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Comparing refugees and non-refugees: The Bosnian experience
* Corresponding author
Nottingham Trent University
Many Bosnian refugees have found life in the UK more traumatic than the situations they left behind in their war-torn homeland, according to a new study at The Nottingham Trent University.
Psychologist Dr Nigel Hunt has compared the experience of refugees who came to Britain with those who stayed in their own country after the Bosnian war. Both groups suffered the same wartime experiences, but Dr Hunt found that the group that went on to develop the biggest post-traumatic stress problems were the ones who came to the UK.
The research found that Bosnian war survivors who moved to the UK were at a greater risk of developing PTSD (Post Traumatic Stress Disorder). This was because refugees had to deal with an alien culture, a new language and possible hostility from the indigenous population. There were many post-migration problems for refugees. Many were unemployed for prolonged periods, often because of the language barrier.
Dr Hunt surveyed 190 participants, of whom 69 were Bosnian refugees currently living in the UK and 121 were Bosnian non-refugees that have remained in their country throughout the war until now. The refugees were asked questions about socio-economic factors and their wartime experiences.
The majority of refugees considered their standard of living to be lower than it was before the war and they scored significantly higher on the scale used to measure stress than internally displaced people. Only a quarter thought their lives had improved.
Dr Hunt said: "They came here to escape the war, but they are the ones who have experienced the most trauma. It is about problems associated with living in a different culture. Those who stayed in Bosnia felt they had a better standard of living.
"This finding indicates that ideally, though this is not always possible, people should be helped to remain in their own country. If they do become refugees then it is important for the host country to provide appropriate assistance, not just in terms of treatment of psychological disorder, but also in providing an appropriate welcome, help with learning the language and help with adapting to the new culture."
Objectives: The study investigated the effects of refugee experience and personality on the development of posttraumatic stress as a consequence of the Bosnian war.
Design/Methods: A questionnaire was administered to 190 participants, of which 69 were Bosnian refugees, currently living in the UK and 121 were Bosnian non-refugees that have remained in their country throughout the war until present. The questionnaire consisted of questions regarding socio-demographic factors and participants wartime traumatic experiences, the Impact of Event Scale-Revised (IES-R; Weiss and Marmar, 1997), and the Tridimensional Personality Questionnaire (TPQ; Cloninger, 1996).
Results: The majority of refugees considered their standard of living to be lower than it was before the war, and they scored significantly higher on the IES-R then internally displaced people. Participants who score higher on the IES-R also displayed more Harm Avoidant personality traits such as pessimistic worry, shyness, fear of uncertainty and fatigability. Traumatic experiences such as threats to the self or family, violence or sexual abuse, witnessing death, personal injury, or witnessing destruction were associated with a higher score on the IES-R.
Conclusions: The findings and implications are further discussed in relation to civilian victims of war.
The forty wars of the past decade, all minor, have resulted in a total of more than two million deaths and twenty million refugees or displaced persons (Firket, 2001). The 1992-95 war in Bosnia resulted in up to 250 000 deaths, 90% of which were civilian, (Goldstein, Wampler, & Wise, 1997). The conflict resulted in crimes against civilians which were by far the worst savagery seen in Europe since the World War II, (Spasojevic, Heffer & Snyder, 2000). It was a bad war from a psychiatric point of view, due to its ethnic / religious background, the direct threat to civilians, as well as the fact that majority of fighters were not even professionals (OBrien, 1994). For approximately four years, thousands of civilians were exposed to mass murder and destruction. The problems did not end with the formal peace treaty signed in December 1995, as the majority of the housing stock, and the industrial infrastructure of the country was destroyed. Several years later, people are still picking up the pieces of their lives. Bosnians are refugees across the world, and many remain displaced in their own country. The country is still divided politically along ethnic lines. Numerous reports of victims of direct violence, personal injury and inhumane treatment are still appearing. During the war concentration camps and prisons were used for organised crime against the civil population, including rape and torture. The personal losses of many civilians, especially those in the worst affected areas were tremendous. It is therefore not surprising that such experiences over a prolonged period of time could produce traumatic reactions, in otherwise normally functioning human beings.
