Introduction

The principal task of the “refugee regime” was to deliver short-term or temporary “emergency life-saving assistance” (Milner 2014). Indeed, the refugee camp was intended to be a temporary solution to an exceptional situation. Since the nineteenth century, humanitarian interventions have grown remarkably (Barnett 2013; Ridley Ngwa 2017) and The United Nations High Commissioner for Refugees (UNHCR), the largest organization mandated to serve refugees, now extends to offering durable solutions (such as local integration), resettlement, and repatriation (UNHCR 2018b). Currently, UNHCR states that the number of forcibly displaced people, which includes refugees, internally displaced people and asylum seekers – terms which will be used interchangeably in this chapter, is 70.8 million worldwide (UNHCR 2018). Sixty-four percent of the world’s refugees no longer live in emergency situations, but prolonged exile (Milner 2014, p. 153). Many camps constitute so-called protracted refugee situations, where residents live in a permanent state of exception to the norms of state sovereignty, without internationally or nationally recognized immigration status and therefore, often, without access to essential rights and freedoms. This can have far reaching political and personal repercussions on a person.

Edward Said wrote: “just beyond the frontier between “us” and the “outsiders” is the perilous territory of not-belonging: this is to where, in a primitive time, peoples were banished, and where in the modern era immense aggregates of humanity loiter as refugees and displaced persons” (Said 2000, p. 177). The camp acts as the material symbol for those who do not belong to the sovereign state and those who are outsiders to communities of citizens. Not only is the camp symbolic of political exclusion but also of the human consequence of conflicts born from the failed liberal globalization project. Peters argued that “the refugee camp is the creation and symbol of the age of failed western globalization policies that point to free trade and liberal international global politics on the one hand and yet on the other involve “globalization as war” and ongoing conflicts over oil, oil pipeline, and strategic territories” (2018, p. 1166). The United Nations 2030 Agenda for Sustainable Development agenda aims to address global economic inequalities and strengthen peace (UN 2020), yet progress is compromised due to rising global wealth inequalities, which also impacts foreign aid donations (World Economic Forum 2019). The amount of international aid reaching certain assistance projects (including refugee camps) is often influenced by the political agendas of the donor countries and the values of the organizations funded to deliver assistance projects (Horst 2008; Kelberer 2017; Loescher and Milner 2006; Marriage 2006; Murat 2020).

Other agendas, as well as the political and economic ones, that shape the type and amount of refugee assistance programs. There have been various attempts to create overarching value systems that can be applied to humanitarian (including psychosocial) and development actors worldwide and promote more collaboration, since at least the 1960s (Thomas 2017). One of the more recent attempts, the Global Compact on Refugees (GCR) (UNHCR 2018a), was a UNHCR led endeavor, providing a framework for international responses to large refugee situations. It constituted an approach that combined humanitarian interventions, development, and resettlement, which had previously been separate. Annex I of the 2016 New York Declaration: The Comprehensive Refugee Response Framework (UNHCR 2019), which was used to inform the Global Comact on Refugees, stressed the importance of self-reliance for displaced people and called for a lessening of burdens on host societies, as well as emphasizing third-country responses and voluntary repatriation (Hansen 2018). One critique of the Global Compact on Refugees was that interventions aimed at improving the psychosocial wellbeing of refugees has depended on which policy the host state wishes to use and is often reflective of other economic and political interests (Alinikoff 2018; Ozcurumez 2018). With regards to the psychology of people residing in refugee camps, the assistance programs delivered to “address psychological needs” are also influenced by the agendas of donor governments and values of the organizations delivering interventions (Weissbecker et al. 2019).

