When There Is No “Post-” to the Trauma
Exploring Continuous Traumatic Stress in Refugee Populations
By Zainab Asad
A couple months ago I was scrolling through Instagram when I came across a post from a Palestinian activist’s account that read “There is no such thing as PTSD for Palestinians.” Something about that sounded off; was this individual simultaneously dismissing the mental health issues of the very same families she was advocating for? I proceeded to swipe through the thread, intrigued by such a bold claim, and came to learn of continuous traumatic stress (CTS), a newly emerging mental health conceptualization too often misdiagnosed as post-traumatic stress disorder (PTSD).
Refugees who fled xenophobic attacks protested in Cape Town demanding to be sent elsewhere.
Brenton Geach/Gallo Images via Getty Images
The term, continuous traumatic stress, was first coined in 1986 by Frank Chikane whilst studying the psychological effects of apartheid in South Africa. Children, he found, were especially vulnerable to developing CTS in response to inescapable long periods of political repression, civil conflict, violence, and racism against their people. Repeated exposure to danger without adequate help to process what is happening left victims trapped in an environment where revictimization was their reality, unlike PTSD victims whose fear stems from experiences in their past implying little to no plausibility of recurrence.
Often, conversations regarding trauma survivors are framed in terms of post-traumatic stress disorder. Individuals who feel frightened in situations that no longer pose any danger exhibit symptoms of PTSD. The assumption is that these people are now in a relatively safe environment yet still feel anxiety, sleeplessness, or hopelessness in the aftermath of a traumatic experience. CTS, on the other hand, refers to those still in danger living in conditions that present a legitimate risk to their safety. CTS patients are preoccupied by the potential of current and future traumatic events rather than past events. Scenarios such as long term bullying, being raised by an alcoholic parent, constant exposure to violence, poverty, police brutality, workplace inequality, homelessness, and food insecurity and malnutrition produce increasing levels of stress and lead to symptoms like learning disabilities, panic attacks, dissociative disorders, general sickness and immune deficiency, violent and impulsive behavior, insomnia, and substance abuse/addiction later in life.
CTS as emotional or behavioral reactions to ongoing danger is frequently experienced by systematically oppressed and marginalized communities that are unable to benefit from an external protection system. The continual threat reinforces their compromised political, social, and economic positions significantly harming their mental health. The notion of prolonged trauma challenges existing conceptualizations of traumatic stress which retain that stressors were only present in the past. This new understanding is vital in grasping the refugee experience which remains subject to worries over finding, let alone moving, from one place of refuge to another insofar as nations allow entrance across their borders.
Israeli soldiers hold Palestinian children under arrest in the West Bank city of Hebron in August 2011. Photograph: Abed Al Hashlamoun/EPA
One of only a handful of psychiatrists in occupied Palestine and chair of the mental health unit at the Palestinian Health Ministry, Samah Jabr, claims PTSD is a western concept that is incapable of distinguishing “justified misery from clinical depression.” PTSD is better suited explaining the experiences of US soldiers whose war-related fears after deployment are imaginary as opposed to Gazans whose horrors of another bomb drop are enduring and real. Misdiagnosis, according to Jabr, imposes experiences onto civilians that are not theirs and vice versa. Moreover, PTSD fails to capture the collective historical trauma instead labeling hyper-vigilance and avoidance as “dysfunctional psychological reactions” when in reality, these are rational behaviors.
Syrian refugees arrive on a dinghy on the Greek island of Lesbos, Sept. 7, 2015. A year and a half later, thousands of asylum-seekers remain stuck on Greek islands uncertain what their future holds.
Credit: Dimitris Michalakis/Reuters
Human suffering, in the psychiatric field, has been collectively colonized by the dominance of PTSD as a diagnostic framework; PTSD acts as a benchmark against which all traumatic-stress-related responses are assessed. Though PTSD can be an accurate analysis of resettled populations who flash back every now and then to the treacherous journey taken to reach their host nation, those currently en route to their next location face exceedingly difficult obstacles in the now, resulting in substantial worries that can only be attributed to outside forces. Unceasing threats to life and bodily integrity are indicative of the permanent emergency state of refugees. Even after resettlement, refugees are liable to never ending identity trauma as anti-refugee rhetoric in xenophobic contexts relinquishes them to harassment, verbal abuse, and criminal attacks.
Syrian refugees who crossed the Evros River wait to be transferred by police to a first reception center in Greece. Alkis Konstantinidis/Reuters
Recovery for PTSD patients involves training the brain to ignore maladaptive false alarm responses, conditioned by previous experiences, in safer current circumstances. Professionals focus on providing safe havens for healing and rewiring of thought processes to assess the surrounding secure situation. Common treatments like this prove inconsequential, however, with CTS patients due to the absence of safe spaces in areas where the threat of arrest or violence is still conceivable. Means of providing aid are limited since day-to-day living and simply surviving require exercising extreme caution. Additionally, the primary task for clinicians dealing with PTSD is addressing aftereffects of victimization. With CTS, the task morphs into preparation for future traumatization and telling the difference between stimuli that pose a real, immediate threat and everyday stimuli. Managing anxiety and regulating one’s emotions of fear are strategies more fit for CTS patients. While slippage into paranoia can occur, most clients, such as those at the Johannesburg Trauma Clinic, self-report doubts in their ability to gauge how serious a threat is; this self-awareness to self-question differentiates people with CTS being that their anxiety is rooted in concerns over perceiving a threat as distorted from reality rather than their anxiety being linked with traumatic stress symptoms. Herein lies the importance of consciously taking into account the lack of protective systems and professionals’ own appraisal of the environment to appropriately advise patients on their optimal threat discrimination capacities.
Continuous traumatic stress proposes a refined approach to examining particular trauma-inducing contexts and their impacts, filling in the gaps of understanding that PTSD falls short of. Characterizing ongoing trauma that progressively worsens in unprotected environments, CTS hones in on present and future exposure, thus legitimizing survivors' continued battle with their current realities. Refugee populations, most notably, experience anticipatory anxiety over accurate appraisal of danger that persists before, during, and after migration. Severe existential risks to safety without secure systems in place yield individuals to imminent danger.
There is no “post-traumatic” safety because victims have not reached the “post-” era of their experience and real, prolonged safety is not a possibility. In place of serving as the alternate psychiatric diagnosis to PTSD, consider CTS as a construct that encompasses the nature of lived experiences in certain disaster- and violence-ridden sociopolitical contexts. The effects are more profound in that they change belief systems due to victims’ anxieties being associated with the world crumbling around them now or in the immediate future rather than irrational reactions to events that happened in their past. As Samah Jabr states, “We describe our psychological experience in terms that we hope to be understood in the West, so we talk a lot about PTSD.” What we fail to recognize is the fortune that comes with finally getting out of that situation into a relatively harmless environment where our fears seem absurd. Sadly, individuals and communities across the globe never left that dark place, instead lingering in the trauma hoping to reach that period of eventual retrospective reflection and treatment.
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