Year : 2021 | Volume
: 19 | Issue : 2 | Page : 261--265
Suicide Prevention and Response Among Refugees: Personal Reflections on Self-Care for Frontline Mental Health and Psychosocial Support Workers
Senior Staff Counsellor, United Nations High Commissioner for Refugees (UNHCR), Geneva, Switzerland
PhD Gail Theisen-Womersley
United Nations High Commissioner for Refugees (UNHCR), 94 Rue du Montbrillant, Geneva, CH1202
No matter how experienced we are as professionals, we need to recognise the emotional and physical toll of the work we do as mental health and psychosocial support (MHPSS) frontline workers. The reflections in this article on the nature of trauma − and of shame − are offered to explore just why working with refugee populations may be such an intense experience for frontline MHPSS workers. Trauma is contagious. Shame and guilt are contagious. Feelings of despair, of anger, of guilt and of confusion are contagious. Suicidality among refugees may be considered a dialogue – often including MHPSS frontline workers. When exposed to such despair, even our physical bodies may carry some of the pain and suffering. When faced with suicidality in our work, an extreme manifestation of this, we cannot help but be affected. We are human.
|How to cite this article:|
Theisen-Womersley G. Suicide Prevention and Response Among Refugees: Personal Reflections on Self-Care for Frontline Mental Health and Psychosocial Support Workers.Intervention 2021;19:261-265
|How to cite this URL:|
Theisen-Womersley G. Suicide Prevention and Response Among Refugees: Personal Reflections on Self-Care for Frontline Mental Health and Psychosocial Support Workers. Intervention [serial online] 2021 [cited 2023 Jun 7 ];19:261-265
Available from: http://www.interventionjournal.org//text.asp?2021/19/2/261/325802
Suicidality is never an act in isolation. It inevitably involves other people, whether or not they are physically present. This includes our frontline MHPSS workers facing suicidal behaviour and other challenges among the populations they serve. What is the impact? In these personal reflections, I explore the interplay between trauma, shame and suicidality among refugee1 populations. More specifically, I explore how these toxic and arguably contagious emotions impact frontline MHPSS workers. Here, I refer not only to trained clinical psychologists, but also to all the staff members of many international and local organisations working with refugees: the protection officers, cultural mediators/translators, social workers, case workers, nurses, doctors and countless others facing suicidality on the frontline.
We sometimes hear frontline MHPSS workers and other actors say that refugees threaten suicide “for attention”: to be noticed, to be removed from unacceptable detention conditions, to get access to services or receive special treatment − the underlying assumption, often, is that it is a form of manipulation. It is not “real”. Suicidal behaviour among refugee populations might be related to an underlying psychiatric disorder. It might be due to a genuine despair: a feeling of no hope for the future. It might be a last resort: a way to change one’s current situation. It might be all of the above. It is possible to both want to manipulate a system to survive, and to be in a genuine state of psychological despair. Whatever the reason, suicidality among refugees has the potential to leave a deep mark on frontline MHPSS workers faced with this horrific reality.
Trauma, Shame and Suicidality among Refugees
As written about elsewhere (Womersley & Kloetzer, 2018), the experience of many refugees is characterised by a social and political marginalisation, as well as the fact of being torn from one’s communal and social fabric. As such, it could be conceptualised as a traumatic experience. Here, to understand what may or may not be defined as trauma, I draw upon psychoanalytic conceptualisations of the term: Trauma is defined as a frightful experience which overwhelms the psyche to such an extent that images, words or other memories related to the event are unable to be integrated into the system of representations which structure the experience of the individual. Within this paradigm, one commonality of trauma experience is the feeling of a chaos of seemingly unutterable experiences collapsing into that “wordless nothing” (Larrabee et al., 2003, p. 354). The act of suicidality in particular is understood to reflect this disintegration.