In this chapter on the psychological impact of residing in refugee camps, it will be argued that camps have become symbolic of “the refugee experience”; microcosms of the discourses and practices associated with refugees that take place outside camps – in political, academic, humanitarian, clinical and social domains. Through critically analyzing the context within which migrant camps function, we can begin to understand how the systems of belief give rise to certain conditions of living, including those which may cause distress for the residents. It will be argued that considering the psychological impact of people residing in refugee camps necessitates a consideration not only of the individual’s psychology and the environmental stressors that they may be responding to, but a much wider understanding of the political, economic and humanitarian agendas that are also environmental stressors, in a much broader sense, which people may directly or indirectly be psychologically and emotionally impacted by. The chapter will also cover some of the other more traditionally recognized factors that can cause distress in a person residing in a camp– including effects on identity, sense of belonging, meaning-making and their role or position in relation to others. Finally, the chapter will consider the types of psychosocial interventions that are administered within camps, in the hope that insights might be gleaned for psychologists, psychosocial workers, social care and humanitarian practitioners in the field. The terms refugee camp, migrant camp and displacement camp will be used interchangeably.

The Global Context

Refugee camps are situated within a broader geo-political, economic and social context. The camp requires funding and the architecture of funding is such that it locates the source of funding in the donor countries. How camps are set up, managed and operationalized (including the psychosocial interventions that are dispensed therein), are all issues influenced by this donor architecture. The process is top down – as long as foreign aid is allocated to projects on the basis of the policies, research agendas and political/humanitarian values of donor country, then the donor government ministries will dictate the amount of funds allocated and the types of causes these should be allocated to (FCO 2020). It therefore becomes a struggle, at times impossible, to start from the perspective of the person who lives in the camp – what their needs are, what their priorities are and what their preferences might be. Consequently, residents of refugee camps can be consulted, perhaps even a needs assessment can be conducted, yet because of the funding architecture, they will always be positioned as recipients rather than active agents within the camp.

The problematic top-down funding model is further compounded by the fact that emergency relief bureaucracies’ profit (either financially or politically) from the amount of the donations they obtain and spend. A perceived need in relation to humanitarian causes is constructed often based on the values and ethos of certain members of the donor country: “In response to this perceived need, budgets for relief work have also ballooned: in 1995 about $8 billion was spent on relief. Less predictable is the fact that these spending increases have not been accompanied by a concentration on one or two major centralized agencies; instead there has been a proliferation of groups. In 1980 there were about 1,600 nongovernmental agencies operating out of the 24 economically developed OECD states. By the mid-1990s there were about 4,600” (Walters 2001, p. 9).

Furthermore, the size of these donations is also at times dictated not by the extent of the recipient’s needs, but the emotional plight of the cause and whether this appeals to the charitable values of the donors. In other words: “the ‘bottom line’ for the humanitarian agencies was not financial profits in a price-setting market, but the ability to attract more dollars through appeals to sympathy, friendship, empathy, and the emotional criteria implied by ‘deservedness’. The engine through which this emotion is generated is the international press, which focuses sympathy through its selection of crises to respond to (Walters 2001, p. 13).” Migrant camps are situated within this larger context which is constructed, in the first instance, to be inherently disempowering for the people “benefitting” from the aid donations that fund the camp and many of the interventions disseminated therein. The implications of these fundamental inequalities and uneven power relations will be explored further in this chapter.

People Who Migrate

Definitions pertaining to migration are multifarious, partly owing to the disparities between disciplines, although largely because definitions are determined by national and international law and political agendas. Within migrant categories there are various and complex subsections defined by the legalities of different stages of the migration process. An important caveat to note, before proceeding to describe definitions, is that beyond explaining legal designations it is useful to consider the tacit and psychological meanings of categorizing people as “forced migrants,” “refugees,” “internally displaced people,” etc. From a constructivist epistemology, how knowledge comes to be known is intimately linked with language – definitions of labels are categories created and developed by a society and are therefore subject to the perceptions, assumptions and alterations of that society. They can also be taken to represent the biases, prejudices, ethical and moral codes of a given society. Definitions point at the prolific tendency of humans toward clustering people into groups and labelling them. Consequently, definitions in this chapter are explored not necessarily because they are valuable or true, but rather because they are what people residing in refugee camps are confronted with.

The international Organization for Migration (IOM) provides the following definition: “forced or involuntary migration – sometimes referred to as forced or involuntary displacement – a distinction is often made between conflict-induced and disaster-induced displacement. Displacement induced by conflict is typically referred to as caused by humans, whereas natural causes typically underlay displacement caused by disasters… forced migration is “a migratory movement which, although the drivers can be diverse, involves force, compulsion, or coercion.”1 The definition includes a note which clarifies that, “While not an international legal concept, this term has been used to describe the movements of refugees, displaced persons (including those displaced by disasters or development projects), and, in some instances, victims of trafficking. At the international level the use of this term is debated because of the widespread recognition that a continuum of agency exists rather than a voluntary/forced dichotomy and that it might undermine the existing legal international protection regime” (IOM 2020).

