Skrivet av: transaktionsanalys | september 15, 2009

TRAUMA AND MIGRATION.

TRAUMA AND MIGRATION.
A TRANSACTIONAL ANALYTIC APPROACH TOWARDS REFUGEES AND TORTURE VICTIMS
This material was originally published in Italian: Mazzetti, M.. (2008). [Trauma e migrazione: un approccio analitico transazionale a rifugiati e vittime di tortura].  Quaderni di Psicologia, Analisi Transazionale e Scienze Umane,  49, 21-53. The article published here is an updated version.
Marco Mazzetti

Summary
This article presents a model that enables us to interpret migration, a phenomenon that involves the relocation of a huge mass of people from their homeland and native cultlure to another place on this planet as a traumatic event. The article describes factors of resilience and vulnerability that affect the psychic health of migrants, and in particular the effects that these events have on refugee populations. Refugees are a group which, due to the events that have determined their migration, are particularly at risk of psychotraumatological pathologies. Migration can have a re-traumatizing effect on them. The specific psychopathological problems of traumatized refugees – in particular of those who have survived torture – will be described from a Transactional Analytic perspective. Indications are also given for the psycho-social management of their difficulties.

Migration
Although it may seem surprising to us today, a sedentary way of life has been the exception rather than the rule in the history of the human race. Humans have always been a nomadic species, perpetually in movement. Today migrants constitute a huge mass of people on our planet. According to The United Nations Fund for Populations (UNFPA), 191 million people live in a country different from that of their birth, to which about 30 to 40 million irregular immigrants must be added (Koser, 2005; United Nations, 2006; UNFPA, 2006). All these put together could constitute the fourth most populated country in the world, after China, India and the United States. In the European Union there were over 27 million foreigners at the beginning of the year 2006 (Caritas, 2007) but this figure would perhaps double if people who were born abroad and have acquired citizenship in the host country were to be considered. A good number of these migrants are refugees. At the end of 2006, the United Nations High Commission for Refugees (UNHCR, 2007a, 2007b) were assisting about 33 million refugees, although of these over 12 million were evacuees in their own countries of origin and, therefore, not technically considered emigrants. In the European Union foreigners make up 5.6% of the total population. This percentage could well double with naturalization. (Caritas, 2007). The consistent arrival of such a massive population has created a considerable challenge for the management of this formidable human resource.
Persons who provide psychiatric and psychotherapeutic assistance have had to take note of such relevant changes in the demographic field. Refugees in particular constitute a high risk group. Among them there are people who have survived torture, mass violence and serious bereavements that leave signs of severe post traumatic pathologies.  New challenges that the new scenario presents to psythotherapists and others in the caring professions are the need to find operative, instrumenal ways to function efficiently with multicultural clients and to respond adequately to the needs of populations that have been consistently disturbed by psychic trauma.
One promising new strategy is that of considering the very event, “migration,” from a psychotraumatological standpoint. My dictionary (Devoto and Oli,1990) defines trauma as “a sudden and violent emotion capable of provoking a permanent alteration of psychic activity.” In my clinical practice numerous observations appear to sustain the idea that migration represents an emotional event leading to a transformation of that type, therefore a trauma.
I have yet to meet an immigrant (including myself, in my own experience of migration) who is not able to remember vividly his or her first day in the country of migration, with the lucidity and emotional participation typical of traumatic events, except for those cases when the seriousness of these events has led to dissociative defences. In the experience of all those I have spoken to, migration has impressed on them an irreversible change in how they viewed themselves in the world, causing a true and real fracture between a “before” and an “after”, reminding us of the etimology of the term, “trauma”, which in ancient Greek means “wound.”
For all those with whom I have spoken, the difficulties have been intense, even if they were overcome successfully and the experience ultimately, over time, was viewed as positive. For many immigrants the migratory experience appeared to be viewed as an initiation trauma, that is, an experience similar to those more or less ritualistic tests which are undergone by adolescents, or by people changing status, in certain cultures. The suffering which has been overcome becomes the proof of success and leads to entitlement to or merit of a new social and psychological status. The development of the personality after trauma, a stressful event that, thanks to the crisis, may afford an excellent opportunity to widen the limits of one’s life script has been well documented in the literature (Allen, Bennet and Kearns, 2006; Sironi, 1999, Tedeschi & Calhoun, 1996,). According to this perspective, we shall see how it is possible to approach the psychology (and thus the psychopathology) of migrants in the same way as we approach traumatic events, taking into account factors of resilience and of vulnerability  that pertain to the event.. In this way it is possible to arrive at  an original reading of the phenomena and from these to develop promising strategies for intervention. Such an approach could be particularly relevant for refugees. As previously mentioned, refugees are a fragile group and of particular interest for psychiatrists and psychotherapists. Approaching migration as a traumatic event will allow us to identify the distinctiveness of refugees and also to understand the difficulties that some of them demonstrate in adapting to the host country. Transactional Analysis will be the main frame of reference for understanding not only the intrapsychic dynamics and relational needs of these subjects, but also for developing a wider socio-cultural comprehension of the phenomena, useful in defining guidelines of intervention.
The second part of this article will refer to strategies for intervening with these patients. These will be interventions of rehabilitation in the general sense, not strictly psychotherapeutic ones. There is a practical reason for not dealing with specific therapeutic techniques. They would require space beyond the limits of this article. There are also epistemological reasons. I believe that the role of psychiatrists and psychotherapists goes beyond the one enacted in their professional offices. Patients are taken care of in the context in which they live. The ability to stimulate and create integrated networks of psycho-social assistance, that are recursively synergestic with one another, capable of giving complex answers to complex problems, is a characteristic of good psychiatric practice. We can be excellent therapists not only closed in our psychotherapeutic practices but also through deciding to be social actors: Transactional Analysis, in my view an efficient transcultural instrument (Mazzetti, 2007), integrates well with this prospect, due to its origins and its tradition, which are closely connected to social psychiatry. Its organizational sensitivity and promising perspective in regard to the social-cultural dimension make it particularly appropriate for use with migrant populations and in a psycho-social perspective.

