his archaic Oedipus Complex (Kleinian version) and by the propensity for self sacrifice, human sacrifice being the hidden order of the Oedipus complex. The author carries this theme through other related themes: the battle between men and women or patriarchy versus matriarchy, the issue of dependency in psychoanalysis and religion, the anatomy of terror, dehumanization and; other themes. Copyright © 2009 John Wiley & Sons, Ltd.
Psychotherapy of people traumatised by war, especially people who have been exposed to torture, as well as their specific emotional and cognitive response to the experience of extreme horror, set many challenges before both participants in the therapeutic dyad and at the same time face them with many delicate questions. Besides usual issues that have been dealt with in this article, such as the issue of criteria for including patients and choice of the type of psychotherapy, followed by the issues of indications and contraindications for using psychoanalytic psychotherapy, as well as the motivation of patients for such treatment, we have also elaborated on the issue of the technique itself in the given context, i.e. specific nature of the patient-therapist relationship, specific features of the setting, adaptation of the technique itself and the particular characteristics of the course and ending of therapy. We have tried to answer what it is that helps torture victims who have been treated in this way, but we also discussed the possible causes of unsuccessful therapeutic outcomes.
Psychotherapeutic work with torture victims is already challenging and demanding for the therapist; I believe this is particularly true in the situation of group therapy. In this case there are some specific aspects related to this particular group - its members had been connected with each other even before the formal establishing of the group for therapeutic purposes. Unfortunately, this connecting factor was their common and simultaneous traumatic experience of war, captivity, torture and life in a new community after exile. During 54 sessi ons, 27 men with various levels of vulnerability and initial position of "permanent helplessness" have through several phases of group work successfully dealt with their paranoid anxiety, established and developed cohesiveness and certain group culture, thereby ensuring their own path towards the phase of opening, working through fears for their own psychophysical integrity by way of hypochondriac elaborations, and finally mustered the strength to voluntarily face again the trauma and torture they had suffered. They have managed to re -incorporate these experiences through the re- integration phase and finally through termination to wind up and attribute the meaning to their emotional turbulences brought by therapy and its closure. Support in the psychotherapeutic work with this group was provided by psychologists from the Centre for Rehabilitation of Torture Victims - IAN Belgrade. By conducting psychological testing they have helped in the diagnostic exploration of these people, while two other important services in IAN - legal department and medical unit with internal medicine and neurology experts - also provided important contribution.
In this new book, Anzieu presents a synthesis of his research and proposes a theory on the functions of 'the skin-ego'.
Just as the skin is envelope to the body, Anzieu sees 'the skin-ego' as a psychic envelope containing, defining and protecting the psyche. From this perspective, the structures and the function of the skin can provide psychoanalysts and psychotherapists with fertile analogies.
Anzieu's concept of the skin-ego is the answer to questions he regards as crucial to contemporary psychoanalysis: questions of topography, left incomplete by Freud; the analysis of fantasies of the container as of the contained; issues of touch between mothers and babies; extending the concept of prohibitions within an Oedipal framework to those derived from a prohibition on touching; questions pertaining to the representation of the body and to its psychoanalytic setting. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Programmes costing millions of dollars to address 'posttraumatic stress' in war zones have been increasingly prominent in humanitarian aid operations, backed by UNICEF, WHO, European Community Humanitarian Office and many nongovernmental organisations. The assumptions underpinning this work, which this paper critiques with particular reference to Bosnia and Rwanda, reflect a globalisation of Western cultural trends towards the medicalisation of distress and the rise of psychological therapies. This paper argues that for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. These concepts aggrandise the Western agencies and their 'experts' who from afar define the condition and bring the cure. There is no evidence that war-affected populations are seeking these imported approaches, which appear to ignore their own traditions, meaning systems, and active priorities. One basic question in humanitarian operations is: whose knowledge is privileged and who has the power to define the problem? What is fundamental is the role of a social world, invariably targeted in today's 'total' war and yet still embodying the collective capacity of survivor populations to mourn, endure and rebuild.
In the works of Freud, the concept of childhood psychic trauma evolves in the direction of increasing complexity. The authors maintain that this expansion corresponds to a new conception of retroactive temporality (Nachträglich), which is precisely the one we use in the analytic process of reconstruction and historicization from the present toward the past. We are thus led to differentiate the extreme form of the unassimilable 'pure' Trauma, nearly pure death drive, from the retroactively historicized forms which are reintegrated into the continuity of a vital flow of time that we 'invent' in analytic work.
tation methods contained in the manual also apply to other contexts, including human rights investigations and monitoring, assessment of individuals seeking political asylum, the defence of individuals who “confess” to crimes during torture, and assessment of needs for the care of torture victims. In the case of health professionals who are coerced to neglect, misrepresent, or falsify evidence of torture, the manual also provides an international point of reference for health professionals and adjudicators alike. Many procedures for a torture investigation are documented in the manual, such as how to interview the alleged victim and other witnesses, selection of the investigator, safety of witnesses, how to collect statements from alleged perpetrators, how to secure and obtain physical evidence, and detailed guidelines on how to establish a special independent commission of inquiry to investigate alleged torture and ill treatment. The manual also includes comprehensive guidelines for clinical examinations to detect physical and psychological evidence of torture and ill treatment. These guidelines represent a consensus among clinicians working in the fields of human rights documentation and treatment of individuals
Over the past decade the approaches adopted towards the mental health care of refugees by a range of national and international healthcare organisations have been the subject of a sustained and growing critique. Much of this critique has focused on the way in which Western psychiatric categories have been ascribed to refugee populations in ways which, critics argue, pay scant attention to the social, political and economic factors that play a pivotal role in refugees' experience. Rather than portraying refugees as "passive victims" suffering mental health problems, critics have argued that attention should be given to the resistance of refugees and the ways in which they interpret and respond to experiences, challenging the external forces bearing upon them. In this paper a range of issues concerning the mental health care of refugees will be examined. These include the role of psychiatric diagnosis in relation to refugees' own perceptions of their need and within the context of general health and social care provision. In examining services the emergence of new paradigms in mental health care is identified. These include the growth of holistic approaches that take account of refugees' own experiences and expressed needs and which address the broader social policy contexts in which refugees are placed. A three-dimensional model for the analysis of the interrelationship between "macro" level institutional factors in the mental health of refugees and the individual treatment of refugees within mental health services is proposed.
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