Lischer (2005) uses descriptive categories based upon the cause of the migration, which has historically been referred to as “push and pull” factors (e.g., persecution, economic, political, cultural, or environmental). In terms of considering displacement as a subjective phenomenon, language describing someone who is fleeing from somewhere or moving toward somewhere has subtle but strong implications. Diaspora comes from the Greek meaning “the movement, migration, or scattering of a people away from an established or ancestral homeland” (Merriam-Webster Dictionary 2020a). The origin of the word “refugee” can be traced back to the seventeenth century from the French word “réfugié” meaning “gone in search of refuge” from the Latin “re” (back again) and “fugiō” (flee) and has also come to mean a place to take shelter (Oxford Dictionary of English 2010). The connotation of the word refugee suggests a moving-away-from; defined as “one that flees” (Merriam-Webster Dictionary 2020b). The United Nations High Commission for Refugees, in a key document in international law referred to as the Refugee Convention, defines a refugee as someone who: “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country” (UN 1967). In 1995 the Convention was altered to incorporate not only victims of specific political persecution but also: “those displaced by war, occupation and events seriously disturbing public order…those who flee poverty and wretched conditions associated with marginalisation and prejudice” (Marfleet 2006, pp. 11–12). Some 150 of the world’s 200 or so states have undertaken to protect and not return refugees to a country where they would be persecuted, by signing the 1951 Refugee Convention and/or its 1967 Protocol. The Refugee Convention relating to the Status of Refugees and its 1967 Protocol (UN 1967) paved the way for succeeding regional laws, which together with international human rights laws, constitute the “international refugee protection regime under which UNHCR exercises its mandate and responsibilities” (UNHCR 2018b, p. 1).

In layman’s terms, refugees are people who experience conflict-induced displacement and migrate across internationally recognized borders. If, after this journey and going through the available legal channels of the host country, a person has been recognized as a refugee (often referred to as being given refugee status), they then have the right to remain in that country and avoid deportation. However, a person who has fled conflict and crossed borders seeking refugee status, yet their claim is being processed, is labelled as an asylum seeker. Those recognized as refugees are in a better position than other forced migrants, in that they have a definite legal status and in theory, the protection of UNHCR. When a person or group flee from their homes because of conflict but do not cross internationally recognized state borders, i.e., they remain within their country of residence, they are legally termed internally displaced persons (IDPs), or sometimes internal refugees. There is no specifically mandated body to provide legal or institutional support for IDPs. International agencies generally grant them protection and support although UNHCR has refused to allow the extension of its mandate to incorporate them (Marfleet 2006).

There is also a debate, largely in the field of international relations, refugee studies and political circles, around whether the term “forced migrant” or “refugee” is more appropriate. Some theorists argue the term “forced migrant” has been used to re-classify migrants who would have otherwise been able to claim political protection under the UN Convention and gain access to additional rights. Mourad and Norman (2019) argue that broadening the remit of the term “forced migrant” to encompass people seeking legal avenues for protection means that governments can abdicate their responsibility, claiming they are other types of migrants. Conversely, there are also authors who argue the concept of “the refugee” is constructed to enforce the notion of sovereignty through a process of exclusions – in other words, the citizen can only exist within the sovereign state of the non-citizen exists (Nyers 2006).

The problem of definitions is once a legal category is designated to a person – refugee, asylum seeker, etc., the label becomes confused with an identity, one which is often imposed without consent. Speaking of a refugee identity is one of uniqueness. Political refugees, environmental refugees, non-status refugees, internally displaced people, involuntarily resettled people, deportees, forced migrants, involuntary migrants, etc. People who migrate under these circumstances are products of an extraordinarily vast and diverse global phenomenon of coerced displacement. To conceptualize one identity is not possible: the experience of forced migration involves no single identity position but rather diversity and variation. Despite this, in the current zeitgeist, depictions of forced migrants often contend that there lies a universal, underlying identity commonly shared by all and such discourses are often are associated with lack or absence and link “the refugee” with invisibility, hiddenness, emptiness and loss.