Resilience Factors

The term “resilience” has recently entered the psychiatric lexicon. The word has distant origins that are found in the material sciences, and in particular in metallurgy. The term denotes the ability of a material to resist impact and tension, thus maintaining its properties, or to recover them at the end of a traumatic event. The word resilience has been successfully transposed into the psychiatric field to express the ability to withstand traumas while maintaining good psychic health.
Which are the factors of resilience that are able to help the management of migration trauma? On the basis of clinical experience and of what has been reported in scientific literature, one can group them in two main sets: those related to individual characteristics and those connected to the migratory project of the individual. A third relevant group can be found in the social supports that the immigrant finds during the migration journey.
Figure 1 summarises the totality of factors  that  pertain to resilience.

Individual characteristics
It is likely that a series of positive individual characteristics may help the management of migration trauma, problematic though it may be to prove this scientifically. It is difficult to construct research models that permit comparison between pre-migratory psychic conditions and the outcome of the immigration experience, in terms of mental health and social integration, for the immigrant. This is also a well-known methodological problem for those who deal with the psychiatric epidemiology of immigration.  As each phase of the migratory process is characterized by many interacting socio-environmental variables, some of which can put psychological adaptation seriously at risk, it is understandable that notable differences in the vulnerability of migrants exist, stemming from pre-migratory characteristics of the person and how the migration itself originated (Mazzetti, 1996).
The wide variation in the factors at play makes it extremely difficult both to trace an epidemiological psychopathological profile of the migrant and to identify the relative risk factors. From an analysis of literature on migration and mental health (Bhugra, 2004), numerous methodological limitations emerge (for example, the heterogeneity of the samples from an ethnic, cultural and migratory point of view; the diversity of the research settings and of the evaluation instruments, the lack of long-term longitudinal studies) that explain the presence of contrasting data and make the extrapolation from one population to the other and generalizations difficult.
Evidence from recent decades appears to indicate rates of prevalence for some pschychiatric disorders in immigrants, in particular for schizophrenia (Bhugra, 2004), as slightly higher. As regards the more common mental disorders, such as the depressive ones (Bhugra, 2003), anxiety and substance abuse, the data are less clear. Other authors suggest that rates of schizophrenia (and probably of other disorders) are lower among immigrants when sending and receiving countries are socially and culturally similar and higher when they are dissimilar (Kinzie, 2006). Some evidence exists, moreover, that, as time passes, immigrants tend to come closer to the epidemiological profiles of the host population. When we speak about individual characteristics, we refer, therefore, to what we can observe in the clinical setting and to how much we are able to reconstruct during the period when patients are under our care.
Solidity of Self: The achievement of migration, particularly when it occurs in developing countries, leads through a series of difficulties which can be particularly intense. A solid sense of self can act as a positive filter that allows the more able, courageous, motivated and healthy person to pass  through these difficulties relatively unharmed. This  resource, at departure, has a protective role from the point of view of mental health and constitutes a solid basis for leaving that can notably protect the migrant, especially during the early phases of migration.
It is easy to see, however,  that this type of selection essentially works with the so-called pioneers of migration, that is, those who are the first to leave intentionally and with strong motivation. This factor is reduced until it disappears in successive migrations (for example, through family reunion) or it may even be inverted in the forced migration of refugees. A solid personality with the ability to know and understand oneself and others and with experience of success in life generally leads to good adaptation. These characteristics are consistent with the literature on psychotraumatology: Allen (2006; Allen et al., 2004) suggests that the most successful results following a trauma depend on the person’s ability to mentalize, that is to conceptualize oneself and others on the basis of each person’s emotions and to behave in a consequent manner. Fonagy and his collaborators (Fonaghy, Steele, Steele and Higgit, 1994), claim that this is a key factor in promoting resilience. The above characteristics successfully express the concept of a solid personality.
Solidity and flexibility of cultural identity: These two characteristics appear to walk hand in hand. Cultural identity can be defined as the capacity to recognize oneself in a coherent system of values and of representation of the world. Having a solid cultural identity is like leaving from a secure “port” for departure; from this point, with the help of good instruments, it is easy to plan a route. To depart with a fragile cultural identity is similar to starting a journey at an unknown point in the middle of the sea; planning a route is then much more complex. A solid cultural identity leads towards a positive process of negotiation with the reality that has to be faced in the land of migration and allows somewhat more comfort with self-chosen flexibility. On the contrary, a fragile identity frequently is the basis of insecurity and fear that leads towards defensive closure and ridigidy towards adaptation. In such subjects it is common to observe, for example, obsessive religious practice in the attempt to anchor oneself to a solid point of reference in order to withstand the adaptation requirements of the host country.
Effective attachment styles: Attachment is a useful instrument in ethnopsychiatry, having been proved valid in the transcultural sphere. Attachment is developed and consolidated in a substantially similar way wherever it takes place in the human species (Schaffer, 1998). Secure attachment, as described also among adolescents and adults (Bartholomew and Horowitz, 1991, Hazan & Shaver, 1987, Simpson, 1990), which Mary Main and her collaborators refer to as “autonomous” attachment (Main, Kaplan and Cassidy, 1985), was effectively shown to be correlated with the Life Position, “I’m Ok, you’re Ok” (Boholst, Boholst and Mende, 2005). A secure attachment that we can in some way identify with the life position + + is helpful in adapting to a new reality by facilitating the establishment of healthy new relationships in a new context. When we construct solid therapeutic relationships, we not only create a tool that is necessary for successive clinical interventions but, in my opinion, we are also actively overcoming disturbances of attachment.
Effective coping styles: The capacity to cope, that is, the efficient management of a traumatic event, is a characteristic of the individual. Everyone has innate resources that develop during the course of one’s life. These resources can also be learned, refined and developed and the very training of coping constitutes one of the possible strategies in the psychotherapy of migrants.
Pre-migratory psychic health: A history of psychic well-being prior to departure appears to be a positive prognostic factor regarding the ability of the individual to manage the trauma of migration.