Horowitz (1986) developed an information-processing model in attempt to explain how people respond to traumatic events. His theory, based on the altering phases of intrusion and avoidance, is widely accepted, and is in accordance with more recent cognitive processing theories of posttraumatic reactions (eg Joseph, 2000). Information is stored in pre-existing schemata. When we are confronted with a traumatic experience the new information is inconsistent with our existing schemas. Consequently, psychological difficulties arise until this new information is assimilated into our schemata (Creamer, Pattison, & Burgess, 1992). Until then the information is stored in our active (implicit) memory, over which we have no voluntary control, and it will continue to produce intrusive upsetting recollections. Avoidance is then used as a defence mechanism against these intrusive thoughts (McFarlane, 1992). Recovery can only occur when the traumatic recollections, stored in the implicit memory are integrated into the explicit, conscious, voluntary memory (Creamer et al, 1992).
Posttraumatic stress disorder (PTSD) was introduced into DSM over 20 years ago (APA, 1980), later updated in both DSM-III-R (APA, 1987), and DSM-IV (APA, 1994). PTSD occurs in many people as a consequence of traumatic life events such as war. Traumatic experiences result in a stress response that constitutes increased hyperarousal, intrusive re-experiencing, and avoidance.
The study of traumatic stress has largely been directed towards the effects of war. Most research examines soldiers and the impact war has on their lives, (OBrien, 1994). Less work has been done on the effects of war on the civilians, even though in recent wars they usually make up the highest proportion of victims in a war zone.
Interest has also focused around the multiplicity of factors that predict the extent and the expression of posttraumatic symptoms. PTSD does not occur in most people exposed to traumatic events (McFarlane, 1997). The psychological and psychiatric literature proposes numerous personal and environmental factors which impact on psychological distress, both pre and post event, which can put individuals at a higher risk of developing PTSD.
Refugee experience can contribute to the onset of PTSD (eg OBrien, 1994). The migration and post-migration experience as a consequence of war is traumatising in itself, resulting in a devastating impact on the individuals psychological health (van der Veer, 1998). The Bosnian war resulted in 1.3 million internally displaced people and 800,000 refugees to other nations, (Goldstein et al, 1997). Large parts of the country were exposed to ethnic cleansing. Researchers who have compared refugees, displaced and non-displaced Bosnians have found that refugees experience can be significantly worse (Adjucovic & Adjucovic, 1998; Kocejan-Herzigonja, Rijavic, Marusic & Hercigonja, 1998). Refugees were forced, (through fear or ethnic cleansing), to leave behind their homes, their jobs, their communities, their friends and in some cases family members. Fear, uncertainty and anxiety about where to go next also accompanied this sudden and unpredictable change of life.
Most studies indicate that refugees have significant rates of PTSD, anxiety and affective disorders (OBrien, 1994). Martic-Bocina, Spoljar-Vrzina & Rudan (1996) conducted a three-year long study to asses the anthropological and psychodynamic characteristics of Bosnian refugees in Croatia. Their finding indicated that trauma was strongly present in their sample during the whole period. Herceg, Melamed, & Pregrad (1996) found that Bosnian refugee children reported significantly more war-related psychological symptoms than non-refugees. Children displaced for a period of 6 months in Croatia have a substantial increase in PTSD symptoms (Adjukovic & Adjukovic, 1998).
The experiences of the asylum seekers in the West are in many ways different from those refugees or locally displaced, who remain in a more or less familiar culture (Richman, 1998, p170). Bosnian war survivors who found refuge in the neighbouring country of Croatia have not had to face a sudden exposure to a new culture. The two countries were until 1991 part of the same nation, yet psychologists have shown how being a refugee in even such familiar culture leaves individuals at a higher risk of developing psychological disturbances such as PTSD (Martic-Bocina et al, 1996; Herceg et al, 1996). Moving to a completely alien environment is likely to result in more severe distress due to the change of culture and language.
Thulesus & Hakanssan (1999) screened for possible PTSD amongst Bosnian refugees who arrived to Sweden in 1993, and found a prevalence of 18-30%. After originally finding a prevalence of 65% of Bosnian refugees with PTSD just after resettlement in the United States, Weine, Vojvoda, Becker, McGlashan, Hodzic, Laub, Hyman, Sawyer & Lazrove (1998) found that even though the severity of symptoms decreased, there was still a high rate of PTSD symptoms, even one year after the resettlement and several years after the initial traumatic experiences.