Refugee Camps

A refugee camp is an impermanent settlement providing shelter for forced migrants. Usually the suppliers of such camps are the United Nations, other international actors and charity organizations. Refugee camps epitomize humanitarianism, and often have various aims including to: “provide refugees with temporary shelter, assistance, and protection until they are voluntarily repatriated to their country of origin, locally integrated in the host state, or resettled to third countries” (Jenny 2014, p. 3). Transit centers are often set up to house forced migrants while they wait to be placed into other camps. Refugee camps differ in capacity; satellite camps usually house smaller numbers and are dotted around the main camp, which can often accommodate thousands of people. While as aforementioned, the migrant camp has become synonymous with the notion of “the refugee,” most refugees – and indeed most forced migrants – do not live in camps but in urban areas often located in neighboring countries: “UNHCR collects data on the type of accommodation in which individuals reside… Accommodation types are classified as planned/managed camp, self-settled camp, collective centre, reception/transit camp and individual accommodation (private), as well as various/unknown if the information is not known, is unclear or does not fit in any of the other categories… The majority of refugees lived [in 2018] in privately hosted and out-of-camp individual accommodation (60%)… in contrast, there were also countries where most refugees were reported as living in some kind of camp setting such as Bangladesh, Tanzania, South Sudan, Ethiopia and Nigeria…. The Syrian refugees were overwhelmingly an out-of-camp population, with more than 98% living in individual accommodation. Afghan refugees were also likely to be in individual accommodation with 80% of the population doing so.” (UNHCR 2018, p. 62).

In 2017, people who left their country of origin in search of security predominantly came from Syria, Afghanistan, South Sudan, Myanmar and Somalia. After leaving the country of origin, the majority of people migrated to neighboring countries (UNHCR 2018b). Humanitarian agencies set up temporary accommodation in the form of camps to receive the communities of people as they cross borders. Therefore, by definition, camps are usually located next to countries that are politically unstable, where there is war or conflict. Because the largest number of refugees worldwide come either from the Middle East or sub-Saharan Africa, the biggest camps in the world are in these regions (as outlined in Table 1 below).

Table 1 The seven world’s largest planned/managed camp
Full size table

Commonly, the host country has primary responsibility for the refugee camp, particularly regarding issues relating to security and protection of basic human rights. In practice, however, at times host countries are unable to secure effective protection, arguably – at least in part – because of the unequal sharing of “responsibility” (Janmyr 2014). Humanitarian agencies do not come under state control, they base their policy and interventions on humanitarian principles (LSE 2009). These are intended to stand above national politics, in theory creating a depoliticized space. The three core principles of humanitarianism are humanity, impartiality and neutrality. In practice, there are substantial challenges to upholding these principles – from donor investment agendas to humanitarian workers faced with ethical dilemmas on the ground (Seybolt 1996; Slim 1997). Claiming to uphold values that in practice are difficult, if not impossible to implement, implies a lack of inherent transparency within the humanitarian sector. One reading of this might argue that this also constitutes an “overcoding,” whereby humanitarian intervention is legitimized through positioning the refugee as a problem to be solved, and humanitarianism as the solution to that problem (Nyers 2006). Relying on a universal morality without explicitly acknowledging its inherent biases, conflicts and prejudices intrinsic in any statement of principles, points to paradox’s and ambiguities within humanitarian and psychosocial spaces (Peters 2018). Furthermore, stating a positionality that cannot be upheld in practice implies unequal power relationships and compromises any possibility of a refugee-centered approach.