Migratory Plan
The migratory project seems be of decisive relevance in protecting the mental health of migrants (Frighi, Piazzi and Mazzetti., 1993; Mazzetti, 1996). The reason is twofold. The migratory project contains motivations that have led the immigrant to undertake the difficult adventure of migration, and high levels of motivation spur human beings to face many problems. If the migratory plan succeeds in some way, the migrant manages to withstand considerable trials while maintaining one’s health. The second, deeper and probably more relevant reason is connected to the fact that the migratory project takes shape as a factor that can give a sense of history to the life of the individual, helping to maintain, through narrative, two images of self (one pre-migration and the other post-migration) that is too frequently split by the fracture of the migratory event, providing a meaning that permits the mending of its existensialist plot. Referring to the model proposed by Stuthridge (2006), we can say that the project can take shape as a narrative capable of integrating different experiences of self.
When migrants leave, they are aware that they are leaving their homeland and their nearest and dearest, but it is only on arrival that they realizes that they have said farewell to something else: to who they were before their departure. The migratory experience has a profound effect on the perception of identity. One of the most important therapeutic challenges is that of helping the person to reconstruct a sense of continuity between the self before and the self after the migration.  The migratory project can play a primary role in this process. The project encompasses the voluntariness of the act and its planning. Its success depends on its being realistic and flexible, as in this case it can be re-elaborated and adapted if the reality of the host-country does not correspond to one’s expectations on departure. Individual characteristics described previously can have a positive influence, as one may imagine, on the creation and realization of migratory projects.
Adequate social support
Adequate social support can sustain individuals both emotionally and materially, accompany them  in their realization of migratory projects and aid their social and psychological integration in the new context. This support can be provided by a great variety of social actors, such as family and friends who have arrived previously and public and private social agencies.
The presence of family or members of the same cultural group in the host country notably influences the level of social support,  which serves as a buffer factor and is protective against the psychopathological effects of traumatic events (Bean et al., 2007; Brewin, Andrews and Valentine,  2000; Gorst-Unsworth and Goldenberg, 1998; Schweitzer, Melville, Steel and Lacherez., 2006). However, this factor can, paradoxically, have the opposite effect, by maintaining conditioning that can hamper social integration. This phenomenon has been observed in the second generation, when the family imposes a style of living and rules that belonged to the country of origin but that can slow or stall the natural integration of young people into the culture of the host country.
Social support, apart from being present must also be efficient, that is, capable of sustaining and promoting psycho-social integration effectively. Socially intense support is not always useful in this area. For example, in the early 1990’s a large migratory wave arrived in Italy from Somalia, following social disorder and civil war in that country. The immigrating Somalian communities were numerous and cohesive and the social support that they offered their members was intense. However, one of the consequences of this phenomenon was the reproduction in the host country of the practice of infibulation,  at the expense of some of the female children. It is difficult to see how for the latter, the social support was in any way beneficial. In addition to physically mutilating these children, provoking irreversible biological damage, the operation also set them apart from the everyday lived experience of their Italian counterparts.

Vulnerability  factors
Already, from a first glance at resilience factors, one can intuitively identify less protected groups of individuals who are potentially more fragile as far as migration trauma is concerned. They are, firstly, people who have migrated without a plan, that is, without a motivating factor that could protect them from the identity crisis that each migrant has to face (Mazzetti, 2003). Individuals without a plan are basically victims of enforced migration: refugees and those seeking asylum.  This includes family members reunited with immigrants, for example minors. The latter sometimes have to confront the trauma of immigration under particularly difficult conditions without significant factors that support resilience. The same two groups, refugees and reunited family members, are among those for whom there may be major problems related to individual characteristics, given that the vicissitudes of life (persecution of refugees and eventual traumatic separation from their parents and other significant family members for children) have weakened them.
Figure 2 summarizes risk factors for the health of those who have faced the trauma of migration

