Recognising Mental Health Vulnerabilities in Conflict for Asylum Seekers: The Case of AS [Safety of Kabul] Afghanistan [2018] UKUT 118 (IAC) – by Ayesha Ahmad
Mental Health Conflicts within Conflict
Speaking stories of trauma are central tenets of seeking asylum from conflict. However, there is a conflict between the trauma that asylum seekers embody, live, and express and the way that such stories are received by the paradigms of psychiatry and law. When I was requested to provide evidence as an Expert Witness as part of a country guidance case for an asylum seeker from Afghanistan in the Upper Tribunal court, which can set precedents for future cases, I knew that explaining the mental health impact of conflict would carry challenges. In this blog post, I sketch some of these challenges that I am currently working on based on the case of AS [Safety of Kabul] Afghanistan [2018] UKUT 118 (IAC) so that our understanding for how we recognise mental health vulnerabilities in conflict for asylum seekers is improved.
The trauma of conflict is not confined to a place or event, nor is trauma narration in the form of symptomology or a singular story. Conveying the complexities of trauma, then, requires a move from confirmation, certainty, and coherency. As conflict betrays the foundations of humanity, and violence is the antithesis of creating, the testimonies of trauma are not new truths, but reach the metaphysical core of the experience of the self and surrounding world. Conflict though, traumatises both of these, and the navigation through a traumatised story needs a new language. Conforming to existing criteria for the constitution of a mental disorder presents challenges for the recognition of traumas on the margins; traumas that rise from vulnerabilities and traumas that are beyond a pathological discourse because of the realism that conflict presents. In other words, a diagnostic criteria of Post-Traumatic Stress Disorder (PTSD) is a normative intervention; PTSD signifies a pathology in the way that the person is responding to experiences of trauma. Reducing trauma to an event and relying on a diagnostic criteria to validate violence, persecution, or torture within conflict is a misnomer. Yet, without a PTSD diagnosis, the challenge to recognise those seeking asylum from conflict as traumatised is a struggle that obscures the need of protection.
Understanding Trauma Narration
These challenges stem from complex frameworks in multiple academic disciplines that determine the concepts and theories that are applied to deconstruct and analyse the words of a trauma narrative, which trauma theorist, Cathy Caruth, coming from a literary perspective, describes as ‘beyond the psychological dimension of suffering it involves, suggesting a certain paradox: that the most direct seeing of a violent event may occur as an absolute inability to know it; that immediacy, paradoxically, may take the form of belatedness’ (Caruth, 2016). In this sense, experiencing trauma also impacts on the way that trauma is communicated.
In addition, cultural idioms and distress of psychiatric disorders in asylum seeker and refugee populations have been overlooked and dominated by psychiatric research undertaken in western populations that are not affected or have not been previously affected by conflict (Summerfield, 2017). Thus, it is recognised that ‘relatively little empirical attention has been paid to understanding how refugees conceptualise’ their own mental distress (Alemi et al., 2017) and the barriers which prevent research in mental health vulnerabilities that are present in conflict settings. The systematic silence and void of voices that are suffering because of unaddressed vulnerabilities is a moral injustice to the framing of a testimony of trauma.
Trauma needs new language, but we, as academics, healthcare professionals, and lawyers, also need new ways to present medico-legal evidence to channel and convey the experiences of those with conflict-related trauma.
Furthermore, as a base-line, traumatic experiences impact on the way that an individual can narrate their trauma. Extenuating factors can also affect the way an individual conceptualises, understands, reflects, and communicates their traumatic experiences. Inconsistencies between accounts of the trauma and re-counting personal narratives are also likely to be high due to the nature of trauma and the way that trauma presents and manifests as a memory. It has been found that there is a relationship between the rate of discrepancies and the type of questions asked—factual questions are more difficult for a traumatised individual to answer because by virtue of the nature of trauma, autobiographical trauma narratives appear incomplete and are experienced in terms of the emotional context of the traumatic event. Yet, these are the spaces I have to explore when providing evidence, both written or oral, because just as the absence of PTSD does not mean the absence of trauma, the absence of language does not mean the absence of a traumatic experience.
Conceptualising Conflict-related Trauma
Another challenge is the phenomenological bearing of conflict on mental health. To understand why conflict is traumatising, we also need to understand the existential encounters that conflict forces a person to confront. Conflict alters humanity. Whilst presenting my evidence, I needed to expound conflict as a structural dynamic that determines the health of a conflict-affected population. In particular, I had to counter a perception that typically reduces conflict to a matter of specific traumatic events, rather than as a socio-cultural landscape where conflict becomes lived (traumatic) experience, and one which belies the notion that for a person to be affected by conflict, a bullet needs to land on every square metre of soil. The notion that conflict-related trauma is a visible and violent inhabitation of a particular person’s body, perpetrated by any of the weapons that a militarised representation of conflict portrays, is perilous when attempting to perceive the positionality of living in conflict for the person seeking asylum.
The case of AS [Safety of Kabul] Afghanistan [2018] UKUT 118 (IAC), however, has allowed the recognition that conflict impacts on mental health in a way that is beyond bullets and battles. I provide comments on how people in general respond to a life lived in conflict including the claim that a childhood in war is a form of childhood trauma, which is especially the case for the young generation of Afghan asylum seekers that I work with, having been born into war. To provide such an argument, I rely on academic literature that recognises the complexities of vulnerability as beyond individual pathology. Rather, the argument that is crucial for cases such as AS is that an individual can suffer psychologically in a war zone even without a diagnosed psychiatric disorder.
Vulnerability of Contexts versus Pathology of Persons
Recognising that trauma relates to vulnerability of a context is a promising development in acknowledging that psychological suffering is beyond symptoms. The absence of PTSD is not an absence of trauma. Similarly, the absence of PTSD does not prescribe immunity from traumatisation. Recommendations for psychiatrists assessing the mental health of asylum seekers must therefore now account for the experience, not merely events, of being situated in a conflict setting. This helps to address that structural dynamics of conflict are instrumental for recognising mental health vulnerabilities. In particular, the deconstruction of mental health for a returnee to a conflict setting needs to examine the socio-cultural response to trauma, such as the nature of stigmatisation and discrimination towards the expression of suffering and including, but not limited to, those who are perceived to suffer from mental illness as well as the availability and accessibility of mental health care support and resources.
Concluding the Way Forward for Medico-Legal Evidence
In conclusion, there is both the under-recognition of mental disorders during conflict and the under-recognition of trauma when either a) mental health problems are not or cannot be disclosed and b) when trauma is experienced in ways other than the criteria of PTSD symptomology. Trauma, then, needs new language, but we, as academics, healthcare professionals, and lawyers, also need new ways to present medico-legal evidence to channel and convey the experiences of those with conflict-related trauma. A starting-point from here is that the phenomenology of vulnerability needs to be recognised in the space of a psychiatric assessment when exploring mental health symptoms and to embody the silence of trauma into the medical gaze. Trauma beyond the margins needs to be reached – only then will the margins fade, and the mental health vulnerabilities in conflict, recognised.
References
Caruth, C., 2016. Unclaimed experience: Trauma, narrative, and history. JHU Press.
Summerfield, D.A., 2017. Western depression is not a universal condition. The British Journal of Psychiatry, 211(1), pp.52-52.
Alemi, Q., Weller, S.C., Montgomery, S. and James, S., 2017. Afghan refugee explanatory models of depression: Exploring core cultural beliefs and gender variations. Medical anthropology quarterly, 31(2), pp.177-197.
Dr. Ayesha Ahmad is Lecturer in Global Health at St. George’s University of London.
Image by Sebastian Pichler on Unsplash.