Receive with no Agency in the Camp

Implicit assumptions within humanitarian discourses and the structure of service provision in camps appeals to sympathy and charity, positioning the giver as powerful and the receiver as a complaint victim. Identities are imagined by the donors, apparent in the funding architecture, top-down governance of the camps and policies affecting refugees in camps. These identities depict humans as passive and hence, the concept of “refugeeness” – a homogenous identity – is conceptualized. Refugeeness in camps is often constructed around meeting basic needs – food, water, sanitation, and medicine. Individuals are silenced, as their political agency has no place in the camp space. In fact; “to be worthy of humanitarian assistance, the receiver must be someone without a past, without political will and without agency. As Nyers, inspired by Ranciere, argues: “the human victim has no way of uttering political voice; he can only groan in pain” (Turner 2016, p. 5). In this way, humanitarian intervention not only fails to acknowledge the individual as active and capable; by reducing the person to a body to be “done to,” the very resources that individual needed to travel to the camp and survive there are being challenged, if not compromised. In other words, humanitarian interventions in these instances not only fails to acknowledge agency, but also potentially corrode it.

Refugeeness in contemporary thought now exists firmly within liminal spaces, characterized through absence and segregation; located outside, displaced, dislocated, and uprooted. Humanitarian principles dictate that interventions should be politically neutral, yet the camp, in promoting such neutrality, positions its residents as outsiders. At times silenced from taking a political stand, residents in camps can be prevented from accessing much needed political resources. Perhaps, in part, this silencing occurs because “the notion of refugees actively contributing to violent resistance predates the contemporary international refugee regime and has existed for as long as individuals have been forced into exile” (Janmyr 2014, pp. 3–4). Nyers articulates this in the following way: “the state logic that runs throughout the discourse of “refugeeness” can also be understood as a power of capture: subjects of the classification regime of “refugeeness” are caged within a depoliticized humanitarian space…sovereign power… tries to capture and over code all that it encounters within its own logic of imminent relations of inclusion-exclusion” (2006, p. xiii). This depoliticized space of “not belonging” is a hostile environment not conducive to promoting psychological or psychosocial wellbeing. Therefore, if communities within camps wish to engage in political discursive spaces this should be encouraged, otherwise depoliticization come to be a form of exclusion with sovereignty as the primary identifier of legitimacy and anyone who is not associated with a sovereign state (e.g., a refugee) is silenced. Engaging in political discussions can assist in building interpersonal relations based on common interests and beliefs, a shared identity other than that of being a camp resident. Politics, in this way, helps transcend the territory of the camp and even of the experience of being exiled (where there are no voting rights). Engaging in discussions on politics is also a part of reconciliation – a discursive space within which to narrate and process experience, which might potentially be helpful.

The Social Fabric and a Sense of Belonging in the Camp

In the context of planned or managed camps, the humanitarian space is not only representational, it is fixed by its own borders. “Belonging” in the camp is in some senses paradoxical – on the one hand people often “belong” in camp spaces for protracted length of time, forming communities and setting up innovative networks (trade, from example) both inside the camp and in surrounding communities. On the other hand, refugees are told they do not belong – camps are constructed as temporary and movement outside the camp is often restricted (e.g., because it unsafe as camps are often next to conflict zones) (Schneider 2015). As well as not “belonging” (according to the management and administration of camps) within these liminal spaces, or to the host country in which the camp is located, the inhabitants may also get the sense that they no longer “belong” to their country of origin, as it is too dangerous to return (and perhaps what they would return to is not what they left). This is to say that: “contested sovereignties in camp settings have been an important theme in refugee research, acknowledging the coexistence of multiple governance actors and a resulting contention of norms, interests and ideologies…established in the territory of a refugee hosting state but containing a population that has no claim to citizenship and whose well-being is often of limited concern to that state.. Refugees themselves play important – but often under-recognized roles in running camps through elected camp committees, unelected traditional authority structures, religious organisations and civil society” (McConnachie 2018, p. 121).

Social resources that existed in an individual’s community of origin can be completely disrupted because of migration. Within camp situations, creating some sort of meaningful social fabric, both in smaller and larger groups, is often made difficult in the face of humanitarian hierarchies, which do not permit such a symbolic order to flourish (Turner 2016). Camp residents “belong” to a place that in the most basic of ways, is insufficient – for example, people may face malnutrition because of insufficient food provision or physical illness because of lack of access to medical provision (either inside the camp or in the surrounding area of the host country). Host country governments, who often perceive refugees as competitors when resources are scarce, or even as security threats, often restrict the free moment of residents outside of the camp or prohibit refugees from working within the host country.

