Psychoanalysis and the third position: social upheavals and atrocity.

Many situations are now characterized by a breakdown of order and structure, leaving people at the peril of unorganized forces (war machines, human traffickers, etc.) resulting in the dehumanizing of ordinary people on a mass scale, especially in the refugee field. The paper focuses on how alienating discourses on "trauma" and society's neglect of traumatized people increase suffering and have grave consequences for coming generations. It reflects on how psychoanalysis may represent a mediating function in relation to regressive processes at individual, group and societal levels. A conceptualization of a third position from which psychoanalysis can work is developed. The third position is seen as inevitable in psychoanalytic clinical work in that symbolization and working though must be anchored in a common cultural discourse. A model for rethinking traumatization is proposed that develops the conception of the third position in relation to a broader field and encompasses the subject's relations to dyadic, bodily-affective relations, to the group and family, and to culture/ discourse. This model may lay the groundwork for understanding how atrocities and social catastrophes such as collective traumatization can be worked through at the individual and social levels. Clinical examples are presented to illuminate these processes.

"Imagine, 7 Years Without a Future": A Qualitative Study of Rejected Asylum Seekers' Life Conditions in Norway.

Asylum seekers are in an extraordinary situation as their future life depend on decisions made by authorities in a bewildering, bureaucratic system, with excessive waiting and unpredictable timeframes. Those that are not granted asylum, and not able to return to their country of origin, can neither spatially nor temporally visualize if, when or how a potential change is going to occur. This paper is part of a larger study based on narrative interviews with asylum seekers and refugees in asylum centers in Norway, exploring their experiences before, during, and after flight. As we found that the life circumstances for those being refused asylum, were highly different from other participants in the project, we chose to address this particular group in a separate paper. The participants in this part of the study consisted of 21 individuals (of a total of 78 participants) in the age range 18-44, of whom eight were female and 13 males. Trough qualitative interviews and participant observation the aim of this study was to explore and describe the life condition and mental health situation of rejected asylum seekers in Norway. We found that the gradual loss of rights, opportunities and finances are experienced as a form of violence that leads to extreme mental and social suffering. This policy clearly conflicts with Human Rights incorporated in the Norwegian constitution, and we argue that it legitimizes treating asylum seekers as a group of undesirable and underserving political bodies, with serious consequences for their mental health and wellbeing.

Predictors of the 10 year course of mental health and quality of life for trauma-affected refugees after psychological treatment.

Background: Trauma-affected refugee patients benefit from psychological treatment to different degrees. Only a handful of studies has investigated potential predictors of treatment outcome that could throw light on the great variability in outcomes reported for this group. Such knowledge may be vital to better tailor prevention and treatment efforts to the needs of different individuals and subgroups among these patients. Objective: In a naturalistic and longitudinal study, the aim was to analyse demographics and traumatic exposure as potential predictors of the participants' long-term trajectories of mental health symptoms and quality of life. Method: A group of 54 multi-origin adult refugee patients with complex traumatic exposure, such as armed conflicts, persecution, torture, and childhood adversities, were interviewed face to face over up to 10 years; at therapy admittance, and at varying points in time during and after psychotherapy. Checklists of war-related and childhood trauma, mental health symptoms, and quality of life were included in the interviews. In linear mixed effects analyses, interaction was analysed with potential predictors included separately because of the sample size. Time was modelled as continuous from inclusion into the study. Results: Gender predicted the course of symptoms of post-traumatic stress, anxiety, and depression, and of quality of life in physical health and social relationships. Childhood family violence and experiences of torture predicted the course of depression, whereas the extent of exposure to war-related trauma events and having experienced torture predicted the course of anxiety. Conclusions: The results indicated greater chronicity in male refugees, in refugees who had experienced domestic violence during childhood, in refugees who had experienced torture, and in refugees with more numerous types of potentially traumatic war-related experiences. The findings highlight the need for gender-sensitive research, rehabilitative efforts, and treatment. HIGHLIGHTS In a 10 year longitudinal and naturalistic therapy follow-up study of traumatized refugees, female gender, childhood trauma, war trauma, and torture predicted mental health and quality of life outcomes.Male participants responded less than females to therapy.

