- FATRA e.V.
Frankfurter Arbeitskreis Trauma und Exil
Psychotherapeutische, soziale und politische Unterstuetzung für Fluechtlinge und Verfolgte
Merianstrasse 39
D-60316 Frankfurt
Phone 0049 (0)69 49 91 74
Fax. 0049 (0)69 49 85 28
Email fatra@t-online.de
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Marie-Luise Roessel-Cunovic, Frankfurt Frankfurter Arbeitskreis Trauma und Exil e. V. – FATRA (Frankfurt Working Group on Trauma and Exile) Short-term therapies for refugees with limited residency permits? The impact of Germany's laws regarding the status of foreigners on the psychotherapeutic treatment of traumatized refugees
- In April 1999, Germany again allowed refugees from the area of former Yugoslavia to enter the country; this time Albanians from Kosovo who had been forcibly expulsed from their towns and villages. Nearly all of these refugees suffered terrifying experiences and continue to suffer from the shock of the threat of death, the loss of friends and family members and of their homes. In the meantime, there is widespread recognition that these refugees are not only physically weakened and desperate when they arrive here. The psychological effects of the war atrocities systematically inflicted upon them may also be extremely severe and long-lasting and may even affect several generations of the families involved.
Today, the term traumatization is frequently heard in connection with the fate of refugees. But precisely because the word "trauma" has become so popular, it seems necessary to sketch what it exactly means for the refugees themselves and for the way larger groups of traumatized refugees are treated, in particular when the focus of media attention on the misery of refugees has moved on to other sites and the initial waves of understanding and charity have died down. The Bosnian refugees who found exile in Germany not so long ago are a striking example of the very contradictory treatment of traumatized individuals in our society.
Not since the Seventies, when refugees from Latin American dictatorships came to Germany, has the media in this country paid such attention to the fate of refugees who survived severe human rights violations. The level of sympathy and willingness to help the Bosnians, as the victims of a brutal, ethnically motivated policy of expulsion, was very high in Germany, as it is today with respect to the refugees from Kosovo.
In contrast to the situation just a few years earlier, the concept of psychological traumatization of refugees due to extreme experiences of maltreatment and persecution began to play a role in the considerations of the relevant German authorities. Gradually, people had come to realize that the survivors of prison camps, rape, and other brutal forms of mistreatment would also require psychotherapeutic support. In spite of this insight, the authorities failed to allocate sufficient funding for the therapeutic capacities required. In early 1996, after the Dayton agreement had been signed, the so-called Repatriation Order (Rueckfuehrungserlass) was implemented by the German government. This order at least provided that traumatized refugees were not to be included in the first phase of repatriation measures, allowing them to remain in Germany and to undergo psychotherapeutic or medical treatment.
But the understanding of what traumatization means for its victims was incomplete and the capacity to remember what the Bosnian refugees had been subjected to vanished with the increasing length of their stay in Germany. The government's repatriation policies in the course of the last two years is sufficient proof of that. The authorities were glad that specialists were available, to whom the traumatized refugees could be sent to have the physical and mental effects of their traumatization treated. But the authorities who dealt with the refugees obviously found it hard to comprehend that the existing social and legal conditions made a psychotherapeutic process nearly impossible. Moreover, the insecure situation in exile often even induced retraumatization by constantly reproducing feelings of powerlessness and threats to one's very existence.
Staff members of the psychotherapeutic counseling center of the Frankfurt Working Group on Trauma and Exile (FATRA e.V.) have, in the course of their work in recent years, repeatedly observed how the social and legal situation in the country of exile contribute to determining whether the existing symptoms of traumatized refugees improve or regress and become chronic. Among representatives of relevant government authorities and in German society in general, there has been a strong tendency to perceive a trauma only at its source, but not where it is maintained or perpetuated.
All of our observations in the course of the process of psychotherapy, as part of many years of psychotherapeutic work with traumatized adults and youths have confirmed that traumatization is not limited to the phase of actual persecution. Academic research in this area, based, for example, on work with Holocaust survivors (Hans Keilson) or victims of torture in Latin American dictatorships (David Becker, Elisabeth Lira), demonstrate impressively that the severity of trauma is influenced not only by experiences during the period of persecution but also by what happens in the sequence that follows. This includes living conditions in the country of exile; whether or not refugee's experiences meet with understanding; whether or not a new life project can be developed; whether psychotherapeutic support is available; whether the perpetrators are punished. All of these factors determine to what degree a trauma produces a deep-seated and permanent shock in the person affected and to what extent it is possible to mitigate her/his suffering.