There are numerous post-migration difficulties that can serve as a continuous source of stress for many refugees when attempting resettlement. For instance, many people are unemployed for prolonged periods, often simply because of the language barrier. Mollica (1987) assessed the rates of depression and PTSD in Southeast Asian refugees and found that 92% were faced with language barriers, 62% had major difficulties in employment, and 54% had problems with housing. Another common problem that many refugees have to face is the fear and uncertainty about their future, as well as their legal right to remain in their country of exile. Steel, Silove, Bird, McGorry & Mohan (1999) formulated a model which attempted to account for numerous factors that can contribute to a display of posttraumatic stress symptoms of refugees. Their research indicated that post-migration components, including adaptational difficulties, loss of culture and support, and health, welfare and asylum difficulties together accounted for 14% of the variance in PTSD symptoms, contributing to over one third of the predictive power of their model. A prolonged asylum process with little or no assurance of success, the uncertainty of their situation and fear of deportation, cause enormous anxiety and obstruct the process of looking forward (Richman, 1996, p172).
Personality is another factor which is associated with PTSD. It has previously been suggested that personality may act as a pre-existing vulnerability to development of PTSD (Williams, 1999). The vulnerability hypothesis is extremely difficult to test, as a prospective study would be ideal. In order to avoid the impact of the traumatic event on personality, this would involve identifying individuals and assessing their personality prior to a traumatic event. Research also shows that personality can influence the course and development of PTSD (Williams, 1999). Holeva & Tarrier (2001) found that neuroticism (as measured by the Eysenck scale) was significantly related to PTSD symptomatology.
Eysencks biological model is relatively crude, but Cloninger has put forward a psychobiological model of personality which has developed considerable empirical support. He defines personality as a dynamic organisation of psychobiological systems that modulate adaptation to experience (Cloninger, 1996), and subdivides it into temperament and character. Temperament is defined as the automatic (unconscious), dissociative responses to basic emotional stimuli, which determine habits and skill. Cloninger (1996) developed the Tridimensional Personality questionnaire (TPQ), which sets out to measure harm avoidance, reward dependence and novelty seeking, which are components of temperament. Cloninger suggests that temperament is involved with automatic, preconceptual, associative responses, which presumably reflect heritable biases in information processing by the perceptual (implicit) memory systems (Cloninger, 1996).
He claims that about 50% of variance in temperament is heritable, that its developed early on in the childhood and that once developed, it remains the same even through adulthood (Cloninger, 1996). A large-scale twin study confirmed that the four dimensions of temperament had between 50% and 65% heritability and were genetically homogenous and independent of others (Cloninger, Svrakic, & Pryzbeck, 1993). Theoretically this would suggest that temperament is unlikely to change, even under conditions of extreme stress, and this is an important consideration when assessing the relationship between PTSD and personality.
Harm avoidance (HA), one of the temperament dimensions, refers to pessimistic worry, shyness and fearfulness. It is a heritable bias in excessive behavioural inhibition, which can predispose individuals to anxiety, depression and low self-esteem, (Cloninger, 1996). A high score in HA correlates highly with DSM-III-R cluster C anxiety disorders (Battaglia, Przybeck, Bellodi & Cloninger, 1996). When PTSD emerged as a separate diagnostic entity in 1980, it was placed amongst the anxiety disorders, presumably because emotional and physical distress and anxiety are affective reactions associated with traumatisation (Wilson, 1994). Hence it can be predicted that individuals who manifest the symptoms of PTSD will score highly on HA.
The trauma experience itself can be influential in determining the course and development of PTSD. In a study conducted with Central American refugees, Michulka, Blanchard & Kalous (1998) clearly demonstrated how war experiences themselves are the best predictors of their victims prognosis. Their results showed that the number of war experiences, as well as their severity, was the only significant predictor of all PTSD symptom clusters. A surprising outcome of their results was that the length of the time spent in a war situation was not indicative of PTSD, (Michulka et al, 1998). Research also indicates that the number of stressors experienced during war was a significantly predictive factor of posttraumatic symptoms (Dahl, Mutapcic & Schei, 1998)
Not everyone exposed to a traumatic event will consequently develop PTSD (McFarlane, 1997). This study focuses on comparing the experiences of refugees and people who are internally displaced. There are three specific predictions. First, it is predicted that refugees will experience more psychological symptomatology. Second, personality factors will be examined (using Cloningers model). Individuals who score higher on the harm avoidance sub-scale are predicted to experience more symptoms. Finally, the role of specific types of traumatic experience will be examined in terms of severity of post-event symptomatology.
