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Bad reception: a new trauma for refugees
A study by Medici per i Diritti Umani – MEDU (Doctors for Human Rights Italy) just published in the International Journal of Social Psychiatry shows that post-migratory stressors, such as precarious living conditions in large and overcrowded reception centres, have negative effects on the refugees and asylum seekers’ mental health like the violence suffered in the countries of origin or along the migratory route. In the specific case of the study, the patients from CARA Mineo (Sicily), the largest reception centre for asylum seekers in Italy, presented significantly more severe symptoms of post-traumatic stress disorder (PTSD) than patients from smaller reception centres. At the moment of our investigation this reception centre was characterised by a greater number of daily stressors than those of medium small centres: strong overcrowding; geographic and social isolation of the facility; very long stay, waiting for the completion of the legal procedures for permanent visa; difficulty accessing the National Health System, difficulty accessing psycho-social and/or legal support; episodes of social degradation, violence and illegality. All these factors constitute as many daily stressors generating insecurity and fear, anxieties already provoked by past trauma experiences. At this regard, the large reception centres, such as CARA Mineo, can be considered as ‘re-traumatising models’ of reception facilities which have detrimental effects on asylum seekers and refugees’ mental health. This aspect is particularly relevant as refugees and asylum seekers are increasingly hosted in huge and overcrowded hotspot and first reception centres, even in Western high-income countries. The Moria camp in Greece, recently devastated by a dramatic fire, is one of the most striking examples in Europe. Moreover, even the New Pact on Migration and Asylum just presented by the European Commission really risks fuelling the model of large centres at the external borders of the European Union. The conclusions of the research pose very topical issues for Italy as well, since the Government and Parliament are preparing to amend the security decrees in the coming weeks. MEDU hopes that the political forces will be able to learn from the past failed experiences. It’s necessary to promote a reception system based on small-scale facilities, integrated in the territory, equipped with appropriate services, capable of promoting real inclusion for the benefit of the refugees hosted as well as the whole national community.
Background. In the last years, a large number of asylum seekers and refugees arrived in Italy and in Europe from Sub-Saharan Africa (according to United Nations High Commissioner for Refugees (UNHCR) data (2020) more than 600,000 migrants and refugees have landed in Italy crossing the Mediterranean Sea in the period 2013–2019), most of them having suffered detention, serious violence and abuse in countries of origin or along the migratory route and particularly in Libya (Medici per i Diritti Umani [MEDU], 2020). More generally, over the past decade, the global population of forcibly displaced people grew substantially from 43.3 million in 2009 to 79.5 million in 2019, reaching a record high (UNHCR, 2020). Indeed, refugees and asylum-seekers are not only disproportionately exposed to cumulative trauma in their countries of origin or along migratory routes, but also experience a multiplicity of stressors in the post-migratory environment (Li et al., 2016). Accordingly, posttraumatic stress disorder (PTSD) is particularly prominent in such groups (Bogic et al., 2015; Fazel et al., 2005; Steel et al., 2009). While it is highly clinically and socially relevant to understand the different ways in which PTSD manifests itself in refugees and asylum seekers, very few studies have examined the manner in which PTSD symptoms manifest in such populations.
Aims: This study sought to investigate the characteristics of PTSD in a sample of African asylum seekers and refugees who had turned to MEDU clinical centres for situations of mental distress resulting from trauma suffered in the country of origin or along the migration route. We also tried to investigate which socio-demographic factors could facilitate the onset of particular forms of PTSD.
Methods: Participants in this study were 122 African refugees and asylum-seekers living in Italy who completed a questionnaire on exposure to potential traumatic events and another on the symptoms of PTSD according to the criteria of DSM-5, one of the classification systems for mental disorders most used in the world. A statistical study called Latent Class analysis (LCA) allowed to identify some subgroups of patients with peculiar symptomatic pictures of PTSD. Finally, a further statistical analysis called multinomial logistic regression allowed to identify the predictors of each identified subgroups.