Individual characteristics.
These characteristics appear to be the mirror image of those described as resilience factors. If we concentrate on refugees, their life experiences may have severely damaged their individual characteristics, particularly if they have been victims of violence or torture. We know that one of the effects of intentional violence (often deliberately sought by the perpetrator) is that of damaging the person’s Self, with the intent to cancel the person’s coping mechanisms and to break up his or her attachment dynamics (Sironi, 1999).  As regards the effects of violence on cultural identity, clinical experience confronts us with a common observation: few people resemble each other more than do patients affected by severe forms of PTSD or other severe post-traumatic pathologies. It is almost as if their personalities, and with this their culture, had disappeared, as the individual has been reduced to the most basic elements of human existence.
The effects of systematic violence have been masterfully described, even before psychiatrists, by the Italian writer, Primo Levi, victim of nazism. His account of life in the concentration camp at Auschwitz, “If this is a man,” introduces the phenomenology of victims of violence better than many scientific works (Levi, 1947). This is what French ethnopsychiatrist, Françoise Sironi (Sironi, 1999) calls “reduction to the universa,l” that is, the “de-culturization” of the individual, separating the person from relatives and from the human species itself, as efficiently described by another French writer, Daniel Pennac (1990): “Torture does not only consist of causing pain; it consists of crushing a human being, leaving the person desolate to the point of separating him or her from the human species, in screaming solitude, with nothing he or she can do about it” (p.60). Torture, systematic violence, genocide, the subversion of one’s world, as has occurred in recent decades in Cambodia, the former Yugoslavia and Rwanda, among others, have resulted, in many cases, in human beings who have been separated from their humanity, which is expressed through their culture.
As far as conditions of psychic health are concerned, growing evidence is appearing of high levels of psychic suffering in immigrants who have undergone oppression, torture and other forms of organized violence (Kandula, Kersey and Lurie, 2004; Kinzie, 2006; Rasmussen, Rosenfeld, Reeves and Keller, 2007). Subgroups of refugees exposed to the traumas of war demonstrate high long-term psychiatric morbility even after many years (Steel, Silove, Phan and Mollica, 2002). Post-migratory experiences, as we shall subsequently see, worsen the situation: often the discomfort and the psychiatric symptoms worsen after arrival in the host country. Epidemiological studies have shown that Post-Traumatic Stress Disorder (PTSD) and depressive disorders are the two most  widespread psychiatric diagnoses and those most easily measurable in refugee populations, with few differences between diverse cultures. These disorders are often in comorbidity and are significantly more prevalent in refugees compared to non-refugee populations, (Mollica, Donelan, Tor et al., 1993; Mollica, McInnes, Saraljic et al, 1999; Victorian Foundation for Survivors of Torture, 1998; Cardozo, Vergara, Agani and Gotway., 2000; Kinzie, 2006). Other anxiety disorders, disorders of somatization and other mixed symptoms of suffering are extremely probable in these groups (Turner and Gorst-Unsworth, 1990).
In my clinical experience, paranoid reactions that sometimes depict a real, genuine portrait of personality disorder, are not rare. Unfortunatly no figures are available, and this is an issue for further research. It has been impossible to discern whether these were, at least in part, pre-existent to the trauma or whether they were the result of it. As we shall see, elements exist that lead us to hypothesize a causal relationship with the stressful event.
Moreover, with regard to pre-migratory morbility, a solid dose-response association between traumas and psychic suffering has been well documented. Cumulative exposure to traumas (undergoing violence and torture; being forced to leave one’s own home; finding oneself near shootings and explosions; oneself and/or one’s loved ones being in danger of imminent death) corresponds to a progressive rise in the risk of psychiatric morbidity (Chung and Kagawa-Singer, 1993; Cheung, 1994, Mollica, McInnes, Pool and Tor, 1998; Molica, McInnes, Pham et al, 1998; Turner, Bowie, Dunn, Shapo and Yule., 2003; Rasmussen et al., 2007), coherent with what is known about the major vulnerability to trauma of those who have already suffered traumas (Kessler, Sonega, Bromet et al, 1995; Breslau and Kessler, 2001). In groups of refugees in war zones the percentage of multiple exposures to these events is very high (Turner, Bowie, Dunn, Shapo and Yule, 2003). Refugees can, therefore, suffer from heavily deficient individual characteristics at the moment of their arrival in the land of immigration and, as a result, be lacking in this basic factor of resilience.

Migratory Plan

The value of a migratory plan as a resilience factor and how the lack of this in some groups (minors, refugees) or individuals can be a decisive factor in vulnerability has already been mentioned. The plan may also have existed at the point of departure and  may have failed (or been in danger of failure) because it was not realistic, or was inflexible, or because some other vicissitude (for example, an illness) impeded it. In therapeutic strategies with immigrants it is at times necessary to undertake a true “planning therapy” that allows therapist and patient to work to reconstruct this fundamental element of resilience.
A key aspect of “planning psychotherapy” is the recognition of the different aspects that constitute formulating a plan. Whereas almost all immigrants are aware of economic-related motivation (finding a good job, earning well) they are not always equally aware of other less evident components (how to recreate a new life after a failed marriage, to experiment with being oneself in a new context, to want to travel and to know the world, to free oneself from difficult family relationships, to live in a context of civil and democratic freedom) that also need to be understood and elaborated. With refugees the question of a plan appears to be a particularly delicate subject. In most cases a migratory plan does not exist; or better, it took place at the moment that they left their home country. The plan was to save their lives.
However, there are often hidden or unconscious fantasies about an improbable future, which basically serve to keep the individual blocked. These fantasies are both of a social nature (the fantasy that the conditions of their country of origin will change radically and that everything will return to how it was) and personal (They will return to being exactly as they were before the trauma or the escape). These “fantasies,” as described in the Racket System by Erskine and Zalcman (1979), are used as a functional way of maintaining a blocked script system. Similar attitudes have been described by Jim Allen (2006) among the survivors of the attack in Oklahoma City in 1995. Unrealistic expectations tend to hook people into the roles in the drama triangle and to be an obstacle to resilience processes.