With respect to the Bosnian refugees, we can describe various events in the phase following the end of direct persecution which represent salient turning-points in their social reality and resulted in changes in their psychological condition and in the psychotherapeutic process.
In the first phase after being allowed to enter Germany, sorrow about the overwhelming losses the refugees had suffered dominated their experience. Some patients had lost nearly their entire family and also many friends. Their faith in social relations and in the validity of legal norms had been destroyed. The war in Bosnia was still going on and the images of destruction were in the media every day. The refugees were overcome by fear for the relatives who had been unable or unwilling to flee.
The situation of the refugees was also characterized by the loss of any form of privacy in their present living quarters - large shelters for refugees or the overcrowded homes of relatives living in Germany who had taken them in. The lack of transparency with respect to the decisions of government authorities was perceived as very worrisome, since no one knew what his or her legal status in Germany was and what the possible implications were. The decisions reached by the authorities were viewed as arbitrary. The refugees experienced themselves as powerless and ambivalent, with feelings of rage towards those who decided their fates but who had also offered them shelter, for which they were grateful. The ambivalence felt by some refugees in this period went so far that they expressed fantasies in which the German authorities were accused of having taken them in with the aim of completing the job their persecutors had begun. The deep-seated loss of faith in social relations due to persecution and expulsion - acts perpetrated in numerous cases by friends and neighbors - manifested itself in mutual distrust and strong tendencies to form splitter groups. Thus, a split arose between those who had been interned in prison camps in the former Yugoslavia and those who had managed to flee more or less uninjured. Uncertainty and lack of trust also lead to the feeling that the German authorities were again persecuting them and to the frequently expressed mistrust of those who, individually or as members of groups, were in contact with the refugees as "helpers", including physicians and psychotherapists, who, some refugees suspected, were solely interested in them as interesting objects for research.
This very skeptical stance was transformed into the fantasy that powerful doctors worked for FATRA, who would be able to prevail in the face of any injustice on the part of the authorities. This had a very appellative character. For us, it was often difficult to differentiate between necessary interventions in the social reality of the patients to prevent further traumatization and attempts to allay the therapists' feelings of helplessness with an excess of activity.
The treatments we undertook in this period were crisis interventions. Most patients were extremely desperate when they came to FATRA. Our talks focused on the breech which war and expulsion had torn open in their lives and the total uprooting, for most, from comfortable lives with professional success and social recognition. Now these individuals were being defined from the outside as a collective and de-individualized , as manifested in the use of language, which labeled and continues to label them as "the refugees" or "the Muslims".
Relations within the families were aggravated by the traumatic experiences of family members, often suffered in isolation from their relatives, by the deep grief caused by their losses, and by the varying forms of protection and defense mechanisms which they employed. Living conditions in exile were so stressful that they were often the focus of conversations during treatment. Due to the day-to-day stress in this period, many patients were unable to deal more intensively and directly with the content of their persecution, since this would have threatened their laboriously maintained psychological stability.
After large-scale shelters for Bosnian refugees were disbanded in the German Federal State (Bundesland) of Hessen, there was a short phase, beginning in the summer of 1995, of greater well-being for the refugees. A kind of "normalization" of daily life had occurred. Many refugees now had their own apartments and employment and the children were attending school. Thanks to the NATO intervention, the armed struggle in Bosnia had come to an end. Relief about the impending peace and hopes that life would change for the better reigned. It was a short breathing spell, a few months in which most patients seemed to re-orient themselves. Only very few new patients appeared to take up our offer for assistance or treatment but patients who had been in contact with us for a long time continued to come regularly. Therapeutic sessions focused on political developments in Bosnia and the patient's own perspective on life in exile and the possibility of returning home.