Antecedentes: Los pacientes refugiados afectados por el trauma se benefician del tratamiento psicológico en diferentes grados. Sólo un puñado de estudios han investigado los posibles predictores del resultado del tratamiento que podrían arrojar luz sobre la gran variabilidad de los resultados registrados en este grupo. Este conocimiento puede ser vital para adaptar mejor los esfuerzos de prevención y tratamiento a las necesidades de los diferentes individuos y subgrupos de estos pacientes.Objetivo: En un estudio naturalista y longitudinal, el objetivo fue analizar los datos demográficos y la exposición traumática como posibles predictores de las trayectorias a largo plazo de los síntomas de salud mental y la calidad de vida de los participantes.Método: Un grupo de 54 pacientes adultos refugiados de múltiples orígenes con exposición traumática compleja, como conflictos armados, persecución, tortura y adversidades en la infancia, fueron entrevistados cara a cara durante un período de hasta 10 años; al ingreso en la terapia, y en diferentes momentos durante y después de la psicoterapia. En las entrevistas se incluyeron listas de comprobación de traumas relacionados con la guerra y la infancia, síntomas de salud mental y calidad de vida. En los análisis lineales de efectos mixtos, se analizó la interacción con los posibles predictores incluidos por separado debido al tamaño de la muestra. El tiempo se modeló como continuo desde la inclusión en el estudio.Resultados: El género predijo la evolución de los síntomas de estrés postraumático, ansiedad y depresión, y de la calidad de vida en cuanto a salud física y relaciones sociales. La violencia familiar en la infancia y las experiencias de tortura predijeron el curso de la depresión, mientras que el grado de exposición a eventos traumáticos relacionados con la guerra y el haber experimentado la tortura predijeron el curso de la ansiedad.Conclusiones: Los resultados indicaron una mayor cronicidad en los refugiados varones, en los refugiados que habían sufrido violencia doméstica durante la infancia, en los refugiados que habían sufrido tortura y en los refugiados con más tipos de experiencias potencialmente traumáticas relacionadas con la guerra. Los resultados ponen de manifiesto la necesidad de realizar investigaciones, esfuerzos de rehabilitación y tratamientos que tengan en cuenta el género.

Short-term risk assessments in an acute psychiatric inpatient setting: A re-examination of the Brøset Violence Checklist using repeated measurements - Differentiating violence characteristics and gender.

This study investigated the association between short-term risk assessment measured by the Brøset Violence Checklist (BVC) and imminent violence using repeated measurements and differentiating violence characteristics and gender. All patients admitted to an acute psychiatric ward during one year (N = 528) were included. Logistic regression and generalized linear mixed model (GLMM) analyses were conducted. Results confirmed BVC's suitability for both male and female inpatients throughout their hospitalization also when differentiating threats and physical violence, and adjusting for diagnostic subpopulations and circadian variability. Results point to modified interpretations of the BVC sum scores. Future research should adjust for repeated measurements.

"I Have No Capacities That Can Help Me": Young Asylum Seekers in Norway and Serbia - Flight as Disturbance of Developmental Processes.

Most studies on refugee populations are organized around trauma-related issues and focus on explaining pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence how developmental tasks are negotiated. This study is part of a larger mixed method study seeking to identify resilience-promoting and resilience-inhibiting factors, on individual and contextual levels, among asylum seekers and refugees on the move (passing through Serbia) and settled in reception centers in Norway. A strategic sample of 20 adolescent and young adult refugees/asylum seekers during flight in Serbia (10) and after arrival in Norway (10) was chosen from a sample of 178 refugees interviewed in depth in Serbia and at receptions centers in Norway. The sample reflects the focus of this paper, which is to explore adolescent and young adult refugees/asylum seekers' psychological and social needs and resources during flight to and after arrival in the host country, including how developmental tasks are negotiated. Through qualitative analysis, experiences associated with the developmental changes the participants experienced before, during, and after flight are contextualized. Their sense of self, their relationships with their families and their perceptions of their situation as adolescents or young adults in a highly unpredictable situation are presented in the light of relevant theory and findings from similar refugee studies. All the participants have fled from dangerous and intolerable situations in their home countries. They describe extreme dangers during flight in contexts that are unpredictable and where they feel lonely and unsupported. Most have unmet psychosocial needs and have received little support or help for their mental health issues during flight or after arrival in Norway. Suggestions for interventions and resilience-promoting actions are given based on the findings of the study.

