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Travma >> Effects of forced migration on psychological effects seen after torture

 BACKGROUND

During the years following the military take-over of 1980, especially in the ‘90’s the “low-intensity-warfare” going on the eastern and southeastern part of the country led to the forced evacuation of many villages in the area. The number of people thus displaced is estimated at 3 000 000 by Human Rights Association (HRA). The number of villages evacuated ranges between around 2 000 according to Turkish government sources and around 8 000 according to HRA.

Istanbul, the largest city in Turkey, was one of the major cities receiving the resultant wave of migration. Some of the immigrants, affected deeply by the events preceding forced evacuation of their villages, the migration process itself, and the cultural change they face after the migration, constitute one of the two major groups presenting to Human Rights Foundation of Turkey (HRFT) Istanbul Office. HRFT is a non-governmental organization which deals with physical and psychological sequelae of torture and provides medical help to survivors.

In our clinical practice, we observed that survivors of forced migration differ in some critical aspects from others, mainly political activists who were subjected to torture. We thought that those differences might have implications for treatment.

The following are the results of a study being conducted in HRFT Istanbul Office.

MATERIAL AND METHOD

Study Population:

The people who presented to HRFT Istanbul Office between January, 1~ and May, 31 ~, 1997, and who had not been treated for their present psychological problems before were included in the study. Exclusion criteria included illiteracy and having had a psychotic disorder.

Instruments

Structured Clinical Interview for DSM-I1I-R (SCID) (Spitzer et al., 1987), Posttraumatic Stress Diagnostic Scale (Foa, 1985), State-Trait Anxiety Inventory (STAI) (Spielberger et al., 1983), Beck Depression Inventory (Beck et al., 1961), and Semi-Structured Interview Schedule for Socio- Demographic Characteristics and Detention History were used.

RESULTS

Socio-Demographics

A comparison of sociodemographic characteristics of two groups revealed that the mean age was higher (p< .05) in the forced migration group, which included more men, though the latter difference was not statistically significant. Subjects in this group also tended to be married (p=.056), had had less education (p<.05), and lacked regular jobs (p<.O5). Subjects in the first group had come to Istanbul a median of 29.0 mouths ago (range 1-141 months). Sociodemographic characteristics of both groups are shown in Table 1.

History of Detention and Other Traumatic Events

Subjects in the forced migration group tended to have had less but longer detentions, although this tendency did not reach the level of statistical significance. A similar tendency was found regarding the duration of last detention. Members of this group also applied for treatment somewhat later (Table 2).

Trauma history as defined by Posttraumatic Stress Diagnostic Scale demonstrates that subjects in both groups have been exposed to multiple traumatic events (Table 3).

The most common traumatic event among those listed under “other” was murder of a family member or very close friend with five subjects reporting such an experience. All of those five subjects were in the forced migration group.

The most traumatic experience reported by the subjects among those listed in Posttraumatic Stress Diagnostic Scale was torture (26 subjects, 84%). Thirteen subjects in each group had reported torture as the most traumatic lifetime event.

Psychiatric Symptoms and Diagnoses

A further investigation revealed that the most common complaint among those subjects who reported torture as their most traumatic experience was having trouble concentrating (II survivors, 84.6%) in the forced migration group and feeling distant or cut off from people around (10 survivors, 76.9%), having trouble falling or staying asleep (10 survivors, 76.90/o), feeling irritable or having fits of anger (10 survivors, 76.9%), feeling emotionally upset when reminded of the traumatic event (10 survivors, 76.9%), and having unwanted upsetting thoughts or images about the traumatic event (10 survivors, 76.9%) in the second group consisting mainly of political activists. The least frequent symptom reported in both groups was inability to remember an important part of the traumatic event, with 2 and 3 survivors reporting it, respectively. Feelings of hopelessness concerning future were somewhat more frequent in forced migration group torture survivors (61.5% vs. 38.5%; P~.10; Table 5).

The groups differed in terms of answers to a critical question: “Did you feel helpless?”. Among those who had reported torture as their most traumatic experience, a total of 19 survivors had answered affirmative and 7 negative to this question. In the first group, 12 out of 13 survivors had experienced helplessness (92.3%), while the respective figure for group 2 “as 7 out of 13 (53.8%). The same subjects in the first group also answered affirmative to the question “Did you feel terrified?”; while in the second group 6 of 7 such and another subject from the 13 (53.8%) reported feeling terrified. There were significant differences between the subgroups consisting of those reporting torture as the most traumatic event they had experienced in terms of answers to these two questions (Fishers Exact test .037, one-tailed p.05 for each question).