Other factors
Among risk factors there are some that exercise their action indirectly, menacing the success of the migratory project, others appear as specific pathogenic noxae. Transcultural stress, something similar to what anthropologists call culture shock or acculturation stress (Jamil, Nasser-McMillan and Lambert., 2007), is the accumulation of traumatic events that accompany the immigrant or refugee’s  reestablishment in the host country.The term transcultural stress defines the totality of the phenomena that involve the migrant in his passage from one land to the other. The complexity of stimuli are such that it is not possible to systemise all of them. We can, however, indicate certain aspects that may converge to create this complexity.
The language is often incomprehensible at the beginning and requires time to be learned; however, the survival of the immigrant depends on it from the beginning. Non verbal communication is complex and often even more difficult to decipher and to learn than the spoken language. The perception of having a foreign body, with somatic traits that immediately indicate a foreign-ness, can be the target of racist or emarginating behaviour that can lead towards common psychosomatic disorders, such as sine materia itching (Mazzetti, 1996, 2003).   Observing the subversion of one’s customs can cause confusion in the immigrant and may lead to ethical crisis  One can imagine, for example,  the effect of finding oneself in a western city on a summer’s day, when in the country of origin women are totally covered by a veil and a long-sleeved, ankle-length outer garment. The geographic distance from the country of origin and, above all, the cultural distance, appear to be particularly relevant in determining the level of transcultural stress (Kinzie, 2006), for example, the passage from socio-centric societies (societies structured in such a way that the individual’s personal identity is determined primarily by the sense of belonging to a particular group) to an ego-centric culture, typical of western societies, with a strongly invidualistic imprint, or the passage from a rural to an urban setting. Another risk factor is the loss of social status. The pathogenic effect of this situation is the rule, in particular among refugees. Many leave high standards of living and high professional status (as health professionals, teachers, journalists, politicians, and so forth, (Sinnerbrink, Silove, Field, Steel, and Manicavasagar, 1997) and it is difficult for them to have their qualifications recognised in the host country (Burnett and Peel, 2001a, b).
The refugee’s mental health is put at risk through the union of past and present experiences. Added to the traumas suffered in the country of origin are the loss of identity and status, at times further violence, racism and discrimination (Levenson and Cooker, 1999). Poverty, moreover, whose negative effect on physical and mental health has been well documented, is the most probable condition facing refugees (Connelly and Schweiger 2000). In this population loss and bereavement are extremely frequent, often of physical people, and always of one’s own land and of one’s own socio-affective world (Mazzetti, 1999).
Social support is often lacking, because frequently the refugee arrives alone, in a random manner, in a country that has not been chosen. Even when the refugee moves as part of a group, as is the case of escape within a country, or to a country nearby, the people with whom one is fleeing may not be able to offer social support because they also are traumatized and suffering. In a study of Iraqi refugees the social variables during exile, in particular the presence of socio-affective support, was found to be so important in determining the severity of psychiatric symptomatology as to be even more relevant than the traumas undergone in the country of origin (Gorst-Unsworth and Goldenberg, 1998). A variable found to be fundamental in the development of psychopathologies was separation from the family (Turner et al., 2003; Schweitzer et al., 2006; Bean et al., 2007), and it is no accident that difficult living conditions and social isolation have been associated with higher levels of depression (VanVelsen, Gorst-Unsworth and Turner; 1996). As a cumulative result of the factors described here, the refugee is depicted as an immigrant in whom the factors of vulnerability far exceed those of resilience. Under these conditions migration can, and in our experience often does, act as a potent re-traumatizing agent.


Transactional Analysis and the trauma of refugees

I experience Transactional Analysis as an excellent frame of reference for understanding and dealing with the phenomena I have described above. TA has the capacity to serve both as an assessing instrument and for intervention at three different levels: personal (intrapsychic), interpersonal (relational) and cultural/social-structural (Drego, 1983, 2000, 2005, Massey, 1996, 2006). I have also found it to be quite effective cross-culturally (Mazzetti, 2007).
While its intrapsychic and interpersonal applications are widely described in TA literature, the social-structural application has not enjoyed the same attention and is still being developped (Massey, 2006).  I think the cultural/social-structural dimension of Transactional Analysis is highly promising, and share Massey’s point of view about the potencial Berne’s constructs in understanding and describing social-structural processes. In the case of refugees the social-structural aspects are of paramount relevance.