The 10-year course of mental health, quality of life, and exile life functioning in traumatized refugees from treatment start.

Refugee patients with severe traumatic experiences may need mental health treatment, but treatment results vary, and there is scarcity of studies demonstrating refugees' long-term health and well-being after treatment. In a 10-year naturalistic and longitudinal study, 54 multi-origin traumatized adult refugee patients, with a background of war and persecution, and with a mean stay in Norway of 10.5 years, were recruited as they entered psychological treatment in mental health specialist services. The participants were interviewed face-to-face with multiple methods at admittance, and at varying points in time during and after psychotherapy. The aim was to study the participants' trajectories of symptoms of post-traumatic stress, anxiety and depression, four aspects of quality of life, and two aspects of exile life functioning. Linear mixed effects analyses included all symptoms and quality of life measures obtained at different times and intervals for the participants. Changes in exile life functioning was investigated by exact McNemar tests. Participants responded to the quantitative assessments up to eight times. Length of therapy varied, with a mean of 61.3 sessions (SD = 74.5). The participants improved significantly in symptoms, quality of life, and exile life functioning. Improvement in symptoms of posttraumatic stress, anxiety, and depression yielded small effect sizes (r = .05 to .13), while improvement in quality of psychological and physical health yielded medium effect sizes (r = .38 and .32). Thus, long-time improvement after psychological therapy in these severely traumatized and mostly chronified refugee patients, was more notable in quality of life and exile life functioning than in symptom reduction. The results imply that major symptom reduction may not be attainable, and may not be the most important indication of long-term improvement among refugees with long-standing trauma-related suffering. Other indications of beneficial effects should be applied as well.

Negotiating identity at the intersection of family legacy and present time life conditions: A qualitative exploration of central issues connected to identity and belonging in the lives of children of refugees.

INTRODUCTION: Most studies on refugee populations are organized around trauma-related issues and focus on explanations of pathological factors. Few studies are anchored in general developmental psychology with the aim of exploring normal age-specific developmental tasks and how the special circumstances associated with forced migration can influence that development. METHODS: Using an ecological and transactional understanding of developmental trajectories, this qualitative study explored issues connected to identity formation processes in an exile context based on interviews with 6 male and 10 female children of refugees (18-26 years) who have grown up in Norway. RESULTS: The findings show that family experiences of war and conflict intersect with experiences of marginalization in exile. The interaction of these experiences influences the development of individual identity in cumulative and complex ways. Many of the participants expressed feelings of isolation, disconnectedness, and a lack of belonging. Nevertheless, though the participants described growing up facing major challenges, they also searched for ways to reframe their difficult personal and family histories into meaningful experiences. CONCLUSIONS: In order to provide conditions and develop interventions that can support well-being and identity development, we need a better understanding of the different forces that influence the identity development of children of refugees. By foregrounding the participants' experiences, and perspectives, we gained insight into different ways in which participants negotiate identity issues in relation to often contradictory demands and messages from family and the wider social context.

The Past, the Present, and the Future: A Qualitative Study Exploring How Refugees' Experience of Time Influences Their Mental Health and Well-Being.