All the survivors reporting to have at least one symptom of PTSD in the forced migration group (n=12) also reported that their symptoms had begun soon after torture. Of those, symptoms in one survivor had a history of less than one month, while the remaining 11 were experiencing these symptoms for longer than 3 months. On the other hand, symptoms in 8 torture survivors from the second group had begun soon after traumatic event, while 5 had seemingly more insidious-onset symptoms, occurring for the first time more than 6 months after torture. A closer investigation revealed that symptoms in 3 of those five survivors became manifest on release from prison. As regards chronicity of symptoms, 2 survivors were experiencing them for lees than a month, 4 for 1-3 months and 7 for three months or longer.

Beck Depression Scale and STAI scores were somewhat higher in the forced migration group, although these tendencies did not reach the level of statistical significance (Table 6).

A total of 13 patients (41.9%) in both groups met the DSM-IV diagnostic criteria for PTSD. Two patients in group 2 did not have a diagnosis of PTSD only on the basis of their not meeting criterion A. Eight of those meeting diagnostic criteria for PTSD were in the forced migration group and five were political activists not subjected to forced migration (53.3 and 31.2%, respectively). The most common psychiatric diagnosis was major depressive disorder, present in 8 subjects (53.3%) from the first and 6 subjects (37.5) from the second group a total of 14 subjects (45.2%). (Table 7).

All of the eight PTSD cases in the forced migration group had an accompanying depressive disorder; major depressive disorder in 6 and dysthymic disorder in 2. Of the five PTSD cases in the second group, 2 had major depressive disorder and none had dysthymic disorder.

All the psychiatric disorders present on the date of psychiatric evaluation had occurred after torture in the forced migration group. Two subjects met the DSM-III-R criteria for past major depressive episode; one occurring after the son of the survivor left home to join a leftist organization, and the other after the son was killed. In the second group, PTSD, major depressive disorder and panic disorder had emerged after torture, while the other psychiatric disorders had begun earlier.

DISCUSSION

This study has several limitations. First, the groups are rather small. Extensive subgroup analyses have not been done for that reason; which rises questions on the comparability of these two groups. Moreover, some of these variables, such as age, education, and time passed since torture and forced migration have a wide range of in-group variability and could have helped differentiating some subgroups among the survivors. Quantitative limitations have precluded application of advanced statistical procedures to determine the predictive or confounding effects of those variables.

Many studies have been conducted on refugees, immigrants and torture survivors (Bagheri 1992). There are also studies addressing the psychological problems occurring in torture survivors who have immigrated to or sought asylum in foreign countries. However, groups investigated in these studies generally consist of torture survivors who have immigrated to countries in which they feel safe and experience lesser economic problems. It can be reasoned that the objective problems those survivors were experiencing at the time of investigation were adaptation problems arising from cultural differences, longing for relatives left back at home country and homesickness (Fullilove 1996). The survivors on which we report, on the other hand, have migrated in the same country. Threat to their lives, although diminished to some degree, is still serious. They are also experiencing overwhelming economic problems, sometimes even being unable to attend psychotherapy sessions simply because they do not have money to buy a bus ticket. On the positive side, many of them know Turkish and have some relatives or fellow-villagers in Istanbul. We could have find in literature a report on a similar population (Dahl et al. 1998, Aaby et al 1999, Dyregrov et al. 1996, Pearn 1996, Laor 1996, Kuterovac 1994, Melvillee& Lykes 1992, . Thus, any comparison with other studies rests solely on the similarity of traumatic life events in study populations. Forced migration is an ongoing process. For that reason it is difficult to get material on the subject in Turkey.