The questionnaire consisted of three separate parts. The first consisted of nine possible types of traumas experienced during the war, as adapted from Thulesus and Hakanssan (1999), it also included further questions about participants age, gender and duration of war experience. The second part was the Weiss and Marmer (1997) Impact of Event Scale Revised, (IES-R). This 22-item scale consists of six items which measure hyperarousal, eight items which measure Avoidance and eight items which measure Intrusion (see appendix 4 for marking criteria). It is scored using a five-point Likert scale. The third part was Cloningers (1996) Tridimensional Personality Questionnaire (TPQ), which is a 100-item measure scored using true/false answers. The scale is used to measure Harm Avoidance traits (anticipatory worry, fear of uncertainty, shyness with strangers and fatigability), Novelty Seeking traits (exploratory excitability, impulsiveness, extravagance and disorderliness) and Reward Dependence traits (sentimentality, persistence, attachment and dependence).
Two versions of the questionnaire were completed, the only difference being in part 1. For refugees this consisted of further questions about their length of refuge, their pre-war and post-war occupations, their rating for a comparison on the pre-war and post-war standard of living and any received treatment in relation to their war experiences. This information was absent from the non-refugee version. Both an English and a Serbo-Croat version of the questionnaire was produced, translated by the second author, and checked by two professional Bosnian psychiatrists fluent in English.
The questionnaires contained instructions for completion. The questionnaires were presented with a letter on the front cover, which contained information about the nature of the study, providing contact numbers for debriefing, available upon request. The letter also informed the participant about their anonymity and their right to withdraw from the study at any point.
The total number of questionnaires handed out was 230, but 40 were not fully completed, so 190 are included in the analysis (82.6%). Of these 190 participants 69 were Bosnian refugees, currently living in the UK, the other 121 were Bosnian non-refugees, war survivors who remained in Bosnia from the start of the war until the present. The non-refugees were currently living in Sarajevo (Central Bosnia), Banja Luka (North-West Bosnia) or Tuzla (North-East Bosnia). Of the 190 participants 76 were male (40%) and 114 were female (60%). The age range of the participants was between 18 and 82, with the mean age of 38.6. The mean age of refugees was slightly higher (43.2) than the mean age for non-refugees (36). All of the participants reported to have experienced at least one type of traumatic event (out of nine possible types). The most commonly reported traumatic experiences were: hiding in fear, (74.2%), witnessing destruction, (68.4%), threats to the self and the family, (47.4%) and witnessing death, (44.7%). Of the Bosnian refugees who currently lived in the UK, 22 were unemployed, 7 were retired, 7 were students, 7 were in professional work and the rest in other type of employment.
Bosnian refugees currently living in the UK were contacted by post or telephone, and asked to take part in the study. Both the English and Serbo-Croat version of the questionnaire were distributed, depending on personal preference. The Serbo-Croat version of the questionnaire was distributed to the Bosnian war survivors (non-refugees) who have remained in Bosnia throughout the war. All participants were asked to read the front cover letter and instructions for completion, before taking their time to complete the questionnaires.
A small majority of refugees living in the UK (51%) considered their standard of living to be worse than before the war, compared with 25% who thought it had improved. Using the clinically-derived cutoff of 45, 108 participants (58%) scored above the cutoff point, indicating levels of symptoms normally associated with PTSD.
Age was positively correlated with score on the IES-R (r = +.376, n = 189, p<.01), with refugees tended to be slightly older (mean = 43.2 years) than non-refugees (mean = 36.0), so age was used as a covariate in the following analyses. Furthermore, differences between levels of traumatic experience were also accounted for.