The experience of time has a decisive influence on refugees' well-being and suffering in all phases of their flight experiences. Basic safety is connected both developmentally and in present life with a feeling of continuity and predictability. Refugees often experience disruption of this basic sense of time in their home country due to war, persecution, and often severe traumatization, during flight, due to unpredictable and dangerous circumstances in the hands of smugglers, and after flight, due to unpredictable circumstances in asylum centers, e.g., extended waiting time and idleness. These context-dependent disruptions of normal experiences of time may lead to disturbances in mental life and extreme difficulties in organizing one's daily life. This article is based on narrative interviews with 78 asylum seekers and refugees in asylum centers in Norway, exploring their experiences before, during, and after flight. The distinction between abstract, chronological time, and concrete time connecting situational experiences (daily activities, such as daily rhythm of sleep and wakefulness) proved important for understanding how the experiences became mentally disturbing and how people tried to cope with this experience more or often less successfully. Prominent findings were loss of future directedness, a feeling of being imprisoned or trapped, disempowerment, passivity and development of a negative view of self, memory disturbances with difficulty of placing oneself in time and space, disruptions of relations, and a feeling of loss of developmental possibilities. Some had developed resilient strategies, such as imagining the flight as a holiday trip, to cope with the challenges, but most participants felt deeply disempowered and often disorientated. The analysis pointed clearly to a profound context dependent time-disrupting aspect of the refugee experience. An insecure and undefined present made participants unable to visualize their future and integrate the future in their experience of the present. This was connected with the inherent passivity and undefined waiting in the centers and camps, and with previous near encounters with annihilation and death. A response was often withdrawal into passivity.

Screening for risk of violence using service users' self-perceptions: A prospective study from an acute mental health unit.

Service users' self-perception of risk has rarely been emphasized in violence risk assessments. A recent review pointed to the importance of a multidisciplinary approach, because different perspectives may provide a deeper and improved understanding of risk assessment. The aim of this study was to investigate service users' perceptions of their own risk of committing violence, using a self-report risk scale, to determine the feasibility and efficacy of this potential violence risk marker during acute mental health hospitalization. All service users admitted to a psychiatric emergency hospital in Norway during one calendar year were included (N = 512). Nearly 80% self-reported no risk or low risk; only seven (1.4%) reported moderate risk or high risk. Service users who reported moderate risk, high risk, don't know, or won't answer were more likely to be violent (OR = 4.65, 95% CI = 2.79-7.74) compared with those who reported no risk or low risk. There was a significant gender interaction with higher OR for women on both univariate and multivariate analyses. Although the OR was higher for women, women's violence rate (11.0%) was almost half that of men (21.8%). For women, sensitivity and specificity were 0.55 and 0.88, respectively; corresponding values for men were 0.40 and 0.80. Inclusion of self-perception of violence risk is the first step towards service users' collaborative involvement in violence prediction; these results indicate that self-perception can contribute to violence risk assessments in acute mental health settings. Findings also indicate that there are gender differences in these assessments.

Our Relations to Refugees: Between Compassion and Dehumanization.

After the so-called refugee crisis of 2015-2016 European reactions to foreigners had come to the fore and we are seeing xenophobic political and populist movements become increasingly mainstream. The massive rejection of refugees/asylum seekers taking place has made their conditions before, during and after flight, increasingly difficult and dangerous. This paper relates current xenophobia to historical attitudinal trends in Europe regarding Islam, and claims that a much more basic conflict is at work: the one between anti-modernism/traditionalism and modernism/globalization. Narratives on refugees often relate them to both the foreign (Islam) and to "trauma". In an environment of insecurity and collective anxiety, refugees may represent something alien and frightening but also fascinating. I will argue that current concepts and theories about "trauma" or "the person with trauma" are insufficient to understand the complexity of the refugee predicament. Due to individual and collective countertransference reactions, the word "trauma" tends to lose its theoretical anchoring and becomes an object of projection for un-nameable anxieties. This disturbs relations to refugees at both societal and clinical levels and lays the groundwork for the poor conditions that they are currently experiencing. Historically, attitudes towards refugees fall somewhere along a continuum between compassion and rejection/dehumanization. At the moment, they seem much closer to the latter. I would argue that today's xenophobia and/or xeno-racism reflect the fact that, both for individuals and for society, refugees have come to represent the Freudian Uncanny/das Unheimliche.

Relationship of Pretreatment Rorschach Factors to Symptoms, Quality of Life, and Real-Life Functioning in a 3-Year Follow-Up of Traumatized Refugee Patients.