Psychotraumatology, from a Transactional Analytic point of view, constitutes a type of natural experiment that indicates how decisive elements of the life script apparatus may be established even long after childhood. The condition is that there be a strong emotional involvement leading to a new intrapsychic resolution in order to survive a critical situation. This is, therefore, a sort of experimental demonstration of what Cornell (1988) noted: “Major script decisions can be made at any point in life” (page 281). Following the same criteria, from my point of view, script injunctions (Goulding and Goulding, 1978, 1979) can also be established at any point in life. Masse (1995), discussing the treatment of Post Traumatic Stress Disorder (PTSD), proposed the establishing of new script decisions as follows: “In reaction to extreme trauma (…) a person can spontaneously regress to an earlier developmental age, and make new decisions about self, others and the world” (p.356). Perhaps, without necessarily thinking in terms of regression to an earlier developmental age, we can hypothesize the action of events that significatively impact the neurological structures delegated to implicit memory and emotional life (thalamus, amigdala, hippocampus and pre-frontal cortex). These structures are those most active in the first phases of life, but do not stop their activity later: so may be responsible for non-verbal learning experiences that establish injunctions. In these cases memories are filed as affective states, senso-motorial modalities, bodily sensations or visual images (van der Kolk, 1996).
Beslija (1997), who has described his psychotherapeutic experience with Bosnian refugees, stated that the survival decision that people affected by PTSD take, when faced with the intensity of trauma and their life being endangered,  is connected with the injunction, “Don’t feel.” The trauma is such that victims unconsciously decide to cancel their emotions and to exclude their Child ego state.
I think that these situations can occur sometimes in the presence of significant disassociation defenses and symptoms of avoidance. However, in my experience this is an infrequent event. It appears to me that the script elements at play are of another nature and that these recur not only in the presence of PTSD, but also in other clinical cases following trauma, such as depressive or anxiety disorders, or paranoid or avoidant personality disorders.
On the basis of my experience, the impact of the traumatic event that lies beyond the individual’s possibility of management, induces in the person a deep sense of insecurity that is translated into an injunction: “Don’t trust”. The person initially feels unable to trust one’s own ability to manage reality; therefore it is a lack of trust, above all, of self that brings about high levels of anxiety. Moreover, when the traumatic event is due to the cruelty of other human beings (as is usually the case in refugees) and not due to natural causes, this is translated into a deep and generalized lack of trust in humanity.
For me these reflections provide a theoretical assumption that may  explain the paranoid clinical pictures that we sometimes come across in patients who are victims of violence. In my experience, those suffering from paranoia are not only people who are defensive in relation to others, but even more so persons who do not trust themselves, do not trust their own ability to protect themselves or feel that they have the ability to discriminate between which people are dangerous and which are not. This profound personal distrust is what is sometimes also induced in victims through torture (Sironi, 1999).  Therefore, I do not agree with the presence of the injunction, “Don’t feel” (Beslija, 1997). It appears to me that people affected by PTSD and other post traumatic disorders “feel” their emotions; they are in fact invaded by them. Even if they fight them, or they mystify them with racket feelings. Instead of anger they feel fear, or instead of fear they permit themselves to feel sadness.
From my point of view there are severe contaminations of the Child over the Adult, who is unable to discriminate any more or to give a sense to his own emotions, rather than an excluded Child (although some areas of exclusion can be present). Rather than “Don’t feel,” I recognize the injunction “Don’t Think,” intended as don’t think about your emotions, don’t discriminate, don’t recognize them. There is an inability to give one’s feelings a meaning. The real challenge for traumatized subjects is to reconstruct a sense to the experiences they have lived through. In this I agree with Stuthridge (2006), who asserts the importance of a coherent narrative of what has happened, in order to heal the trauma.
On the basis of my experience I think that healing the post traumatic pathology must be undertaken essentially at a cognitive level in order to succeed in making sense of what has happened. Making sense of the persecutors’ behaviour and of one’s own behaviour seems to be the main road to success. In this perspective emotions are understood, explained, made sense of, rather then re-lived. This strategy, among other things, leads towards the activation of less resistance.
Facing the the above injunctions, the drivers (Khaler and Capers, 1974, Khaler, 1977) that seem to recur most often are: “Be strong,” declined as, “Fight with all your strength against what you are feeling,” and, “Try hard”, or, “Try in all ways possible to keep your emotions at bay.” From a structural analysis perspective (Berne, 1961), these drivers are often expressed as a contamination by the Parent of the Adult that, in critical terms, reminds the person that he/she is not OK, because he cannot put internal experiences under control. This type of contamination plays a primary role in posttraumatic depressive synptoms.
The overall framework can be schematized in the diagram of figure 3.