Participants. The asylum seekers (94%) and refugees (6%) participating in the study had recently arrived in Italy (an average of 11 months) and were hosted both in large reception centres with over 1000 guests (16%) and in small to medium centres with less than 1000 guests (80%) and in other small reception facilities (4%). The participants came mainly from West Africa (91%) and a small number also from North Africa (6%) and East Africa (3%). The vast majority of them (91.0%) reached Italy from Sub-Saharan Africa, crossing both the Sahara Desert to Libya and then facing Mediterranean Sea with makeshift dinghies. All routes controlled by smuggling or trafficking networks. The sample of participants reflected in terms of gender (86% men) and age (25 years on average) the composition of migrants and refugees arriving in Italy in recent years via Central Mediterranean route.
Results: Among participants, 79.5% had a probable diagnosis of PTSD. Previous studies have suggested that the prevalence of PTSD in refugee groups was approximately 30% (Steel et al., 2009). As a general consideration, the high rates of PTSD in our study was likely due to two reasons. First of all, our sample was not recruited among the general population of asylum seekers and refugees but is represented by patients sent to our services for the presence of various forms of mental distress for which a possible post-traumatic origin was hypothesized. Secondly, our patients were survivors of multiple complex traumas, that means repeated, prolonged, interpersonal traumatic events. These types of trauma are those with the highest psychopathogenic power; in fact, a large literature attests that the highest rates of PTSD are found following intentional traumatic events (violence, abuse, torture, etc.) compared to traumas of an impersonal nature (for example accidents). Patients in our sample had been exposed to a mean of 8 types of traumatic events (but some went through 18 traumatic events!), including torture (82%), detention (68%), physical assaults (65%), having witnessed the killing of one or more people (51%), being close to death (47%), kidnapping (46%), sexual violence (18%) and many more. LCA allowed to identify three groups of patients with post-traumatic patterns who presented a different clinical profile: a group characterized by a high probability of intrusions and avoidance symptoms (45%) , such as intrusive memories, nightmares and flashbacks of traumatic experiences or avoidance or attempted avoidance of memories, thoughts, emotions and external factors that recall traumatic experiences; a group with moderate clinical severity and high probability of avoidance symptoms (22%) and at the end, a group with high probability of presenting all symptoms (32%), i.e. intrusions and avoidance symptoms, negative thoughts and emotions, altered arousal (insomnia, irritable behavior and outbursts of anger, reckless or self-destructive behaviour, difficulty concentrating, persistent feeling of being in danger, etc.). This last group of patients, defined by us as “pervasive PTSD”, is the one that has the greatest clinical severity and therefore requires the most intensive and prolonged therapeutic approaches. A particularly interesting fact found in our study is that none of the variables examined (legal status, sex, age, education, months spent in Italy, number of traumatic event types, occupation) significantly predicted belonging to the three groups with the only notable exception of the reception conditions. In particular, living in large reception centres for asylum seekers (over 1,000 people) rather than small to medium-sized centres (less than 1,000 people) was associated with a greater likelihood of belonging to the group with the most severe and disabling PTSD symptoms (i.e. pervasive PTSD).
Conclusions: This finding bolsters the growing literature emphasising the importance of the post-migration environment on mental health outcomes. Our finding is also consistent with the ecological model of refugee distress proposed by Miller and Rasmussen (2017) drawing on research demonstrating that mental health among refugees and asylum seekers stems not only from prior traumatic events exposure, but also by an individual’s social ecology, encapsulating both displacement-related and ongoing stressors (e.g. living conditions in the reception countries). Indeed, our sample participants who lived in a large reception centre all came from the asylum seeker reception centre of Mineo in Sicily (CARA Mineo). At the time of our research, this center, promoted by the Berlusconi government as a “new model of reception” in 2011, was characterized by a greater number of daily stress factors than those of medium-small centres: strong overcrowding (the facility, which had a capacity of 2,000 places, has come to accommodate over 4,000 people); geographical and social isolation; very long stay, waiting for the completion of the legal procedures for permanent visa (18 months on average); difficulty accessing the National Health System, difficulty accessing psycho-social and/or legal support; episodes of social degradation, violence and illegality (MEDU, 2015). At this regard, numerous studies emphasise the importance of several post-migration factors as predictive of PTSD symptomatology over and above pre-migration trauma in refugees. Among them, several factors characterising ‘the large reception centre model’ of Mineo included: living difficulties (Aragona et al., 2012; Minihan et al., 2018), long-term institutional accommodation (Porter & Haslam, 2005; Rangaraj, 1988), loneliness (Chen et al., 2017), poor social integration (Chen et al., 2017), difficulties accessing health care and social services (Steel et al., 1999), prolonged process of obtaining permanent visa (Chu et al., 2012; Laban et al., 2004; Nickerson et al, 2019; Steel et al., 1999). All these factors constitute as many daily stressors generating insecurity and fear, anxieties already provoked by past trauma experiences. At this regard, the large reception centres, such as CARA Mineo, can be considered as ‘re-traumatising models’ of reception facilities which have detrimental effects on asylum seekers and refugees’ mental health. This aspect is particularly relevant as refugees and asylum seekers are increasingly hosted in huge and overcrowded first reception centres, even in Western high-income countries (EU Agency for Fundamental Rights, 2019). The Moria camp on the island of Lesbos in Greece, recently devastated by a dramatic fire, is one of the most striking examples in Europe. When the fire happened, about 13,000 refugees were living in poor reception conditions in a space designed to accommodate 3,000 people. The Moria hotspot was built in 2015 at the behest of the European Union as part of the European Agenda on Migration which provided for people arriving from Turkey by sea to stay in the centrefor only a few days, to be identified before being transferred on the mainland and in other EU countries through relocations. However, in 2017 the resettlement program from Greece and Italy was suspended and the length of stay in Moria increased dramatically. Moreover, even the New Pact on Migration and Asylum just presented by the European Commission really risks fuelling the model of large centres at the external borders of the European Union.
Returning to the research, while mental health interventions for refugees and asylum-seekers have been largely trauma-focused (Miller & Rasmussen, 2017), our findings imply that post-migration reception conditions should also be considered in the conceptualisation and implementation of PTSD treatments and prevention. Ignoring the daily stressors suffered by refugees living in inadequate reception conditions may impede treatment outcomes, as distress and psychopathology may be misattributed to trauma exposure and individuals may not have the emotional and/or cognitive capacity to effectively engage in treatment before such living conditions are addressed and changed. At this regard our study emphasises the importance for host countries to implement models of first reception centres that provide effective protection, concrete integration, adequate housing and services. As Silove and Ekblad (2002) appropriately commented, although preventing trauma inflicted on refugees in source countries may be beyond our control, recipient countries can exert an influence on the post-migration challenges faced by incoming refugees. In our response, it is important that we extend our deliberations beyond the short-term goal of immigration control to a more global perspective on public health. If not, posttraumatic symptoms in refugees and asylum seekers may be prolonged and intensified and society in the global sense might ultimately bear the health, social and economic costs. It is undeniable that the words of the two authors sound like prophetic today in Italy and in Europe. The post-traumatic disorders and the depressive syndromes often associated with them represent in fact a formidable obstacle to the integration process of forced migrants, fueling a vicious circle in which the post-traumatic symptoms favor the isolation of the individual which in turn amplifies the psychological distress and the PTSD symptoms.
In conclusion, we believe that a particularly interesting element of our study lies in the fact that, although numerous previous studies have demonstrated the impact of post-migratory living conditions on post-traumatic stress disorder of forced migrants, this is the first research which scientifically demonstrates the negative impacts of a specific reception model (the mega-centres overcrowded and isolated from the social context such as CARA Mineo in Italy or Moria camp in Greece) on the mental health of asylum seekers and refugees. In other words, the mega centres in which to amass asylum seekers and refugees, not only have proved harmful to the health of people but ultimately also represent a short-sighted choice from a purely utilitarian point of view as they produce in the medium and long-term heavy economic and social costs for the entire community. In our opinion these considerations are very topical for Italy when in the coming weeks the Government and Parliament are preparing to amend the two security decrees strongly promoted by Mr. Salvini when he was Minister of the Interior and therefore to also review the reception system for asylum seekers and refugees severely affected by these legislative measures. MEDU hopes that the political forces will be able to learn from the past failed experiences. It’s necessary to promote a reception system based on small-scale facilities, integrated in the territory, equipped with appropriate services, capable of promoting real inclusion for the benefit of the refugees hosted as well as the whole national community.