A large body of literature highlights the mediating effect of trauma and dissociation on suicidality (for a comprehensive review, see Ford & Gómez, 2015). The high prevalence of self-harm and suicidality among asylum seekers should therefore come as no surprise. As noted by Finklestein and Solomon (2009) and others, there has been an increasing awareness of the traumotogenic nature of the refugee experience. This includes a focus on “systemic trauma” (Goldsmith et al., 2014) related to the “experiences of systematic oppression, loss, displacement and exposure to violence” (Newman, 2013, p. 213). Trauma associated with the refugee experience may similarly invoke a severe disruption of the relational processes in which meaning is dialogically created − the bedrock of which is social recognition. Viewed through a dialogical system lens, the traumatic world’s slipping away from the categories of meaning can be seen as a severe disruption of those relational processes in which meaning is formed (Sucharov et al., 2007). Trauma begets trauma. Exposure to trauma, itself connected to a breakdown in social connection, risks the individual being caught up in a vicious cycle where no addressee may be found, no language exists to form a coherent narrative whereby the event may itself be collectively made sense of. For those whose landscapes have been disrupted by trauma, “their problem is not the limits of memory but of language—the inadequacy of ordinary words to express all they have witnessed” (Kirmayer, 1996, p. 4). When words fail, when “the temporality of linguistic convention, considered as ritual, exceeds the instances of its utterance, and that excess is not fully capturable or identifiable” (Butler, 1997, p. 1), it naturally falls upon the body to become the site of (reconstructive) action. Butler, for example, has marked the body as the stage on which traumatic disconnection unfolds:
Loss and vulnerability seem to follow from our being socially constituted bodies, attached to others, at risk of losing those attachments, exposed to others, at risk of violence by virtue of that exposure…the body implies mortality, vulnerability (Butler, 2003, p. 10).
When the image or content of a traumatic memory is unavailable, it is the bodily aspects of memory which persist. In the absence of language, the body holds what the mind cannot.
Furthermore, we cannot ignore the cultural context of these experiences. The importance of culturally contextualised understanding of trauma when working with refugee populations in particular has been explored, among others, by cultural psychiatrists (Greene et al., 2017; Hassan et al., 2015; Kirmayer, 2001; Rousseau et al., 2014; Silove et al., 2017). In cultural psychiatry, cultural idioms of distress refer to common modes of expressing distress within a culture or community that may be used for a wide variety of problems, conditions or concerns. Explanatory models refer to the ways that people explain and make sense of their symptoms or illness, in particular how they view causes, course and potential outcomes of their problem. This includes how their condition affects them and their social environment and what they believe is appropriate treatment. These cultural psychologists therefore argue that what they refer to as culturally shaped or collective representations of trauma may provide a frame for the construction of narrations which informs the processing of traumatic experiences and the way in which the individual may be able to convey their distress in socially understandable and acceptable ways. This includes, for example, theories about the origins of pain and the possibilities of healing, conceptions of family and social bounds, religious or metaphysical conceptions of the world, ideologies or positions in a field of political conflicts.
Not only does the literature attest to the high levels of trauma among refugee populations, research in the past decade has increasingly revealed the hidden yet pervasive role that shame may play in posttraumatic symptomatology. As defined by Wilson and colleagues, “in the posttraumatic self, shame develops from traumatic experiences that render the victim fearful, powerless, helpless, and unable to act congruently with moral values” (Wilson et al., 2006, p. 127). In the context of forced migration in particular, both trauma and shame are ubiquitous, pervasive and contagious.
Like trauma, shame similarly shapes the refugee experience, linked particularly to extreme feelings of powerlessness, degradation and humiliation. It may emerge as a result of the many forms of torture, sexual violence and other atrocities experienced in the country of origin, yet is equally exacerbated by degrading and humiliating asylum procedures, having to accept a new and often devalued social identity of being an asylum seeker, and the embarrassment of not meeting culturally informed expectations to financially support the family. Shame pervades the experience of no longer being “at home” at home, of being cast out of one’s country, of having to metaphorically knock on the door of a potential host country and beg to be accepted, only to be met by significant social discrimination, scrutiny and disbelief at one’s claim to asylum.
