Mental Illness, Trauma

1
Mental Illness, Trauma Asylum Issues for Women
Prisoners

• Professor Ian Robbins
• European Institute of Health Medical Sciences,
  University of Surrey, and The Traumatic Stress
  Service, St Georges Hospital

2
Aim of This Presentation

• To explore mental health issues common to women
  prisoners
• Specifically to look at the problems of asylum
  seekers/refugees
• To focus on trauma and PTSD
• To examine treatment approaches

3
Why the Interest?

• A significant problem in terms of numbers,
  severity of difficulties, and lack of appropriate
  help
• Refugee issues are common with other trauma
  survivors, rape survivors, victims of sexual
  crime, domestic violence survivors
• Represents a major economic, human rights and
  gender issue

4
The Scale of the Problem

• 2003 49,405 asylum seekers (41 reduction on
  2002)
• 23 initially successful 20 on appeal
• 75 from countries with conflict
• Increasingly stringent criteria
• Speeded up process
• Multiple health problems

5
Phases of Refugees Experiences

• Increasing cycles of political repression
• Specific traumas - disappearances, arrests,
  detention, torture, rape, robbery, death, grief.
• The process of leaving
• Arrival in UK - dislocation, poor welcome,
  racism, bad news, detention
• Uncertainty about asylum status
  

6
Specific Refugee studies

• Repression. Bernstein-Carlson Rosser-Hogan
  (1993)
• Combat/Violence during exodus. Mollica et al
  (1992), Hauff Vaglum (1993).
• PTSD. In treatment seeking groups gt50.
• In non-clinical groups 9(Hauff Vaglum, 1993)
  to near 100 (Bernstein-Carlson Rosser- Hogan,
  1991). De Jong et al (2000)

7
Specific Prison Studies

• Victimization common 81 sexually victimized
  20 in childhood
• 64 mental health problems
• 83 substance abuse
• 8 severe mental illness substance abuse
• Ethnic minorities over-represented

8
Psychological Effects of Rape

• Depression (Resnick et al 1993)
• Suicidality - 30 contemplated (Resnick et al
  1993) - 33 attempted
• Generalised anxiety (Resnick et al 1993)
• Sexual dysfunction - (Becker et al 1984)
• Post traumatic stress disorder (Kessler et al
  1995)
• Substance use (Kilpatrick et al 1997)
• Obesity 11.2 vs 5.7 (Resnick et al 1993)

9
Response to Domestic Violence

• Battered Women Syndrome (Walker 1979, 1980, 1984)
  is a sub category of Post Traumatic Stress
  Disorder (APA 1994)
• Psychological/emotional and cognitive components
  behavioural deficits, including
• Learned Helplessness (Seligman 1975)
• Traumatic pathological attachment (Dutton
  Painter 1981)
• Decreased capacity to manipulate the environment
  constructively (Dalton Kantner 1983)

10

• DIAGNOSTIC CRITERIA
• FOR PTSD

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DSMIV Criterion A

• directly experienced, witnessed, or was
  confronted with an event that involved actual or
  threatened death or serious injury or a threat to
  the physical integrity of the self or others ....
• AND
• responded with intense fear, helplessness or
  horror

12
DSMIV PTSD Criterion B

• Re-experiencing the traumatic event by
• Recurrent and intrusive recollections
• Recurrent distressing dreams
• Acting or feeling as if the event was
  happening again
• Intense distress at reminders of event
• Physiological reactivity when reminded of the
  event

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DSMIV PTSD Criterion C

• Efforts to avoid thoughts and feelings or
  activities associated with the trauma
• Inability to recall aspects of the trauma
• Decreased interest in significant activities
• Feelings of detachment from others
• Restricted range of affect
• Sense of foreshortened future

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DSMIV PTSD Criterion D

• Persistent feelings of increased arousal include
• Insomnia
• anger outbursts
• poor concentration
• hyper vigilance
• exaggerated startle response
• physiologic reactivity when reminded of the event

15
DSMIV PTSD Criterion E

• Duration of at least one month

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PTSD - COMORBIDITY

• Depression (major)
• Panic Disorder
• Generalised Anxiety Disorder
• Axis II disorders
• Drug and alcohol abuse
• Physical symptoms
• (Kulka et al 1990, McFarlane and Papay 1992,
  McFarlane et al 1994)

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Disorders of Extreme Stress Not Otherwise
Specified (DESNOS)

• Alterations in regulating affective arousal
• Alterations in attention and consciousness
• Somatisation
• Chronic characterological changes
• Alterations in systems of meaning

18
Enduring Personality Change after Catastrophic
Experience

• Permanent hostility and distrust
• Social withdrawal
• Feelings of emptiness and hopelessness
• Increased dependency and problems with modulation
  of aggression
• Hypervigilance and irritability
• Feelings of alienation

19
COMMON THEMES IN UNCOMPLICATED PTSD

• Shame and anger over vulnerability
• Fear of repetition of trauma
• Rage at the source
• Rage at those exempted
• Fear of loss of control over anger
• Guilt or shame over surviving
• Activation of latent self-image

20
PREDICTORS OF PTSD

• Pre-trauma vulnerability
• - Includes genetic and biological risk
  factors, life events, rearing environment,
  mental health and personality
• Preparation for the event
• Magnitude of the stressor
• Immediate (peritraumatic) and short term
  responses - includes dissociation, coping
  behaviours
• Post trauma response