A short time later, in early 1996, a new phase began, marked by the acceptance of the Dayton agreement and, in particular, by the beginning of the repatriation policy implemented by the Ministers of the Interior of the German states (Bundeslaender). Nearly without warning, the survivors of severe human rights violations were confronted with the prospect of being forced to return to their homes, in a situation in which destruction and instability reigned and their former tormenters still held positions of power. The majority of our patients came from regions in Bosnia with a particularly high incidence of human rights violations. Many of them are survivors of the death camps in Omarska, Keraterm, and Manjaca, who, as witnesses of crimes perpetrated there, must still fear for their lives and safety if they return to the region. Only a few were called as witnesses to testify before the La Hague court and thus have received personal protection guarantees. But even they soon received letters from the German authorities, announcing that they were to be among the next to be sent home. The first executive order passed by the Ministers of the Interior of the states recognized in principle the existence of traumatized refugees who were not to be sent back until a later date, but neither this order nor a later order granted these refugees secure residency status - which should have been the case, in keeping with the Geneva Refugee Agreement. Since 1996, we have witnessed the implementation of a series of such orders which purportedly secured the status of traumatized persons in Germany. But these guarantees proved to be questionable since many refugees are always one step away from expulsion and forced to avert being repatriated against their will with the help of lawyers and medical expertises, in some cases on a monthly basis. Permission to remain in Germany is only granted to refugees who provide proof that they are traumatized, that their traumatization is recognized as a mental illness and that they are undergoing treatment by a physician, a medical specialist, or a psychotherapist. These refugees must also provide proof of the experiences which caused the trauma. The authorities reserve the right to employ counter-experts who assert that the experiences cited are too general in nature or not severe enough to be recognized as causes of a trauma.
For the refugees this means the following:
- They must talk about their traumatic experiences in order to avert expulsion, even if they are unable to do so, since they must still protect themselves from these stressful memories, in order to maintain mental stability.
- They must find their way to a counseling center or a psychiatrist where they can speak and be treated - if possible in their native language or with an interpreter. Treatment must be without charge or paid for by the local welfare office. This is quite a high hurdle which many traumatized refugees fail to take, since competent centers soon lacked capacities to accept further patients for treatment.. Since the summer of 1998, FATRA was also forced to refer refugees to other centers or therapists, since our capacities had already been exceeded and no funds were available to employ more personnel.
- Traumatized refugees often received a restricted form of permission (so-called Duldung or toleration) to stay in Germany and these permits were valid for a limit period only, in spite of expertises from physicians and psychotherapists. Since the spring of 1998, permits were granted for one year at most. Up to spring 1998, the relevant authorities frequently questioned the diagnosis of a posttraumatic stress syndrome which FATRA specialists determined in some of its patients. In their opinion, "posttraumatic stress syndrome was diagnosed with a strikingly frequency." They were unwilling to accept so many traumatized refugees and maintained that there had to be "malingerers" among the patients. Now, the extent of terror which reigned in this war and its effects on individuals were being negated to a great extent. Even identification papers from prison camps were rejected with the argument that prison camp arrest in itself was not significant, although UNHCR reports described the daily acts of violence to which prisoners interned there were themselves submitted or forced to observe.
The permanent uncertainty regarding their possible expulsion led to an aggravation of symptoms in all patients, including those who had entered a relatively stable phase. Feelings of anxiety and panic dominated, reports of sleep disorders, flashbacks in the daytime and nightmares at night, severe psychosomatic ailments and thoughts of suicide became more frequent. Many patients walked a thin line on the brink of a mental breakdown. The threat of expulsion by the authorities was perceived as a devastating threat to one's very existence, for it constituted a real threat but was also linked emotionally to the traumatic experience of aggression inflicted upon the refugees in their home country. By denying in many cases that a particular refugee had such traumatic experiences, the authorities denied part of his/her individual history and reinforced the feeling that his/her perception was incorrect. He/she doubted whether the unimaginable things which he/she experienced really did occur. Some patients felt better when the UNHCR sent them, in response to an inquiry, a written communication indicating that they were indeed prisoners in a camp, in which camp and for how long - and an extensive description of what had occurred in the particular camp. This validation was of great significance for the patients, even if it did not directly influence their legal status in Germany.
From one year to the next year, counselors and therapists had to invest more and more time and energy in securing continued residency in Germany for their patients. This was due to on-going disagreements with the employees of the Auslaenderamt, the authority which issues residency permits for foreigners, with government doctors, and with the employees of the Ministry of the Interior who are responsible for the repatriation program. The process of preparing medical expertises every three months according to a fixed catalog of criteria was extremely time-consuming for the therapists and a source of a great deal of anxiety for the patients. Again and again, the patients experienced the uncertainty as to whether their permission to stay would be extended or the expertise would be rejected by the authorities. Furthermore, the necessity of writing such medical/psychotherapeutic expertises created a significant imbalance in therapeutic relations with the patients: a kind of dependence on the "good works" of the therapists developed. In this situation, patients could no longer risk expressing aggressive impulses during the therapeutic process. The authorities stipulated that expertises record the beginning and the probable duration of therapy, presumably because they imagined that there is a kind of singular, severe experience of persecution - "the trauma" - which should respond to therapy within a few hours. Afterwards, repatriation could take place. In the face of the threat of repatriation, who can really feel better, even if her/his mental condition improves?