Response to mental health treatment varies highly among refugee patients. Research has not established which factors relate to differences in outcome. This study is a follow-up of Opaas and Hartmann's (2013) Rorschach Inkblot Method (RIM; Exner, 2003) pretreatment study of traumatized refugees, where 2 RIM principal components, Trauma Response and Reality Testing, were found descriptive of participants' trauma-related personality functioning. This study's aims were to examine relationships of the RIM components with measures of anxiety, depression, posttraumatic stress, quality of life (QOL), employment, and exile language skills throughout 3 years. We found that impaired Reality Testing was related to more mental health symptoms and poorer QOL; furthermore, individuals with adequate Reality Testing improved in posttraumatic stress symptoms the first year and retained their improvement. Individuals with impaired Reality Testing deteriorated the first year and improved only slightly the next 2 years. The results of this study imply that traumatized refugee patients with impaired Reality Testing might need specific treatment approaches. Research follow-up periods should be long enough to detect changes. The reality testing impairment revealed by the RIM, mainly perceptual in quality, might not be easily detected by diagnostic interviews and self-report.

Unconscious phantasy and its conceptualizations: An attempt at conceptual integration.

That there is a lack of consensus as to how to decide between competing, at times even contradictory theories, and about how to integrate divergent concepts and theories is well known. In view of this situation, the IPA Committee on Conceptual Integration (2009-2013) developed a method for comparing the different versions of any given concept, together with the underlying theories and fundamental assumptions on which they are based. Only when situated in the same frame of reference do similarities and differences begin to appear in a methodically comprehensible and reproducible form. After having studied the concept of enactment followed by the publication of a paper in this Journal in 2013, we proceeded to analyze the concept of unconscious phantasy while at the same time continuing to improve our method. Unconscious phantasy counts among the central concepts in psychoanalysis. We identified a wide range of definitions along with their various theoretical backgrounds. Our primary concern in the present paper addresses the dimensional analysis of the semantic space occupied by the various conceptualizations. By way of deconstructing the concepts we endeavoured to establish the extent to which the integration of the different conceptualizations of unconscious phantasy might be achieved.

Relationships of Childhood Adverse Experiences With Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre-Flight Experiences of War and Human Rights Violations.

Adverse and potentially traumatic experiences (PTEs) in childhood were examined among 54 adult refugee patients with pre-flight PTEs of war and human rights violations (HRVs) and related to mental health and quality of life at treatment start. Extent of childhood PTEs was more strongly related to mental health and quality of life than the extent of war and HRV experiences. Childhood PTEs were significantly related to arousal and avoidance symptoms of posttraumatic stress disorder (PTSD) and to quality of life, whereas pre-flight war and HRV experiences were significantly related to reexperiencing symptoms of PTSD only. Within childhood adversities, experiences of family violence and external violence, but not of loss and illness, were significantly related to increased mental health symptoms and reduced quality of life. These results point to the importance of taking childhood adverse experiences into account in research and treatment planning for adult refugees with war and HRVs trauma.

A psicanálise na China: evolução e desafios / Psychoanalysis in China: developments and challenges / El psicoanálisis en China: evolución y desafíos

A China é um país em rápido desenvolvimento, que apresenta necessidade crescente de atendimento psiquiátrico e psicoterapêutico devido a um aumento do sofrimento mental ligado tanto a mudanças na sociedade como a condições traumáticas do passado. O entendimento psicanalítico e as terapias psicanalíticas, cada vez mais, vêm atraindo o interesse dos profissionais e da sociedade. Neste artigo, descrevemos o desenvolvimento da psicanálise na China, e alguns dos desafios envolvidos no ensino da psicanálise e na formação de profissionais em psicanálise e psicoterapia psicanalítica. O conhecimento das diferenças culturais existentes entre a China e o Ocidente é enfatizado.

China is a fast developing country with growing need for psychiatric and psychotherapeutic services due to increase in mental suffering connected changes in society but also with traumatizing conditions in the past. Psychoanalytic understanding and psychoanalytic therapies has had growing interest among professionals and in the public. In this article we describe the development of psychoanalysis in China and some of the challenges involved in teaching psychoanalysis and training professionals in psychoanalysis and psychoanalytic psychotherapy. Awareness of cultural differences between China and the West are underlined.