Trauma does not stop at the border. The process of migration may therefore be in and of itself a shameful experience for many refugees, wherein individual and social identities risk being negated through the systemic trauma associated with legal and social practices of exclusion (Goldsmith et al., 2014). The bureaucratic systems and procedures with which migrants are faced upon arrival in a host country may echo feelings of powerlessness and helplessness experienced throughout the migration journey. Indeed, the very status of “victim”, of “asylum seeker” may be innately shameful to some. The outright expulsion of many migrants, the deterioration of living conditions, the uncertainty regarding legal status, the deprivation of rights and the implementation of mechanisms designed to prevent the construction of social links have arguably led to a shameful “construction of invisibility” (Sanchez-Mazas et al., 2011). Administrative provisions may often make the very presence of refugees as subjects within a state no longer accepted and “this translates all too quickly in the fact that the person as such is no longer accepted” (Torre, 2016, p. 2). The physical, social and political isolations so typically experienced upon arrival to host countries serve only to feed monstrous feelings of invisibility and disconnectedness (Bhimji, 2015). In this space, social bonds and connections are disrupted which themselves are, paradoxically, necessary for finding the language to make sense of traumatic experiences in the form of a coherent narrative.
Language, Trauma and Suicidality: The Need for a Listening Other
Torn from the communal fabric of being-in-time, trauma remains insulated from human dialogue (Stolorow, 2011, p. 56).
The interplay between language, trauma and the sociocultural context is a complex and mutually reinforcing one: Traumatic events may overwhelm and even rupture the semiotic systems in language which connects the individual to the communicative and social resources necessary to its very regulation and healing, thus perpetuating a vicious cycle of isolation and disconnection. Cast outside the containment of human plurality as a result of a myriad of political and social mechanisms of exclusions, I hypothesise that suicidality among refugees serves as both an escape and a protest, both a “relational striving” for “being in the world” − profoundly embedded in an intersubjectively constitutive context, and a “being-toward-death” (Stolorow, 2011). Is the act of suicide both a significant indicator of deep psychological distress and despair, as well as an attempt to restore a connection to the world of the living? I argue that the utterance is at once disruptive and engaging, destructive and constructive, a conflict and a collaboration, a death instinct towards destruction but a “destruction as the cause of coming into being” (Spielrein, 1994). This echoes the conclusion of Ford and Gómez (2015) who suggest that acts of self-harm
that occur in a dissociative state or in the context of ongoing problems with posttraumatic dissociation may be an interpersonal communication, intentional or unintended, of either seeking or feeling unable to find or experience social support when emotionally dysregulated…[they] for instance, may be a frantic cry for help or an attempt to get others to recognise and share pain and distress… an attempt to withdraw into isolation or to reinstate a sense of secure attachment by expressing solidarity with others who are traumatised or marginalised (p. 252).
Paradoxically, suicidality may reflect an attempt to heal from trauma, a co-constructed inquiry to begin to try and put symbolic expression to experience (Rosenbaum, 2016). A “social interaction in its own right” (Rasool & Payton, 2014, p. 240), it represents an intersubjective and possibly even resilient attempt to restore interaction. As such, it is a way of metaphorically construing and narrating experience; a compelling narrative enjoining others to take action (Kirmayer & Ramstead, 2016). This is a dialogical utterance: a living, social interaction which demands a response from the addressee, the Other. It demands social recognition.
For vulnerable populations such as refugees, acts of self-harm have therefore been theorised as a resilient attempt to overcome invisibility (Bhimji, 2015; Butler & Athanasiou, 2013; Dudley, 2003; Hedrick, 2017). When there are no words, when oppressed and dispossessed minorities find themselves on the outskirts of public visibility, one recourse is to use the body as a communicative tool. One extreme example of this is suicidality, used as a tool by various oppressed groups around the world, notably including asylum seekers and refugees (Jeffers, 2009; Laloë, 2004; Shakya, 2012; Tsoneva, 2013).
Disruptions created by trauma are embedded within an intersubjective context wherein severe emotional pain cannot find a relational home in which to be held and integrated (Atwood et al., 2002; Stolorow, 2011). Trauma disrupts the intersection of the individual and their social context and related to safety, trust, independence, power, esteem, intimacy as well as spiritual and existential beliefs. These disruptions have been theorised as representing a threat not only to one’s core sense of self, but also a violation of self-understanding and worldviews to the extent that it disrupts attachment and interpersonal dialogue necessary for meaning making in the social world (Goldsmith et al., 2014; Liddell & Jobson, 2016; Maercker & Hecker, 2016). Particularly in cases where trauma has been prolonged, “the survivor may be left with large chunks of endured experience with no meaning, creating disquieting gaps and discontinuities in the experience of one’s life history” (Sucharov et al., 2007, p. 2).