Comparing refugees and non-refugees
A clinically derived score of 45 or above on the IES-R is indicative of possible PTSD. In total, 77% of refugees scored 45 or above on the IES-R, in comparison to 45% of non-refugees (Ç2 = 17.61, df = 1, p<.001). Table 1 compares the IES-R scores of the two groups, refugees and non-refugees. With age and experience as covariates, there is still a significant difference between the two groups, with refugees scored significantly higher than non-refugees F(1,188) = 15.81, P<.01).
INSERT TABLE ONE HERE
The impact of personality
The relationships between self-reported TPQ personality dimensions and IES-R score are summarised in Table 2.
INSERT TABLE TWO HERE
Pearsons correlation revealed a significant positive relationship between IES-R score and total harm avoidance (HA) score on the TPQ. The HA score significantly correlates with the IES-R sub-scales intrusion and hyperarousal, but there was no significant relationship between HA score and avoidance. The relationship between the IES-R scores and HA remains similar when the effects of age are partialled out (r = +. 189, n = 158, p < .01). The analysis also revealed a significant negative correlation between the IES-R score and Novelty Seeking (NS) score on the TPQ, but when the effects of age are partialled out there relationship disappears, suggesting that age mediates the correlation. There was no significant correlation between the IES-R score and Reward Dependence (RD).
Type of traumatic experience
Table 3 shows the proportion of participants scoring above the cutoff point on the IES-R (45) for each type of traumatic experience. A greater proportion of participants scored above the cutoff for the traumatic experiences: threats to self or family, victims of violence or sexual abuse, witnessing death, witnessing destruction, and personal injury.
Table 3 also shows the percentage of refugees and internally displaced people who had the particular experiences. Refugees experienced a significantly higher percentage of death of family members, threats to the self and family, victim of violence or sexual abuse, hiding in fear, and personal injury than internally displaced people.
INSERT TABLE THREE HERE
The results show that refugees have higher scores on the IES-R than non-refugees. Refugees perceive themselves to have a lower standard of living than before the war. There is a positive correlation between IES-R and harm avoidance. The results also demonstrated that certain kinds of war trauma lead to higher levels of distress than others, specifically threats to self or family, victims of violence or sexual abuse, witnessing death, and personal injury, and refugees were more likely to have experienced certain types of traumatic event, such as death of a family member, threats to the self and family, violence or sexual abuse, hiding in fear, and personal injury.
The present study supports the previous findings that showed that refugee experience is a contributing factor to the overall stress response following war trauma (Steel at al, 1999; Martic-Bocina et al, 1996; Herceg et al, 1996). Migration and post-migration refugee experiences, such as language barriers (Molleca et al, 1987), prolonged asylum process (Richman, 1996), loss of culture and support (Steel et al, 1999), have a negative impact on the psychological well-being, compared with people who have had a prolonged exposure to war. Though the latter had a prolonged experience of war-related traumatic experiences, they displayed fewer posttraumatic symptoms. This supports previous findings, which indicated that the length of time spent in a war situation was not indicative of PTSD (Michulka et al, 1998).
The results also confirmed the prediction that participants who score high on the IES-R also tend to score higher on the harm avoidance subscale of the TPQ. A high score on HA relates to a heritable manifestation of traits such as anticipatory worry, fear of uncertainty, shyness and fatigability (Cloninger et al, 1993). These traits are associated with DSM-III-R cluster C anxiety disorders (Battaglia et al, 1992). The correlation is as predicted because PTSD is also classified under the DSM-III-R anxiety disorder. Causation cannot be established from this relationship. This is a problem commonly found in research concerning individual characteristics and PTSD, as to date they have been correlative or retrospective studies (Willson, 1994). It is possible that trauma experience and the consequent development of PTSD have caused a personality change. In any war zone, the unpredictable outcome combined with the prolonged exposure to traumatic events may alter a persons outlook on life leading to a change in personality. The experiences of life threatening traumas and consequent PTSD symptoms such as hypervigilance could actually result in an increased display of personality characteristics such as pessimistic worry and continuous fear of uncertainty, ie harm avoidant symptoms. For instance, the TPQ HA item 5 Usually I am more worried than most people that something might go wrong in the future. Using this example, it can be assumed that people who have experienced war-trauma would become more speculative and uncertain about their future. This is regardless of their outlook on life prior to their war experience.