Drivers: Be Strong, Try Hard

Contamination: People without control on themselves
are weak and without value

Contamination: the world is a dangerous place. It is
better to hide and not be seen

Injunctions: Don’t trust, Don’t Think
Decision: to survive I must always be alert
and fight against my feelings

This violent battle against themselves is what absorbs a great part of the energy of those who suffer from PTSD and other post-traumatic pathologies, to the point of leaving little energy available for the healing process. The patient fights against his memories, against his emotions, and doing so fills them with new energy. It is what happens when a spring is compressed: the propulsive force rises. It is here that it is useful to take care of these people. The spring of their energy needs to be discharged, by first legitimizing the malaise as a normal reaction to an abnormal event and then voicing the pain, giving it sense, so that the psychic life of the person can resume fully. The need for this reaches its apex in regard to the consequenses of torture.
“Scientific” torture, which spread during the 20th century, especially after the Second World War when the first evidence of experimental psychology gave it a scientific basis, aimed towards obtaining the following:
1. Destroying the individual’s self-confidence (by inducing the injunctions “Don’t trust”, “Don’t think”)
2. Destroying the trust of the individual in other human beings (through the injunctions, “Don’t trust”, “Don’t belong”)
3. Convincing people of their unworthiness  to exist (thus inducing the injunction “Don’t exist”)
Torture aims towards repeating traumatic events in an obsessively repetitive manner in order to bring these situations to intolerable, self-reinforcing levels. The final aim of torture is to establish a process that feeds  itself so that the individual, once freed from the torturers, continues the process of self-torture at an intra-psychic level.
The first step is that of constructing a situation of total impotence. In many cases the first step in torture is to arrest that person, close him in isolation, and to “forget”  him (or her) there, probably in the dark. The individual remains hours, days, without any external stimulus, tormenting oneself about what might happen, in a condition of total impotence.
Physical violence follows this more or less long period. The sense of impotence arises from the perception of one’s own body, abandoned without any possibility of defense in the persecutor’s hands. The intent is to give the victim the sensation of having lost all control of himself. Very often the violence is disconnected from the objective of forcing information. Consequently the individual cannot influence what is happening, not even by confessing in order to interrupt the brutality. The victim is simply a body thrown into the hands of the perpetrators who can do what they will.
Apart from the sensation of having lost control over one’s own body, which is the first step towards inducing loss of confidence in self, the persecutor’s aim is to create in the victim the conviction of not being able even to control  one’s own thoughts.
The methods with which this objective is reached are various: one of those most practiced is deprivation of sleep, to which bizarre and illogical sensorial stimulations are added. Testimonies from the former Yugoslavia portray victims hung from a pole to whom, during the intervals between one session and another of physical violence, bizarre images were projected; or they were surrounded by people who ignored them and who did other things with great self-assurance, as if the victim did not exist. For example, a couple entered and performed the sexual act in front of him. The aim of these stimulations is, as previously mentioned, to bring the individual to the point of thinking he is going mad, has lost control of his cognitive capacity, so that he renounces thinking, internalizing the injunction, “Don’t think.” Torture aimed towards keeping the individual constantly on the border of life and death is also a frequent practice. Fake executions are an example. The victim is brought before an execution squad,  possibly one that has executed another person in front of him. The rituals take place, and then the persecutors shoot a salvo in order to immediately deride and humiliate the emotional reactions of the victim.
Apart from these procedures, which are quite successful in destroying the individual’s self-confidence and faith in humanity (“Don’t trust,” “Don’t belong”), there are others directly connected to convincing him of his worthlessness in living. In these cases the aim is to induce the injunction “Don’t exist.” To obtain these objectives, a classical method is that of inducing intolerable experiences of self-blame, typically showing the victim how, through their fault, other people have been ruined. The persecutor obtains this result through forcing the victim to witness the torture of his friends, convincing him that it is his fault that they are being tortured, or subjecting his nearest and dearest to violence, under the victim’s eyes.
Such testimonials, frequent under former Latin-American dictatorships, came successively from Iraq or the former Yugoslavia, where sometimes the victim was forced to execute relatives or friends with his own hands. The sense of blame, of profound lack of worth, that these tortures induce is responsible for the not rare cases of suicide, even many years after the traumatic event. Precise epidemiological data are lacking because what pertains to the survivors of torture is nebulous and dark, as part of the clinical findings regarding these persons is their attempt to hide themselves, to disappear, not to look for a cure. However, cases of suicide which come to the awareness of those who care for refugees are not rare, even in the absence of statististics, that are very difficult to obtain with these “hidden patients”.
The persecutor has achieved his aim when the victim, desolate on the psychic level, has  begun a vicious circle of self-punishment that guarantees that he will continue to self-inflict the condemnation in the future. At this point the victim can be set free. He  or she is no longer able to do damage to the regime, and can only harm oneself and one’s cause.
Trauma and migration
Although little research exists about post-exile factors that influence the psychic morbidity of refugees, there is general agreement, supported by clinical experience, underlining the impact of migration. This is accompanied by the observation that often the discomfort and the psychiatric symptoms of refugees worsen after their arrival in the host country. As previously mentioned, a subject who has suffered psychic traumas will be more easily traumatized if he or she is again exposed to stressors,  resulting in a  cumulative process of damage. Traumatized refugees, therefore, are not only more fragile individuals as migrants, because factors of vulnerability are dominant over those of resilience, but are particularly so due to psychotraumatology. Having already been traumatized, they are particularly vulnerable to new traumas.
Migration acts as a re-traumatizing event under three main conditions:
The creation of a deculturalizing context: Transcultural stress has its deepest and most violent effect on subjects who are already suffering a crisis of cultural identity, because they have been “deculturalized” by violence, social subversion and/or torture.
Social solitude: Asylum seekers are often accommodated in places with other people only on the basis of sharing a judicial status with them. As a result they have to cohabit with individuals who do not speak the same language and do not understand each other’s habits. This enhances the perception of isolation and alienation from one’s surroundings. These factors are re-traumatizing for those who have lost all their social contacts as well as their most intimate personal relationships.
Exposure to provoking stimuli: The first contact with the host country often takes place in the presence of the military or police forces. Exposure to uniforms in subjects who have learned to fear them, and  who respond with the augmented arousal typical of PTSD, can provoke violent anxiety reactions,. The centers that accommodate asylum seekers, which  sometimes were built as places of detention (guests sequestered, bars on the windows), can constitute a re-traumatizing situation for someone who has had experience of being sequestered. In some cases migrants are even kept in common prisons (Silove et al., 2001).
However comfortable the place of detention may be,  keys turning in keyholes, the noise of cell doors opening or closing and the sight of uniforms can evoke extremely strong traumatic memories (Burnett & Peel, 2001a).
The procedures that the asylum seeker undergoes (repeated interrogations, often with an investigative, distrustful attitude towards the migrant) can cause a repetition of past experiences of detention and police interrogation in the native land. It must be remembered that these events take place in a difficult emotional situation. The procedure for seeking asylum often takes a long time and is characterized by continuous terror of being sent back to the country of origin (Sinnerbrink et al., 1997).
Similar considerations are also valid in regard to apparently innocuous procedures such as the medical examination. Exposing one’s naked body among dressed ones, being manipulated by strangers, can provoke sudden anxiety attacks in victims of torture.
Lack of awareness of the risk of re-traumatization can have paradoxical effects opposite to those hoped for in the socio-rehabilitative procedures. Recently a refugee under the care of our service was offered a program of assisted reintegration into the workplace by an organization  that allocated him to maintenance work in a cemetery. Among his duties was the exhumation of human remains in order to place them in a smaller burial place. He had fled from his country, which was at war, and dreamt of corpses almost every night. This type of job had the result of aggravating his symptomatology.
The repetition of traumas – due to the context of de-culturalization, isolation, the menace of enforced re-patriation and the evocative stimuli of a terrifying past, such as those previously described – augment the risk of severe mental disorders that impair the  ability to adapt to the host country, and may have disabling long term effects.