For the transformation of traumatic memories into semiotic forms which connects it through language to its rightful place in time, the elaboration needs to be socially situated and “intersubjectively acknowledged” (Zittoun, 2014, p. 485). This is because social resources provide a time orientation, and consequently, a self-continuity between past and future (Kadianaki & Zittoun, 2014) necessary for the construction of a coherent narrative, and ultimately, the reconstruction of the Self. From a dialogical perspective, the psychological processing of trauma cannot merely be internally homogenous but involve multiple voices, texts, interests and traditions embodied in each individual’s own varied histories and in the artefacts and norms of the system − a source of trouble and of innovation (Bakhtin, 1981). This can only take place in the context of “interlocution” or “addressivity” − a dialogue between the person’s inner world and the sociocultural context in which traumatic events are processed (Goldsmith et al., 2014; Lemma & Levy, 2004). The critical issue here is that of the notion of reciprocity (Van Der Kolk, 2015) inherent to social recognition (Marková, 2016). Thus, it is within this dialectal sphere between the internal and external, Self and Other, the personal and political where coherent narratives of the event may be formed as part of the process of healing.
Personal Reflections on the Impact of Suicidality for Frontline Workers/MHPSS Actors: Self-Care and Duty of Care for Staff
No matter how experienced we are as professionals, we need to recognise the emotional and physical toll of the work we do as MHPSS frontline workers. The above reflections on the nature of trauma − and of shame − are offered to explore just why working with refugee populations may be such an intense experience for frontline MHPSS workers. Trauma is contagious. Shame and guilt are contagious. Feelings of despair, of anger, of guilt and of confusion are contagious. Suicidality among refugees may be considered a dialogue – often including MHPSS frontline workers. When exposed to such despair, even our physical bodies may carry some of the pain and suffering. When faced with suicidality in our work, an extreme manifestation of this, we cannot help but be affected. We are human.
Trauma and shame among refugee populations often remain unnoticed. Their powerful yet seemingly invisible impact may be hidden behind a myriad of emotional cloaks − anger, dissociation, blame, resentment - even more so in the context of suicidality. Many humanitarians continue to labour under the misapprehension that “we are the saviours, we are strong, our work is to help others, and that any help we need to require ourselves may be seen as a sign of weaknesses”. Too often, this similarly may evoke feelings of shame for not being “up to the job”. Conversely, it may also lead to forms of emotional “hardening” so to speak, a coping mechanism characterised by denial of our own feelings and consequently a “numbness” or lack of empathy to the feelings of others. Ethically, clinically, professionally and humanly, we cannot ignore the powerful impact of these experiences on ourselves as frontline workers and as human beings. Neither can organisations afford to ignore this.
Some MHPSS frontline workers themselves report feeling significant shame (“how dare I return to my comfortable home and binge watch Netflix, knowing their suffering?”) anger (“how could my own country, my own city, my own community, be treating refugee populations in such an unacceptable manner?”) or despair (“there is no solution, no future, no way out - we are trapped”). Others experience vicarious or secondary trauma. This often corresponds to symptoms of re-intrusion (for example, constantly thinking about traumatic events/stories of suffering even outside work), avoidance (feeling numb or detached: “I don’t care anymore, I’ve lost my empathy, I can’t bear to hear another difficult story”) or hyperarousal (constantly being in a state of alert and not being able to calm down or “switch off”). Fragmented states of mind are common. Some even experience the same disconnection from reality as is found among the refugee population with whom they work. These reactions are understandable.
As frontline MHPSS workers, we need to ensure that we take care of ourselves before taking care of others. Let us never forget the basic principles of ABC:Accept that this work inevitably impacts our mental, emotional and physical wellbeing.Balance the work with other enriching aspects of life.Connect to friends, family, communities and activities which bring joy.