To belong in a camp demands the resident to be complicit in the restricted freedom of moment. It has been argued that these assumptions could be challenged if camp residents were permitted to freely participate with and contribute (e.g., their skills or knowledge) to neighboring communities (Papadopoulos 2008). The camp is therefore created as temporary but the situation is protracted, the camp proclaims to offer emergency life-saving support but at times does not meet basic needs, residents are told they cannot leave the camps parameters to meet these basic needs for themselves (e.g., seeking employment in host communities). Camps could be spaces of opportunity for the people who live there and those in local neighboring communities (Corbet 2016; Turner 2016; Werker 2007). If such attempts were not prohibited by camp policy then individual, communal and relational identities and networks could form organically, providing a key resource for individuals.

Furthermore, within some camp’s, refugees are often assigned numbers. When administering food or other types of interventions, individuals recite their number (rather than presenting their name) and humanitarian workers and other professionals do the same. Numbers are used to categorize substances and objects, to calculate quantities, and so on. Replacing an individual’s name and imposing a number as their identity is not only an imposition of power but a dehumanizing act. In order to belong in the camp then, one must remain anonymous, hiding one’s prior identity and subjectivity behind a number. As humans, psychologists and psychotherapists posit that how we come to understand our own identity and whether this was chosen or imposed can have a profound impact on a person’s sense of freedom and fulfilment (Spinelli 2005). Therefore, it is fundamentally important to people’s wellbeing that we have agency in affecting how we come to understand ourselves as belonging in the world – including being called by name.

Psychosocial Interventions

Psychosocial support are terms largely used in the humanitarian community, some limited communities in psychology and within academic circles (Bemak and Chung 2002) to describe support that considers the refugee’s psychological and social wellbeing. It was decided that the terms allied with psychology (such as “mental illness”) were no longer appropriate as they were associated with identifying and treating isolated, pathological so-called mental disorders, which were seen in isolation rather than a response to one’s environment. This interpretation of how psychology views so-called mental illness lead to the creation of the term “psychosocial” – to acknowledge the interplay of context and psychological state. Contemporary literature often refers to “psychosocial support” and “psychosocial wellness” (Ahearn 2000). Despite this careful consideration of what language should be used to talk about people with this shared experience and the type of interventions provided to them, it has arguably been in vain, as Ahearn (2000) argues: “it is interesting to observe that there is little agreement as to what constitutes psychosocial well-being. It is much easier to describe factors associated with well-being, especially negative factors that connote a lack of well-being. This approach has limitations for it highlights weakness and pathology rather than strength and health. It focuses on the negative rather than the positive, oftentimes ‘medicalising’ the problem, and…the vast majority of researchers in this field prefer to study trauma, stress, and the like rather than investigate psychosocial well-being” (2000, p. 5). What constitutes psychosocial support has historically been an area of confusion in the field and interventions are a varied mix, from peace building, advocacy and human rights to individual psychotherapy. It is noteworthy that there has been some shift from predominantly one-to-one or individual counselling, which historically was the main psychosocial intervention, toward calls for more of a community focus (Prewitt 2008; Purgato et al. 2018) as well as more culturally adapted interventions (Tribe et al. 2017).

The Inter Agency Standing Committee (IASC) is the highest level of coordination at international level within the humanitarian sector and their Guidelines on Mental Health and Psychosocial Support in Emergency Settings hold considerable weight within organizations providing psychological and psychosocial interventions. One of the main aims of the guidelines is to stipulate, in detail, potential interventions to be “mobilised,” “administered,” and “coordinated” in emergency situations (IASC 2007). The pretext of these interventions is built upon defining resources and deciding where and how these are lacking. The other facet of this rests within the interventions themselves and whether they are founded either on evidence, empirical findings, research, etc. or conversely, on a strategy that is not evidence-based. While it is accepted there is a lack of evidence for which interventions are effective or beneficial, it is also asserted that support can actually be harmful: “Work on mental health and psychosocial support has the potential to cause harm because it deals with highly sensitive issues. Also, this work lacks the extensive scientific evidence that is available for some other disciplines (IASC 2007, p. 10).” In layman’s understanding, “support” is typically beneficial, but in this conceptualization, support can be damaging. This contrast between help and harm creates an uncomfortable risk where “support” is presented on the surface as helpful and well-intentioned but can do quite the opposite in practice. In 2014 the IASC guidelines were reviewed, with calls for more evidence-based practice in the policy and practice of psychosocial interventions (IASC 2014).