China es un país en rápido desarrollo, que presenta una creciente necesidad de atención psiquiátrica y psicoterapéutica debido al aumento del sufrimiento mental relacionado tanto a los cambios en la sociedad como a las traumáticas del pasado. La atención psicoanalítica y las terapias psicoanalíticas están atrayendo un interés creciente entre los profesionales y la sociedad. En este artículo describimos el desarrollo del psicoanálisis en China y algunos de los retos involucrados en la enseñanza del psicoanálisis y en la formación de profesionales del psicoanálisis y de la psicoterapia psicoanalítica. El conocimiento de las diferencias culturales existentes entre China y Occidente también se destaca en el presente trabajo.

Towards a better use of psychoanalytic concepts: a model illustrated using the concept of enactment.

It is well known that there is a lack of consensus about how to decide between competing and sometimes mutually contradictory theories, and how to integrate divergent concepts and theories. In view of this situation the IPA Project Committee on Conceptual Integration developed a method that allows comparison between different versions of concepts, their underlying theories and basic assumptions. Only when placed in a frame of reference can similarities and differences be seen in a methodically comprehensible and reproducible way. We used "enactment" to study the problems of comparing concepts systematically. Almost all psychoanalytic schools have developed a conceptualization of it. We made a sort of provisional canon of relevant papers we have chosen from the different schools. The five steps of our method for analyzing the concept of enactment will be presented. The first step is the history of the concept; the second the phenomenology; the third a methodological analysis of the construction of the concept. In order to compare different conceptualizations we must know the main dimensions of the meaning space of the concept, this is the fourth step. Finally, in step five we discuss if and to what extent an integration of the different versions of enactment is possible.

[Physicians' attitude towards treating refugee patients]. / Legers forhold til flyktningpasienten.

BACKGROUND: The refugee patient's complex problems represent a challenge for primary and secondary health care. Language problems and cultural differences may cause difficulties in understanding symptoms and ailments. We have assessed how physicians relate to and perceive their competence for treating this patient group. MATERIAL AND METHODS: A questionnaire covering health political and work- related themes is sent to a representative sample of Norwegian physicians every second year. In 2006 11 questions were included on physicians' experience with having refugees and asylum seekers as patients. RESULTS: The majority reported to have middle-level competence in treating this patient group. 28 % of regular GPs assessed their competence to be low. 29 % of regular GPs reported how they liked to work with these patients as "below middle level" or "low". 70 % of regular GPs and 55 % of psychiatrists said it was difficult or impossible to get advice and guidance from experts. 51 % reported to have bad experience with referring to a psychiatrist or a psychiatric hospital department. Doctors reported to often not know whether their patients had been traumatised. INTERPRETATION: The regular GP (who often has the main responsibility for treating these patients) experience that the general conditions for treatment and rehabilitation are insufficient and that psychiatric health services do not offer adequate help.

The influence of extreme traumatization on body, mind and social relations.

Extreme traumatization affects the individual's relation to others in several social and psychological ways. The post-traumatic experiences are characterized by helplessness, insecurity, anxiety, loss of basic trust, and fragmentation of perspectives on one's own life. Special considerations should be given to the destruction of the ability to regulate negative emotions (extreme fear, distress, anguish, anger, rage, shame) in relation to others and activate internal good and empathic object relations. Destruction of the capacity for symbolization of traumatic experience may threaten the mind with chaotic states against which the 'I' tries to defend itself and find a balanced psychic mise-en-scene. The authors emphasize three dimensions that the analyst should observe in his understanding of the traumatized mind and its conflicts. The proposed dimensions are called the body-other dimension, the subject-group dimension, and the subject-discourse dimension. All three dimensions have specific structural characteristics that are expressed in the analytic relation. Extreme trauma causes disturbances in each of these dimensions. The authors present clinical material from a traumatized refugee to illustrate the analytic work.