Are We All Post Traumatic Yet? A Critical Narrative Review of Trauma Among Arab Refugees

The Impact of Trauma Surpasses “Individual” Distress

Most papers saw that war and political violence are pervasive and extend to virtually everyone in the Arab region. The war reaches the homes and communal spaces of civilians and is at their doorsteps. ²⁰ As Giacaman and colleagues argued, trauma was often framed as a collective or communal, rather than an individual experience, that results from brutal and large-scale exposure to war and violence causing suffering and humiliation on a national level. The exposure, including but not limited to bombing, shooting, killing, injuring, shelling of neighborhoods, tear gassing and sound bombs thrown indiscriminately, especially around checkpoints, were shared, not individual, isolated, experiences.^19,33 The articles noted that trauma vulnerability and resilience operate not only on individual but also on communal levels. ³⁴

Afana ³⁵ argued that PTSD research has not focused enough on how traumatic events are experienced by families, subgroups, communities, or cultures in the Middle East, and how the shared response of these groups affects and is affected by the individual experience. As collective trauma is influenced by social processes such as meaning making, its complex determinants should be considered when formulating clinical diagnoses and interventions. Kira's model of cumulative trauma makes the point that in contexts of collective trauma, traumatic events are often experienced and expressed in relation to one's social identity and role within the community, leading to symptoms that are more focused on social and interpersonal aspects. ³⁶

Wells and colleagues, ³⁷ on the other hand, adopt a functional approach and propose an ecological/transactional model that recognizes how traumatic exposure to war and displacement severely disturb social systems and thus undermine the overall stability and coherence of a society. We note here that this approach has often been critiqued for its tendency to reduce psychological processes, such as adaptation, to functional roles, while overlooking salient factors that influence intrapsychic processes, such as constantly changing societal norms and inequalities. ³⁸ However, the model proposed by Wells and colleagues also attempts to go beyond functionalist assumption of social stability. They explain that adaptive processes and individual resource building are mediated by “identity markers,” which include gender, age, ethnicity, sexuality, disability, trauma history, and financial and sociopolitical status. While doing so they acknowledge that such factors have an ever-changing and dynamic nature, as they are based on the interaction between individuals and their social context in war and displacement settings. ³⁹ This model can explain how communities respond to challenges such as human rights violations, and in turn shape their collective response.

Wells and colleagues base their model on transactional models, which describe how people use available resources to cope with adversity and develop a niche for adaptation and cultural inheritance in which the individual and the collective are intertwined. Their model includes four nested layers: intra-individual, family/peers, society, and culture. ³⁷ To mirror this concept of layers, Afana studied ¹⁶ Palestinian idioms of distress like “Sadma” صدمة (trauma as a sudden blow with immediate impact), “faji’ah” فاجعة (tragedy), and “musiba” مصيبة (calamity) as culture-specific reactions to trauma ³⁵ that impact not only one's family functioning but disrupt the overall functioning in all four layers, thus creating a social crisis.

The Nature, Location and Longitude of Trauma

The nature and scale of the traumatic events was also a recurrent theme in each article. While the PTSD model emphasizes a single traumatic event in the past, the articles emphasized that the nature of trauma in the Arab region is ongoing. There is an ongoing exposure to a variety of forms of violence, people live in “chronic warlike conditions” ³³ that lead to a loss of protection embedded in the ways of life. Continuous exposure to war profoundly affects physical, mental, and social health by producing a relentless anxiety, exhausting hypervigilance, loss of control, helplessness, and, ultimately, a chronic social crisis. ³⁴ Entire communities experience severe insecurities, instability, uncertainties, deprivation, loss of dignity, and humiliation that lead to deep internal wounds of survival. The events were seen as causing social suffering on the continuum of ease–disease that is distinctively different from yes/no diagnostic cutoffs of PTSD. As Giacaman argues, the exposure is cumulative, and the survivors of wars oscillate back and forth on the spectrum of ease–disease.^20,33

Another distinct difference about the traumatic event is that while in the PTSD model the triggering event is “exceptional,” for refugees and people displaced by wars, the ongoing wars become everyday experiences. It becomes the ordinary rhythm of life that reaches civilian homes; the “home front becomes the battlefront” ³³ to create sadness and misery. ⁴⁰ People do not only experience the violence of war as a traumatic event, but also the destruction of the entire cultural, material, and social worlds they live in that define values and roles. In that sense, war creates trauma and destroys the ability to deal with it by destroying the coping or protective mechanisms people and communities have. The social suffering and injustices that survivors of war trauma report are not scattered personal events but rather connected to political points in history such as the “Nakba”^41,42 النكبة (catastrophe) and different wars for Palestinians, the War in Iraq and Syria, and other political events. Other scholars have also made this distinction between the experience of living in violence versus the experiencing of encountering it. These distinct experiences predicate different forms of psychological and social suffering. ⁴³