Let us not forget that we are a resource who needs to be taken care of: We need an active commitment to our own mental wellbeing, not only to be kind to ourselves, but also for our colleagues and the beneficiaries of our services. Furthermore, care for our wellbeing as frontline MHPSS workers facing suicidality should not only be an individual responsibility. Organisations have a duty of care to protect their teams from such noxious effects as trauma and shame: This may extend to trainings (formal and informal), group supervision sessions and adequate time off. Let us not forget to care of our carers. This begins with organisational culture, where from the senior management level down, an environment is created whereby there is an active engagement with these processes. Organisations need to be prepared to engage both reactively, intervening following critical incidents for example, as well as proactively, through prevention work.
We need to consider shame and trauma in the context of suicidality among refugees − not only because it may influence our professional work in profound yet often barely perceptible ways, but also it is our ethical duty as human beings to reflect on these intersubjective encounters.
Financial support and sponsorship
Conflicts on interest
There are no conflicts of interest.
1Here, I use the term “refugee” broadly to refer to refugees, asylum seekers, internally displaced populations and other persons of concern to UNHCR.
|1||Atwood G. E., Orange D. M., Stolorow R. D. (2002). Shattered worlds/psychotic states: A post-Cartesian view of the experience of personal annihilation. Psychoanalytic Psychology, 19(2), 281.|
|2||Bakhtin M. (1981). The dialogic imagination (trans. by Caryl Emerson and Michael Holquist). University of Texas Press.|
|3||Bhimji F. (2015). Collaborations and performative agency in refugee theater in Germany. Journal of Immigrant & Refugee Studies, 14(1), 1-23.|
|4||Butler J. (1997). Excitable speech: A politics of the performative. Routledge.|
|5||Butler J. (2003). Violence, mourning, politics. Studies in Gender and Sexuality, 4(1), 9-37.|
|6||Butler J., Athanasiou A. (2013). Dispossession: The performative in the political. John Wiley & Sons.|
|7||Dudley M. (2003). Contradictory Australian national policies on self-harm and suicide: The case of asylum seekers in mandatory detention. Australasian Psychiatry, 11(Suppl 1), S102-S108.|
|8||Finklestein M., Solomon Z. (2009). Cumulative trauma, PTSD and dissociation among Ethiopian refugees in Israel. Journal of Trauma & Dissociation, 10(1), 38-56.|
|9||Ford J. D., Gómez J. M. (2015). The relationship of psychological trauma and dissociative and posttraumatic stress disorders to nonsuicidal self-injury and suicidality: A review. Journal of Trauma & Dissociation, 16(3), 232-271.|
|10||Goldsmith R. E., Martin C. G., Smith C. P. (2014). Systemic trauma. Journal of Trauma & Dissociation, 152, 117-132.|
|11||Greene M. C., Jordans M. J., Kohrt B. A., Ventevogel P., Kirmayer L. J., Hassan G., Tol W. A. (2017). Addressing culture and context in humanitarian response: preparing desk reviews to inform mental health and psychosocial support. Conflict and Health, 11(1), 21.|
|12||Hassan G., Kirmayer L. J., Mekki-Berrada A., Quosh C., El Chammay R., Deville-Stoetzel J., Coutts A. (2015). Culture, context and the mental health and psychosocial wellbeing of Syrians: A review for mental health and psychosocial support staff working with Syrians affected by armed conflict (pp. 14-15). UNHCR.|
|13||Hedrick K. (2017). Getting out of (self-) harm’s way: A study of factors associated with self-harm among asylum seekers in Australian immigration detention. Journal of Forensic and Legal Medicine, 49, 89-93.|
|14||Jeffers A. (2009). Looking for Esrafil: Witnessing ‘Refugitive’Bodies in I’ve got something to show you Get Real (pp. 91-106). Springer.|