Conversely, personality characteristics may indicate a pre-existing vulnerability to development of PTSD (Williams, 1999). Personality influences the way one perceives a threatening situation and hence the way one reacts to it. According to Cloninger (1996) temperament (which includes harm avoidance), is heritable, as well as developing through in childhood, while remaining stable throughout adulthood. According to this there would be little or no change in HA scores before and after the traumatic experience. Those who have shy, worrying, fearful personalities, (high HA) may initially subjectively perceive, appraise and encode their traumatic experience as more life threatening. This initial response to a traumatic life event has an adverse effect on the long-term stress reaction (Foa, Steketee, & Rothbaum,1989). In order to determine causality a prospective study needs to be carried out. Personality characteristics could be measured before and after a traumatic experience. This has practical and ethical difficulties, though such a study could feasibly be carried out by assessing individuals joining the emergency services or the armed forces.
Participants who experienced certain traumas reported more PTSD symptoms. These traumas included threats to the self and/or family, being a victim of violence of sexual abuse, witnessing death and personal injury. These traumas are directly life threatening to the person compared with the other traumas listed on the questionnaire, eg active role in combat and Exposure to combat on the other hand do not necessary involve direct threat to the self, especially if no deaths were witnessed. The nature of the war in Bosnia meant that many people may have considered themselves to be actively involved in combat even if they were simply wearing soldiers uniforms or if they possessed some sort of a weapon. This particular type of trauma should have been stated with more specificity. Similarly there is not necessarily a direct threat to life when witnessing destruction and the death of a family member providing that it occurred away from the individual. The DSM-III-R (1987) revised the stressor criterion "A" of the PTSD classification to indicate that the more severe and life-threatening the event is the higher the probability that it will produce traumatic consequences such as PTSD.
The present study has highlighted the prevalence of long-term posttraumatic stress symptoms in both refugees and internally displaced people, particularly the former. The study demonstrates the importance of making professional assistance available to refugees upon their arrival into the new country, as intervention should take place as early as possible. In many cases such people also develop a range of other disorders such as depressive disorders, panic disorders, and generalized anxiety disorders as well as PTSD (McFarlane, 1995).
The study shows the complexity of the relationship between stressors and consequent display of PTSD symptoms. Further research should therefore consider other influential factors concerning the development of the PTSD such as family history of psychiatric disorders, present living conditions, support, coping strategies, as well as socioeconomic, cultural and religious factors, all of which can influence the perception of the severity of the traumatic event. Complex personal histories, especially with regards to previous traumas, should be fully accounted for, before conclusions are made, even in studies concerning one specific traumatic event.
The present study has highlighted the importance of accounting for the full complexity of posttraumatic stress disorder; both types of stressor and individual factors are important. Refugees experience more difficulties than internally displaced people. This occurs for a variety of reasons. The refugees have to deal with an alien culture, a new language, and possible hostility from the indigenous population. Internally displaced people, while losing their homes, do not have these extra difficulties. This finding indicates that ideally people should be helped to remain in their own country, but if they do become refugees then it is important for the host country to provide appropriate assistance, not just in terms of treatment of psychological disorder, but also in providing an appropriate welcome, help with learning the language, and help with adapting to the new culture.
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Table 1: The difference on IES-R score between Refugees and non-refugees.
Table 2: Results of the Pearsons Correlation Showing linear relationships between the TPQ and IES-R
N = 161
N = 161
N = 161
N = 161
| + .172*
N = 162
| + .120
N = 162
| + .278**
N = 162
| + .243**
N = 162
|Reward Dependence (RD)||
N = 142
(*) relationship significance at .05 alpha level, (two-tails)
(**) relationship significance at .01 alpha level, (two-tails)
Table 3: IES-R scores for participants that experienced the listed types of Trauma.
>cutoff on IES
N refugees experiencing event
N displaced experiencing event
|Death of family member||61||NS||51||32||>.01|
|Active role in combat||68||NS||20||14||NS|
|Exposure to combat||62||NS||36||27||NS|
|Threats to the self or family||77||>.001||65||37||>.001|
|Victim of violence or sexal assault||92||>.01||12||3||>.05|
|Hiding in fear||59||NS||64||80||>.05|