The changes after the traumatic events (refugeehood, displacement) also continue for decades, in itself creating and worsening ongoing trauma due to precarious life in refugee camps or in a state of refugeehood and dependency on international aid.^19,40 For example, Arethun and colleagues found that Syrian refugees attributed their symptoms to various cumulative stressors, including trauma, family, and financial problems. Some mentioned overcrowded or unsafe housing, poverty, separation from family members, and caring for dependents in difficult circumstances. Stressors that were found to persist or increase over time included loss of social networks, culture-related difficulties, and bureaucracy-related problems. ⁴⁴ Afana argued that such ongoing context stressors should be incorporated in trauma models, as empirical studies show that being worried about personal safety and the ability to fulfill basic needs had a more significant impact on the severity of PTSD symptoms than the severity of the traumatic or violent events themselves. ⁴⁰

In his 2010 work, Kira also suggested that the traditional PTSD model assumes a one-time traumatic event and focuses on symptoms that are immediately observable and measurable. However, in situations of ongoing and repeated trauma exposure, such as in many war-affected areas, the symptoms of PTSD may become cumulative. Thus, the traditional PTSD model may not fully capture the complexity of experiences and symptoms that people may have. ¹³ Kira proposes the post-cumulative traumatic stress disorders (PCTSD), which is the result of multiple or ongoing traumas, or other vulnerability contexts—for example, social and economic marginalization or exclusion in which people are exposed to multiple types of interpersonal trauma, as opposed to a single, personal traumatic event.

The Normalization of Traumatic Stress

The articles show that participants are aware of their own distress, as Aarethun and colleagues point out that participants recognized and identified with symptoms of PTSD, but never explicitly named it: “Participants also normalized symptoms, however normalizing symptoms of PTSD does not necessarily entail a de-emphasis on the character's psychological pain” ( ⁴⁴ p. 4). By normalization, the authors meant that in contexts of protracted violence, anxiety, depression, and other PTSD symptoms are seen as enduring states that people adapt to and learn to live in. ⁴⁰ Multiple causes were given to these processes of normalization, like the prevalence and enduring nature of violence and other stressors, or the communal nature of exposure.^37,40,44 Another reason given for normalizing symptoms, for example, is that Palestinians normalize their suffering within the political context of their experiences. While the distress remains, this normalization allows for positive actions to be taken to alleviate their distress and change living conditions instead of seeking psychological aid. ⁴⁰ Articles propose that a fine balance needs to be struck between maintaining and incorporating the wider sociopolitical context of distress/symptoms conceptualization and not dismissing personal experience of suffering and the burden of these symptoms on people.

We use the term normalization here in reference to its use in the articles presented to describe the effect of prolonged exposure to violence and the process of habituation, how it changes notions of normalcy, and the conceptual and clinical implications of this process. We are, however, aware of the critique of the concept of “normalization” and the history of its use as a tool of power in determining norms and deviance, as well as in deciding which narratives are included or marginalized.^45,46

The Medicalization and Decontextualization of Trauma

Studies emphasized the ill fitness of biomedical individualized instruments to capture shared experiences of trauma. ³³ Two articles ^{19 , 33} raised doubts about the capacity of disciplines like clinical medicine and psychology—which typically concentrate on individual cases in a clinical context—alone to adequately comprehend and conceptualize shared experiences in their models of trauma. They suggested that disciplines such as public health, which emphasizes the population level, will be able to offer insights for understanding and recovery of shared trauma, ¹⁹ as these fields take into account the “causes of causes”. ²⁰ Researchers argue that at this point, it has become obvious to practitioners and scholars that individualized treatment with counseling and medications could not address the “underlying causes of ongoing collective trauma” (^33, p. 15) after witnessing the limited efficacy of repetitive short-term cycles of aid projects lasting two to three years. ¹⁹

And thus, studies propose that medicalizing the entire process—from conceptualizing war trauma as a biomedical illness to medicalizing recovery with multiple treatments—framing war suffering as a mental condition rather than a social and political issue became “questionable, if not downright harmful”(^33, p. 16). ⁴⁰ Some authors showed concern as terms like PTSD, psychosocial, and counselling rapidly became hegemonic points of reference in this “new realm of humanitarian concern”( ¹⁹ , p. 549). The authors were also concerned with the fact that even though many communities have relied on family support and community aid, international agencies adopted Western-designed trauma programs that were seen by local practitioners as out of context.^19,34,40

The articles recommended a change of perspective from one that is “outcome based on medical indicators, injury and illness”( ¹⁹ , p. 556) to a framework based on social suffering and human rights violations experienced by ordinary people. This move should also include aid agencies that should shift the short-term humanitarian response to a long-term development with local partners combined with international advocacy for the respect of human rights and the restoration of justice. ¹⁹ Some of the articles suggested specific communal trauma intervention models that focus on shared trauma^34,36