|15||Kadianaki I., Zittoun T. (2014). Catalysts and regulators of psychological change in the context of immigration ruptures. In Cabell K. R., Valsiner J. (Eds.), The Catalyzing Mind (pp. 191-207). Springer.|
|16||Kirmayer L. J. (1996). Landscapes of memory: Trauma, narrative, and dissociation. In Antze P., Lambek M. (Eds.), Tense past: Cultural essays in trauma and memory (pp. 173-198). Routledge.|
|17||Kirmayer L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 62, 22-30.|
|18||Kirmayer L., Ramstead M. J. (2016). Embodiment and enactment in cultural psychiatry. In Durt C., Fuchs T., Tewes C. (Eds.), Embodiment, enaction, and culture: Investigating the constitution of the shared world 397-422. MIT Press.|
|19||Laloë V. (2004). Patterns of deliberate self-burning in various parts of the world: A review. Burns, 30(3), 207-215.|
|20||Larrabee M. J., Weine S., Woolcott P. (2003). “The wordless nothing”: Narratives of trauma and extremity. Human Studies, 26(3), 353-382.|
|21||Lemma A., Levy S. (2004). The impact of trauma on the psyche: Internal and external processes. Whurr Publishers.|
|22||Liddell B. J., Jobson L. (2016). The impact of cultural differences in self-representation on the neural substrates of posttraumatic stress disorder. European Journal of Psychotraumatology, 7, 30464.|
|23||Maercker A., Hecker T. (2016). Broadening perspectives on trauma and recovery: A socio-interpersonal view of PTSD. European Journal of Psychotraumatology, 7, 29303.|
|24||Marková I. (2016). The dialogical mind: Common sense and ethics. Cambridge University Press.|
|25||Newman L. (2013). Seeking asylum—trauma, mental health, and human rights: An Australian perspective. Journal of Trauma & Dissociation, 14(2), 213-223.|
|26||Rasool I. A., Payton J. L. (2014). Tongues of fire: women’s suicide and self‐injury by burns in the Kurdistan Region of Iraq. The Sociological Review, 62(2), 237-254.|
|27||Rosenbaum P. J. (2016). How self-harmers use the body as an interpretive canvass. Culture & Psychology, 22(1), 128-138.|
|28||Rousseau C., Guzder J., Santhanam-Martin R., de la Aldea E. (2014). Trauma, culture, and clinical work: The “House of Stories” as a pedagogical approach to transcultural training. Traumatology: An International Journal, 20 (3), 191-198. doi: http://dx.doi.org/10.1037/h0099850|
|29||Sanchez-Mazas M., Efionayi-Mäder D., Maggi J., Achermann C., Schaer M., Escoda R. I., Coumou-Stants F. (2011). La Construction de l’Invisibilité: Suppression de l’Aide Sociale dans le Domaine de l’Asile. Geneva: IES. Shakya, T. (2012). Self-immolation: The changing language of protest in Tibet. Revue d’Etudes Tibétaines, 25, 19-39.|
|30||Silove D., Ventevogel P., Rees S. (2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry, 16(2), 130-139.|
|31||Spielrein S. (1994). Destruction as the cause of coming into being. Journal of Analytical Psychology, 39(2), 155-186.|
|32||Stolorow R. D. (2011). World, affectivity, trauma. Routledge.|
|33||Sucharov M. S., Buirski P., Kottler A. (2007). Kafka’s window and Kohut’s mirror: A dialogic journey to the center of traumatic worlds. In Buirski P., Kottler A. (Eds.), New developments in self psychology practice (pp. 193-206). Jason Aranson.|
|34||Torre L. D. (2016). The Sans-Papiers. In Torre L. D. (Ed.), National Centre of Competence in Research − The migration-mobility nexus (Vol. 2016). http://blog.nccr-onthemove.ch/the-sans-papiers/?lang=fr: NCCR On the Move.|
|35||Tsoneva J. (2013). Bulgarians in flames: on the current wave of self-immolation. Left East.|
|36||Van Der Kolk B. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin.|
|37||Wilson J. P., Droždek B., Turkovic S. (2006). Posttraumatic shame and guilt. Trauma, Violence, & Abuse, 7(2), 122-141.|
|38||Womersley G., Kloetzer L. (2018). Being through Doing: The self-immolation of an asylum seeker in Switzerland. Frontiers in Psychiatry, 9, 110.|
|39||Zittoun T. (2014). Three dimensions of dialogical movement. New Ideas in Psychology, 32, 99-106.|