Psychological determinants when assessing violence

Experiencing adverse life events such as war, hunger or sexual abuse can determine future psychological disorders. Little information is given to professionals to assess and to build rapport with the patient in order to evaluate these situations of violence. In this post, we discuss the different psychological consequences of traumatic events as well as the lack of screenings that take place in health reports regarding violence, in comparison to other predicaments.

Since 2015, we have witnessed an increasing number of people escaping conflict zones such as Syria and Iraq. Several efforts have been made from different institutions and governments to give shelter and to face what it is said to be the worst refugee crisis since the Second World War (according to the UNHCR, the number of refugees migrating from Syria to neighbouring countries was  more than 4.000.000 people in 2015)

Mental health professionals agree that adverse life events, such as having survived violent episodes or war conflicts, have an important impact on the early and later onset of psychopathology (for a review on assessing violence exposure, you can click here). For example, regressive behaviours in children as well as a marked change in attitudes towards the future have been found (Pynoos & Eth, 1986; Pynoos & Nader, 1991). Authors such as Rousseau (1995) found that going through experiences of war, killing or torture, increased the risk of psychological distress and thus, the development of psychiatric disorders such as PTSD or depression (cited  here). It is well-known that PTSD can influence several developmental processes including cognitive functioning, personality and impulse control (Pynoos & Nader, 1991).

 Organisations such as Doctors of the World (MdM), continuously document the hardships migrants must face during their journey. For example, in 2015 they published an annual report on the access to healthcare for people facing multiple vulnerabilities in 26 cities across 11 countries.

However, although the questionnaires which formed the basis for this report contained a detailed section on violence experiences, responses to these questions are available for only a small proportion of the individuals interviewed (1,809 of the 23,241 individuals interviewed). As the MdM concluded in their report, this low number of responses might reflect how violence was insufficiently screened by their on-site teams. But it seems it is not solely the problem of MdM, but a recurring problem among health professionals: the literature reports scarce studies on the experiences of violoence and the mental health of asylum seekers. In particular, there are relatively few studies documenting the psychological perspective of refugee minors and unaccompanied children. Moreover, clinicians state there is a lack of evidence-based guidance in order for them to deal with this subject in their consultations (as in this practitioner review).

 The MdM 2015’s data was collected using three different questionnaires pertaining to social and medical matters. Questions referring to violence included yes/no questions such as if the patient had lived in a country at war or if he/she has been beaten or sexually assaulted during, before or after he/she decided to migrate.

Results show that, for example, among the adult screened population, 52.1% had lived in a country at war and 43.3% had been physically threatened, imprisoned or tortured.

No official data on violence suffered by children was available in this report.

On the other hand, in this year’s report, despite all the medical justifications for a systematic screening for violence, these issues are still seldom raised in MdM and partners’ programmes and so, violence remains insufficiently screened: only 24.0% of men and 27.9% of women were questioned about this issue during their first consultation or follow up.

Data regarding children’s experiences of violence is even scarcer (only 250 out of 1300 children were surveyed on this matter and not in every country where MdM has a centre and participated on the project): 6.1% of the surveyed children under 18 years old reported they had suffered psychological violence before, during or after arriving to the MdM centre; 24.7% had lived in a country at war and 38.8% have claimed they suffered from hunger. The UK centres reported that 16.7% of the interviewed minors had been physically beaten (at home). In Sweden, 25% of the surveyed children had been raped (N=16).

Given the serious and frequent nature of the violent experiences being reported, as well as the effects these may have on individuals’ health and well-being, the question then arises, why are we continuing to under-screen for violent situations, year after year? Are professionals not well trained to ask the proper questions or to establish a pertinent rapport with the patient? Are they faced with a moral or legal barrier? Or is it that patients find it too difficult to talk about their previous experiences?

We need to create new protocols for surveying violence or for creating the correct settings that can give answers to this problem. More research has to be conducted in order to provide clinicians with the tools to evaluate violence and its effects on mental health. This research has to be made not only from a patient’s point of view, but also from the interviewer’s.

After arriving to the host country, migrants not only have to handle psychological distress and to heal the emotional wounds of such a terrible experience but also several administrative limitations like asylum applications, dealing with small financial support, or frequent accommodation changes. For example, this study has found that that current procedures for dealing with asylum-seekers may contribute to high levels of stress and psychiatric symptoms in those who have been previously traumatised.

A correct assessment of violence is crucial not only for a correct estimation of the psychological and physical status of the patient, but also to provide baseline data and a starting point from which to develop new and more solid social and psychological programs that can, together, take into account their complex experiences.

Chauvin, P., Simmonot, N.,Vanbiervliet, F., Vicart, M., Vuillermoz C. (2015). Access to healthcare for people facing multiple vulnerabilities in health in 26 cities acrosss 11 countries. Report on the social and medical data gathered in 2014 in nine European countries, Turkey and Canada. Paris: Doctors of the World- Médecins du monde international network, May 2015.

Derluyn, I., & Broekaert, E. (2008). Unaccompanied refugee children and adolescents: the glaring contrast between a legal and a psychological perspective. Int J Law Psychiatry, 31(4), 319-330. doi:10.1016/j.ijlp.2008.06.006

Ehntholt, K. A., & Yule, W. (2006a). Practitioner review: assessment and treatment of refugee children and adolescents who have experienced war-related trauma. J Child Psychol Psychiatry, 47(12), 1197-1210. doi:10.1111/j.1469-7610.2006.01638.x

Silove, D., Sinnerbrink, I., Field, A., Manicavasagar, V., & Steel, Z. (1997). Anxiety, depression and PTSD in asylum-seekers: assocations with pre-migration trauma and post-migration stressors.Br J Psychiatry, 170, 351-357.

Stover, C. S., & Berkowitz, S. (2005). Assessing violence exposure and trauma symptoms in young children: a critical review of measures. J Trauma Stress, 18(6), 707-717. doi:10.1002/jts.20079