A comparison between the two groups reveals that subjects in the forced migration group live tinder more difficult conditions. The length of time in detention, which generally reflects duration of torture, is also greater in this group. Although only three survivors from this group reported presence in military combat or a war zone, an item in Posttraumatic Stress Diagnostic Scale, as a traumatic event, it is evident that they understood the question differently, i.e. as presence in field of war; since Turkish government has more than once described the situation in the East as “low-intensity warfare”, which means that survivors in the forced migration group had lived in a war zone for years. As a result of this situation, and mostly after forced military evacuation of their villages, have they sought asylum in Istanbul, where threat to their lives and threat of torture continues. They do not have social security, health insurance or unemployment insurance of any kind and are sometimes starved to death. On the other hand, subjects in the second group have problems of their own. Although never asked directly during the interviews, most of them seem to be politically active and are under risk of detention and torture because of their past and/or present activities. Many of them are also defendants in ongoing trials, generally seen in State Security Courts and face the threat of imprisonment or conviction to long terms of sentence if found guilty. Thus, it seems inappropriate for either group to evaluate torture as a past traumatic event and suppose that the survivors are in the post-traumatic period. The persistence of traumatic experiences gives rise to questions on the applicability of PTSD as a diagnostic entity for these people. The diagnosis of PTSD, by its very name, suggests that the traumatic experience is over. Would it be wise to base a clinical •judgement about these people on questions like “Do you feel as if your future plans or hopes will not come true?”

All but two subjects in the forced migration group come from villages evacuated by force. Trying to adapt living in the big city is a serious stressor for them. All, with the exception of one survivor immigrated 10 years ago and another 7 years ago when only 11 years old, are grieving for the loss of their homes. They continuously think of “good old times” in the day and dream of their homelands in the night. They also feel guilty towards their killed relatives for being unable to visit their graves back there.

The statistically significant differences between the two groups concerning answers to two PTDS questions “Did you feel helplessness?” and “Did you feel terrified?” can be explained by different degrees of political involvement. Although no direct question was employed, all but two survivors in the forced migration group gave the impression of not being politically active, while all the subjects in the second group seemed to be politically active at the time of detention and torture. Three of them reported putting an end to their political activities later. Finaly held political beliefs are likely to have critical importance in determining perception of and attitudes towards torture. Such survivors report being prepared to torture, feeling little or no pain during torture, feeling to have the control of situation since some of them were more experienced than their torturers, and concentrating on torturers instead. For them, being affected by torture is a great shame, equivalent to being a confessor. Thus, people with ongoing political activity are quite unlikely to report feeling “helpless” or “terrified” as put in DSM-IV criterion A for PTSD, even if they had felt like that at the time. Indeed, two torture survivors in group 2 were not diagnosed as having PTSD solely for not meeting Criterion A. It seems that changing the criteria ‘for PTSD or defining a new entity for these people should be considered; since they have other symptoms of PTSD and might benefit of similar treatment, which might otherwise be withheld.

It is reported that certain phases of resettlement are characterized by greater mental health risk. Tyhiurst (1951, 1977) suggested that immigrants are at maximum risk for developing psychiatric disorders 2-3 months after arrival, but Rumbaut (1985) placed the risk period during the second year of resettlement. In a study from Turkey (Kara el aI, 1996) on 117 forced migrated people subjected to forced migration, it has been reported that major depression rate is 29.1%, panic disorder rate is 15.4% and somatization rate is 18.8% three months post-migration. PTSD prevalence and history of torture or other traumatic events were not investigated. The depression prevalence is higher in our group. Presence of a history of torture and the wide variability in the duration of time past since migration in our study population may explain this difference. All subjects in the migration group reported that their PTSD and depressive symptoms had begun soon after torture. This finding is inconsistent with other studies suggesting peak incidence rates for psychiatric disorders occur later.

Lack of college education and life stress before and after trauma are reported to he among the risk factors associated with psychiatric disorders occurring after trauma. Survivors in the forced migration group had received less education than the political activists and also led —and are still leading— more stressful lives. Thus, it is not surprising that they have more psychiatric disorders. In this group, PTSD always presented with comorbid depressive disorder. However, presence of symptoms such as depressive mood, anhedonia or decreased self-confidence is quite natural in the face of ongoing trauma and are unlikely to disappear solely by psychotherapeutic intervention. An important finding was the absence of feelings of guilt or suicidal ideation in these cases. Absence of feelings of guilt probably protect against suicidal ideation in these survivors.

Although many cases did not meet PTSD criteria fill, we found high prevalence rates for individual PTSD symptoms in both groups. In the literature, symptom prevalence rates lay in a broad sped ruin. Our findings are consistent with some of the other reports.

Table 1. Socio-Demographic Characteristics Of The Study Population 

Table 2. Detention and Arrestment History 

Table 7. Psychiatric Disorders Among The Survivors

Table 8. Comorbid Depressive Disorders With PTSD

Nuray Türksoy Karalı, Şahika Yüksel

Poster, Fifth European Conference on Traumatic Stress,
29 Haziran-3 Temmuz 1997, Maastricht, Hollanda.