Western Therapeutic Paradigms

In the present context of humanitarian emergencies, it is important to examine the theoretical underpinnings of the psychological approach being drawn upon. Western therapeutic paradigms are based on the assumption that certain emotions, thoughts and behaviors are problematic/maladaptive/dysfunctional/sedimented (the language varies dependent on the therapeutic modality) and suggests various ways in which change can be brought about. This notion in and of itself is constructed and feeds from and into social narratives and generally accepted wisdom. In other words: “in contemporary psychology, the prevalent symptom-based approach, which emphasizes the measurement of observable phenomena and encourages the practitioner to interpret this within a framework of illness, disease or dysfunction is one example of dichotomizing the behavior-experience polarity. This polarization is evident in, for example, the invocation of the four “Ds” (Deviance [from a statistical norm], Distress, Dysfunction and Danger) when conceptualizing and providing therapeutic intervention based on psychiatric labelling (Davis 2009). When adopting this approach to understanding experience, criteria are set in order for a phenomenon to be considered legitimate. The psychologist defines, or rather consults, predetermined criteria, for example, as set in the DSM-V (American Psychiatric Association 2013), for what behavior they will consider as evidence of a given phenomenon. In this way, the phenomenon is confused with the criteria set to define the phenomenon (e.g., sadness is the amount of times someone cries). It is in this way that mainstream psychology, based on the natural scientific method, limits itself to engaging with only one aspect of the behavior-experience polarity (namely, behavior) (Valle et al. 1989). Furthermore, the evidence base for consistency and validity for concepts and diagnosis is poor in the symptom-based model, yet this model remains prevalent in mainstream psychology” (Luca et al. 2019, pp. 55–56). This is imperative to bear in mind when practicing in other cultures which may not share the many, varied assumptions that are held within the general concept of therapy, as well as each of the therapeutic modalities.

In the present context, the cognitive-behavioral approach is often used to inform psychological and psychosocial interventions. It understands humans as being made up of four aspects (cognition, behavior, emotionality, and physicality). These aspects are seen as interrelated, with problems occurring when negative processes affect them. Cognitive-behavioral interventions aim at changing these processes, usually by focusing on one of these aspects, for example by changing anxious thought patterns through relaxation exercises. Based on this understanding, it is common for humanitarian aid workers to learn and provide stress-management interventions to encourage refugees to reconsider how they view their situation and how related thoughts/feelings/behaviors/physical states can be managed. The humanistic paradigm, in general terms, understands humans as tending toward self-improvement. How humanitarian interventions were provided historically reflects these humanistic beliefs, in so far as food and shelter were distributed in refugee camps with the assumption that communities would then resolve other issues. Cognitive-behavioral and humanistic approaches are only two in a plethora of psychological theories and associated interventions but these, aside from the psychopathology, feature most in the theory underpinning psychological and psychosocial interventions. It is noteworthy that all the aforementioned approaches assume that talking about personal difficulties with a therapist is helpful. Wessells asserts that: “counselling methods in general place significant emphasis on disclosing feelings and personal information, which may be useful in some contexts. The disclosure of distress, however, is inappropriate in some cultures, particularly if negative disclosure reflects badly on one’s family (Lee 2001). Moreover, talking about one’s experience can be harmful in some contexts” (2009, p. 845). There is paucity in the literature which grounds such psychological/psychosocial interventions in evidence that substantiates their usefulness in the context of a refugee camp. From the perspective of psychology, the need to base therapeutic interventions in a cohesive understanding an approach that places the client at the heart of the work is essential to good practice (Cooper 2008; Woolfe et al. 2016; Tribe 2002).