Intervention strategies
The following are strategies of welcome and intervention specifically considered to be effects of psycho-social networks, based on psychotherapeutic assumptions, even though these may be carried out by various social workers. They are aimed towards reinforcing the resilience factors shown in figure 1 and reducing the vulnerability factors listed in figure 2. The strategies are summarized in figure 4.

INTERVENTION STRATEGIES

* Choice/training of reception personnel
* Suitable reception areas
* Procedures for granting asylum
– clear, comprehensible, accessible and rapid
– commission trained in dealing with psychiatric disorders of asylum seekers
– escorting during interrogation sessions
– facilitation of family reunification
* Organization of specific services
– promotion of socialization
– monitoring of psychic condition
* Construction of services network
* Protection of cultural identity
* Offer of specialized psychotherapy

As can be seen,  [the] mental health strategies depend only in part on psychiatric personnel and are largely connected to adequate social interventions. In this sense, the general frame is to establish and maintain Ok-Ok relationships, to aswer in a positive way to the needs of stimulus, contact, recognitions, and structure (Berne, 1970, 1972), to promote a positive stroke economy (Steiner, 1971).
Particular points that support resilience in immigrants and victims of torture are considered below:
Reception personnel. The first welcoming committees should be composed of civilians, not military personnel or police, even if the latter are well trained to face the situation, since seeing them can trigger anxiety reactions among PTSD patients.
The main challenge is to develop and maintain a healthy “I’m Ok – you’re Ok” position, which  is not always easy to do with these persons. Personnel must be sufficiently trained to be able to manage the complex relational stimuli that arise in asylum seekers. For example, sudden dysphoric crises and controversial statements are not necessarily the sign of an aggressive personality or an attempt to lie, but may be symptoms of specific psychic illness.
Counselling, provided by persons able to screen subjects at psychopathological risk must be offered to all. Active offers are essential because the refusal to ask for help is part of the clinical  profile that we have described and of the corresponding script decisions. Medical assistance must also be provided, and doctors, as previously mentioned, must also have relational skills. When a subject who has been tortured is seen by a doctor, the risk is present for severe anxiety reactions; hence, the doctor and his assistants should be careful not to induce them inadvertently.
Reception areas: Apart from providing basic necessities for personal hygiene, these places must be peaceful areas, where separate spaces are possible and where rest is facilited. A common experience for doctors is that of meeting a patient suffering from sleep deprivation. Increased arousal brings about continual wakening and anxiety attacks, in which noisy stimuli (people who enter and leave the room, banging doors) are repeated. These subjects need to live in an environment where they can have control. The goal is to offer them a structured setting where they can feel secure, to avoid increasing their feelings of “not belonging” and of “not trusting”. Obviously prison-like environments must be avoided.
Countries granting asylum must provide clear, comprehensible, easily accessible and rapid procedures for recognizing refugee status. The personnel of the commissions that grants asylum must be trained to understand the difficulty of asylum seekers in telling their stories. Possible contradictions in a story can be signs of temporal disorientation, which many victims of violence suffer from, and not of lies. In our experience some victims of torture were denied the status of refugee because they were unable to reconstruct their story with precision.
Asylum seekers must be allowed to appear before the commission with someone they trust. In this way the emotional impact of the interrogation is alleviated, the resemblance to police interrogations without legal defence reduced, and the sense of social support strenghtened. These procedures are of great value in treating script issues related to refugees’ status. Massey wrote: “Exploitation and abuses of power buttressed by scripts based on socialization supporting discounting being and doing along with conformity to aggressiveness and violence fortify negative social structure” (Massey, 2006, p. 143). Refugees are heavily imprinted by thiese kinds of negative social structures. They need healthy social structure to help the healing of their destructive, socially-induced script elements. For the same reason, beaurocratic procedures for reunification of the family must follow an easier and quicker path, in comparison to what happens to other migrants.  This must occur as soon as is possible.
Asylum seekers must be provided, from the beginning of the bureaucratic procedure, with information about the advantage of having the appropriate medical or psychiatric certification to successfully undergo a hearing with the Commission that grants asylum. They should be informed of how to obtain  this.
Specific services. Programs of assistance for refugees must provide specifically trained social and health personnel and the services offered must be actively provided, for the reasons cited above.
The first aim of these services must be to promote protected socialization, first of all to answer to the motivational needs (Berne, 1970) to restore healthy ways of structuring time (Berne, 1964, 1966, 1970, 1972) and to exchange positive strokes (Steiner, 1971).
This end can be reached in various ways: through discussion groups with the goal of helping the person to make sense of past experiences and to share them in an intimate environment: through group activities such as art-therapy, through language courses taught by instructors who are able to understand their learning difficulties, which are often present as a result of their psychic suffering. Throughout all these activities it is necessary to repeatedly inform and reassure the refugees that their difficulties are normal reactions to abnormal experiences and not a sign of  personal weakness.
Ongoing surveillance of the conditions of the refugees’ mental health is necessary, to offer immediate specialized therapeutic interventions when necessary.
Construction of a service network: The refugee often requires many different services: medical, psychological, social and legal help, job training, and help in seeking a place to live. These services must be organized as an integrated and interlocking network. Apart from the practical results obtained, there is also the added advantage of psychic health, because a network of this type, composed of qualified personnel, contributes towards breaking through the social isolation of the refugee: it can costitute a kind of community to which the refugee can experience a sense of belonging that can help to cure the traumatic script conclusions. The best solution is to have a professional as a point of reference (social worker or other) able to act as a bridge between the various services and who will accompany the person throughout the procedures.
Protection of cultural identity. When the social and political conditions of the host country and the state of health of the individual permit the promotion of occasions to meet  with other co-nationals, it will be useful to organize them, with the aim of strengthening or restoring a sense of belonging to a community. National feasts, cultural activities, preferably in small  groups, with the support of the country of origin, if changed political conditions permit this, can provide precious help, particularly when foreseeing possible repatriation.
Specialized psychotherapeutic help. The offer of psychotherapeutic assistance necessitates not only specialists who are experts in the field of psychotraumatology, but also people with specific training in the sector of intentional violence. Treating a victim of torture is different from the rehabilitation of a person after a road accident or an earthquake. The intention of the act, as we have seen, has specific consequences, both on the psychodynamics of suffering and on the complexity of the symptoms,  thus  specialized interventions are required.

Conclusions
Approaching migration as a traumatic event allows us to offer clinical immigrant and refugee patients management strategies that relate to resilience and vulnerability. This provides us with a model for understanding how refugees may be re-traumatized in the country of asylum and, therefore, enables us to plan specific protection strategies for the clinical management of the symptoms of these persons, based on the integration of various psycho-socio-health services planned from a psychotherapeutic viewpoint, inside the frame of reference of Transactional Analysis.
It is interesting to note that the advantages of this broad way of thinking and operating,  which comes from our clinical practice and that is aimed towards building integrated networks of psycho-social help, does not stop at the hoped-for benefit to our patients. The care of traumatized patients appears to also benefit the society that accepts them, both because people who would otherwise be a burden for society are re-habilitated. and because the networks built up around needful refugees constitute positive examples that can be extended to other sectors of social assistance in the host country. In this context, Transactional Analysis appears to be a precious instrument since, in addition to being a theory of the personality, of psychopathology and of psychotherapy, it is also a useful theory of organizaton, that has a promising social-structural dimension and appears to be an effective cross-cultural tool.
A pleasant surprise in creating such integrated networks is that not only can we cure people, like torture survivors, who a few years ago appeared incurable, but that in doing so we are curing our own societies and further developing our theorethical understanding.

Marco Mazzetti, M. D., psychiatrist, is a teaching and supervising transactional analyst in psychotherapy (TSTA-P), a member of EATA and ITAA and a university lecturer. Marco carries out his clinical, training and research activity at the Centro di Psicologia e Analisi Transazionale and at the Ethno-Psychiatry Service Terrenuove of Milan, Italy. He is supervisor and scientific director of the project “Invisible Wounds” for the care of survivors of torture at the Health Service of Caritas, in Rome. He can be reached at Centro di Psicologia e Analisi Transazionale, Via Archimede, 127, 20129 Milano, Italy; e-mail: marcomazzetti.at@libero.it.

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