21
PTSD and Social Impairment

• Associated with impaired social and interpersonal
  functioning
• poor work record (Eitinger and Straus 1973)
• criminal records (Raeside et al 1995)
• drug use (Fullilove et al 1993)
• homelessness (North and Smith 1992)
• violence (Chemtob et al 1994)

22
Memory and PTSD

• Traumatic memories qualitatively different from
  ordinary memories
• Intense sensory experience but unable to describe
• Breakdown of integrative functions of the brain
• Lateralisation of brain function - right side
  limbic system overactive, Brocas area inactive
• Breakdown of sequential memory - flashbacks,
  inability to construct a coherent narrative and
  sequence

23
PTSD Prospective Controlled Studies
24
PTSD - Epidemiology

• Helzer et al (1987) - ECA
• Lifetime PTSD - 1.35 Females higher
• Breslau et al (1991) 1007 adults
• 39 exposed to a traumatic event
• PTSD in 23.6 of exposed
• Lifetime prevalence of 9.2
• Norris (1992) 1000 adults
• 69 traumatic stressor (21 past year)

25
PTSD - Epidemiologic Studies

• Kessler et al (1999) sample of 8,098
• Males 60.3 - Stressor A
• Females 50.3 - Stressor A
• Lifetime prevalence of PTSD 6.5
• Women highest rates

26
PTSD - Prevalence in High Risk Sample

• 50 concentration camp survivors
• 50 torture survivors
• 46 rape crisis
• 30 combat veterans
• 24 mixed trauma
• 14 fire-fighters
• 3 natural disaster

27
Crime Related PTSD
28

• THE IMPACT OF
• DETENTION

29
Keller et al (2003)

• 70 asylum seekers in US detained one month to 4.5
  years
• Psychological health of asylum seekers extremely
  poor
• Gets worse the longer the detention
• Depression 86, Anxiety 77, PTSD 50
• 58 poor mental health at migration 70
  experienced major deterioration since detention

30
Victorian Foundation for Victims of Torture 2001

• File Audit of 46 Cambodian Asylum seekers some
  detained gt2years
• Very high levels of pre-migration trauma
• 62 PTSD, all met criteria for depression
• 94 Clinical anxiety
• Conclusion length of detention a significant
  contributing factor to psychopathology

31
Thompson et al (1998)

• 25 Tamil asylum detainees compared to community
  based equivalent
• 72 torture survivors, 92 witnessed murder of
  friends or relatives, 88 threatened with death
• Detainees more depressed, suicidal, more PTSD and
  somatic symptoms.
• Differences not entirely accounted for by
  pre-migration trauma

32
Sultan (2001)

• 36 detainees in Australia (gt12 months detention)
• 33 major depression, 3 mild depression
• 22 taking antidepressants, 9 refusing
• 6 developed clear psychotic symptoms
• 5 strong aggressive impulses and self harm
• Most had little or no symptoms when first detained

33
Pourgourides et al (1995)

• Qualitative study of 15 asylum seeker detainees
• Most had high levels of premigration trauma
  including torture
• High levels of depressive and post traumatic
  symptoms
• Profound despair, high levels of suicidal
  ideation and deliberate self harm

34
Sultan OSullivan (2001)

• 33 detained gt9mths mean 2.1 yrs, 58 torture
  survivors
• Pattern of psychological reactions characterised
  by increasing distress and psychopathology
• Severe depression, despair, hopelessness,
  paranoia, chronic rage, persecutory delusions,
  sub clinical psychosis, stereotypy and persistent
  self harm
• All but one displayed symptoms at some point
• 85 depression 65 markedly suicidal

35

• TREATMENT
• APPROACHES

36
The Treatment Model

• Safety
• Remembrance and Mourning (Trauma Focused Work)
• Re-integration
• Herman (1990), Turner et al (2002)

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Establishing safety

• Building a therapeutic relationship
• Basic needs have to be addressed The
  immigration process, NASS, Housing, family
  contact, DSS.
• Addressing physical health needs
• Stabilisation medication, normalisation,
• Risk assessment
• Advocacy local and wider context

38
Remembrance Mourning

• Construction of a coherent narrative and
  addressing the cognitions and emotions associated
  with this.
• Memories transformed and integrated into
  autobiographical memory
• Speed of exposure a negotiated process
• Exposure, testimony with the therapist validating
  and witnessing
• Wider social network involvement

39
Reintegration

• Development of a sense of future
• Resumption of routine activities
• Rebuild new life work, study, relationships
• Re-establish beliefs and values
• Reduce isolation and shame
• Reclaim sense of dignity and worth
• Restore ability to give to others
• Give testimony

40
Positive predictors

• Previously well adjusted
• Good relationship with family pre trauma
• Continued family contact
• Educated, professional
• No long lasting physical injury
• Refugee status established

41
Negative predictors

• Poor pre-trauma adjustment and relationships
• Low level of language skills
• Poor level of education
• Previous incarceration/torture
• UK Detention
• Unresolved asylum status
• Serious physical health problems
• Serious Substance abuse
• Psychotic features

42
Service Issues

• Knowledge of trauma and its consequences
• How to make appropriate use of interpreters
• Ability to tolerate distress
• Need for advocacy/practical help
• Sense of helplessness/hopelessness vs anger
• Emotional labour

43
Conclusions

• Large population exposed to trauma
• Multiple mental and physical health problems
• Shame / stigma prevents service use
• For asylum seekers decreased time scale
  exacerbates problems
• Dispersal increases difficulties
• Detention increases problems
• Lack of specialist knowledge