Social Justice as Recovery

In continuation with the previous section, and with the recommendation to depart from biomedical models, the authors emphasized the importance of the context. Recovery was seen by the authors not as an individual process but as an etiological reconstruction of a disturbed social world and injustice causing subsequent suffering. In such a paradigm shift, genuine recovery would correlate with social justice, access to resources, strength, cultural stability, and social support, among other factors.^20,36 The articles called for a shift from international aid policies based on medical mental health determinants and outcomes to policies that combine a public health approach to mental health with international advocacy for human rights and justice. ¹⁹ The articles emphasized that it is important to differentiate between mental disorders and the social suffering of war: “Attempts to measure the social suffering of populations affected by complex political emergencies are therefore part of an overall approach that places the demands for rights and justice at the center of global health” ( ¹⁹ , p. 555). The aim of the intervention should be “the reversal of historical injustice” (p. 555). This is a priority for the protection of mental health in war affected regions. ¹⁹

Moreover, in reconstructing a social world, some authors suggested that part of recovery was the creation of routine and a sense of normality that defies chaos and hopelessness: “Social capital, in the form of a tight network of family support, peers, friends, caring adults, clubs and schools, nurtures and sustains the sense of optimism and hope” ( ¹⁹ p. 556).

Diagnostic Recommendations

Addressing and reversing the mental health effects of war-related trauma requires tackling root causes of armed conflict, colonial legacies, and settler colonialism in order for communities to flourish in a safe, stable, and healthy environment. ^e However, the authors were not disillusioned about the fact that in a region marked by expanding warfare and displacement, some of these recommendations become impractical in the short term, and pragmatic and actionable steps are needed. The articles offered several concrete recommendations for scholars working on traumatic stress among Arab refugees. They suggested and, in some cases, developed new measurements for health-related quality of life that are specific to the local context, such as a measurement for humiliation, human insecurity scale, scale of distress, and scale of deprivation. Those scales capture more accurately the lived context of the studied communities than the World Health Organization's (WHO) standardized quality of life scale, which was seen as weak on the social domain and devoid of a political domain. ³³

Local idioms of distress assist scholars in the understanding of shared suffering as complementary to but distinct from individual suffering. Such idioms are not diagnostic entities that require treatments but terms through which distress is expressed and social support is sought and mobilized.^19,37,40 Afana ⁴⁰ emphasized that the same PTSD symptom endorsed by two individuals from different cultural backgrounds does not necessarily have the same meaning. Moreover, within the same culture, the same PTSD symptom will have various representations depending on the severity of impact on communal health, as we have seen in the case of sadma (trauma as a sudden blow with immediate impact), faji’ah (tragedy), and musiba (calamity). ⁴⁰ The use of idioms and metaphors to describe psychiatric symptoms reflects a socially based vocabulary. From the perspective of clinical phenomenology of symptoms, certain authors added that PTSD or responses to exposure to violence among Arab populations is a collection of symptoms (including PTSD, anxiety, depressive, somatic, and dissociative), and research should focus on the heterogeneity of responses to trauma to develop more appropriate conceptual models and treatments that demonstrate cultural competence and cultural humility.^36,37,40,47

Knowledge Production

For the authors, it was evident that a lack of local high quality research on the topic exists, as “When a nation is struggling with day-to-day survival, the development of evidence-based mental health policies and services is unlikely to be a priority” ( ¹⁹ p. 357). It was clear to the authors that the flow of information and research in the forms of diagnostic tools and intervention in global mental health is unidirectional, from high income countries of the Global North to passive and silent recipients in the Global South. As Yudkin and colleagues argue, “In fact, post-traumatic stress disorder (PTSD) was originally conceived and defined within the population of U.S. war veterans, yet it is regularly applied to heterogeneous populations and experiences across the globe” ( ³⁴ , p. 300) This leads to a Western hegemony in coining and distributing scientific concepts and reproducing coloniality, the epistemic effects of colonialism. Such coloniality that imposes Western sociocultural-moral constructs onto “theoretically marginalized” communities was seen as unethical and carrying dangerous adverse outcomes. ³⁴

In line with this observation, the articles we reviewed also highlighted that to better understand the impact of violence on human suffering in the diverse societies of the Arab region, local researchers should prioritize cultural validity and local community interests in their qualitative and quantitative studies. In this process of “decolonization” and emancipation, Arab researchers should also use scientific methods that reflect the region's values, not replicate studies designed for different cultural contexts in the Global North. Throughout the articles, the authors emphasized the importance of having Arab researchers develop their own research methods and priorities, taking into consideration the cultural and sociohistorical values of their patients and communities. Conducting studies that could translate into health benefits within their societies is crucial, and will also contribute significantly to the global but multipolar trauma field.^40,48,49