The patients had no guarantee that there would be sufficient time to work through their traumatic experiences within the framework of psychotherapeutic treatment. They had reason to fear that the end of their treatment might be abrupt and dictated from outside. We repeatedly were forced to ask how a refugee can be expected to open up in the course of the psychotherapeutic process and develop a relationship of trust if she/he does not know whether she/he will see the person she/he is communicating with one week later? How can one conduct trauma therapy under such conditions, unless it is conceived as a form of permanent crisis intervention?
Experience shows that traumatized individuals need a great deal of support, in order to begin developing trust in themselves and in their relationships to others - and they need to regain a secure feeling that there will be a future for them "afterwards." Psychotherapy can help in both respects. But for psychotherapy to work, the right political decisions must be reached. In recent years, therapy centers have been expected to implement solutions on a psychotherapeutic level, at the same time there was a lack of willingness to implement the necessary political measures. Traumatized refugees require secure legal status in the country of exile. They must not experience the feeling that they can be "driven put” again at any time. Only then does it become possible to working through traumatic experience with the help of psychotherapy.
Bosnian refugees - as well as refugees from other regions - have been forced to experience how humanitarian gestures have given way to mistrust, at times even hostility. This transformation is particularly trying for refugees whose trust in social relations has been deeply shaken by their experience of violence and expulsion.
The insecurity of traumatized refugees is made real in the story of a young woman from Bosnia who was undergoing treatment at FATRA because of the effects of her traumatization. She came to treatment one winter day in 1998 and told her therapist of an occurrence which, in another situation, would have been trivial but which had been the cause of sleepless nights for her. She had been sitting in the waiting room of the Auslaenderamt when a young man passed by, greeted with a nod of his head and asked "How are you?" "Good" she answered, but then was alarmed. The young man was the public employee who processed her application for an extension of her permit to stay in Germany (Duldung); in contrast to his usual habits, he appeared to be in a good mood. She was there to apply for a somewhat longer extension on the basis of a psychotherapeutic expertise which she had brought with her that day. But she was granted only four weeks extension and blamed herself for having responded thoughtlessly to the polite gesture. In her opinion, there was a connection between this short exchange of words and the short extension of her permit. Her therapist reacted to the young woman’s sharp self-reproach by trying to calm her down and saying that she didn't think it likely that there was a connection. That was the last therapeutic conversation, since, a few days later, the young woman was sent back to Bosnia by the German authorities - in spite of her medically attested traumatization, with no forewarning and before the four week extension of her Duldung had run out.
This paper is a revised version of the lecture held in Hamburg on 03.12.1998 during the trauma network´s founding conference.
Translation from German: Paula Bradish
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Short biographical note Marie-Luise Roessel-Cunovic holds a degree in education (Diplom-Paedagogin) and is currently in training as a family therapist. Born in 1956, she studied education with a focus on psychoanalytic pedagogics in Frankfurt. She became a member of the Board of Directors of medico international (socio-medical aid and human rights organisation in Frankfurt) in 1981 and worked for medico international in the area of projects providing psycho-social health care for Latin American countries from 1988 to 1995. She co-founded FATRA e.V. in 1993 and since 1996, she heads FATRA’s project offering counseling and treatment for traumatized refugees from the former Yugoslavia.
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Citation Marie-Luise Roessel-Cunovic, FATRA. Short-term therapies for refugees with limited residency permits? The impact of Germany's laws regarding the status of foreigners on the psychotherapeutic treatment of traumatized refugees. In: Trauma Research Newsletter 1, Hamburg Institute for Social Research, July 2000.
URL http://www.TraumaResearch.net/net1/portrait1/fatra.htm
Copyright © 2000, Marie-Luise Roessel-Cunovic and trauma newsletter, all rights reserved. This work may be copied for non-profit educational use if proper credit is given to the author and the trauma newsletter. For other permission questions, please contact via email the editor Cornelia_Berens@his-online.de
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