Psychopathology

The notion of psychopathology asserts it is possible to define “normal” and “abnormal” behavior and identify associated “treatments” thereof. This approach is pervasive in the forced migration field (Summerfield 2001). Psychopathology as a way of understanding distress is prevalent in forced migration literature and is the major framework for understanding “the refugee experience”; therefore, this approach will now be given special consideration. Psychopathology is based on the premise that problems are either physical (tangible) in nature or psychological (intangible) and behave predictably, in a linear, cause-and-effect fashion. This assumption is founded on Cartesian logic (Descartes 1996). Psychopathology makes claims that experience can be categorized in terms of mental illness and within that there are categories that can be diagnosed by experts. The Diagnosis and Statistical Manual (DSM) currently in its fifth edition (APA 2013) outlines such categories and is used internationally to classify people’s mood and perception. “Mental disorders” are based on the Western biomedical model of health and focus entirely on biological factors and neglects psychological, environmental, and social influences. Diagnosis can be useful, for example in can be helpful to have a common language with which to describe specific problems for certain professionals to communicate. It can also be helpful in some instances for the person having the experience as it can serve to normalize and provide certainty or assurance. However, the DSM has been critiqued for inaccurately basing understanding the human condition through the bio-medical model of health which is more appropriate to understand biological and physiological functioning of the body. It has been said that the use of the DSM reflects “a growing tendency in our society to medicalize problems that are not medical, to find pathology where there is only pathos, and to pretend to understand phenomena by merely giving them a label and a code number…” (Kutchins and Kirk 2001, p. X).

If “the refugee experience” is understood in terms of pathology – including diagnostic labelling, there is a danger of medicalizing distress, when perhaps distress is an understandable response to the injustices and oppression’s – including within the camp itself – that the person may have experienced. Furthermore, if psychopathology is prioritized as a lens through which to view experience, there is a risk that what is meaningful to that person might be overlooked. White posed: “we spend so much of the time…trying to “work out” our problems, or figuring ways to be rid of the psychological demon’s that plague us.…It fails to occur to us that…the symptoms of our dis-ease are precisely the statement of the soul’s discomfort which, because we will not heed its knocking at our door, must come in by the window” (2015, p. 7). Pathologizing distress has also been critiqued for devaluing and overlooking the natural resilience humans show in crisis situations (Bonanno 2004). Wessells (2009) states: “the exclusive focus on deficits frequently creates a biased picture that limits program alternatives, supports stereotypes of people as helpless victims, and reflects the researchers’ biases rather than the complex realities at hand…Significant numbers of emergency-affected people exhibit remarkable resilience in that they function well despite adversity, do not experience profound suffering, and cope reasonably well with their problems of living. In my experience, resilience is the untold story of emergencies, and is seldom addressed by researchers and workers conducting assessments” (2009, p. 848). Psychosocial practitioners need not overly focus on resilience either but rather, first adopt a curiosity about how interventions, if at all, can facilitate individual and collective processes that already occur.

Trauma and Other “Mental Illnesses”

In part, pathologizing “the refugee experience” has led to the popularity in research, assessment, diagnosis and treatment of trauma as the experience of forced migration as often seen as “traumatic” (Bhugra et al. 2010; Farrell et al. 2020; Miller et al. 2010; Neuner et al. 2004; Tarricone et al. 2005). Where trauma, often used interchangeably with Post Traumatic Stress Disorder (PTSD), has become tantamount to the concept of the “refugee experience,” “the refugee” is transformed into the disordered subject. The measure, as stipulated by APA, for being diagnosed with PTSD includes meeting two criteria from the following list (described in greater detail within the DSM-5): “exposure to a traumatic event; intrusive recollection of that event; persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness; persistent symptoms of increasing arousal” (APA 2013). The diagnosis of acute or chronic PTSD is determined by the duration of symptoms and to what extent the person’s ability to function has been disturbed. Furthermore, research on outcome measurements for trauma treatment have been conflicting; some evidence suggests no correlation between psychosocial interventions for the treatment of trauma and the improvement of “symptoms” (Tol et al. 2011), whereas other evidence suggests interventions are effective (Schauer and Schauer 2010).

Assumptions implicit within the trauma paradigm when used to understand the “refugee experience,” include:

Assumption 1:

Experiences of war and atrocity are so extreme and distinctive that they do not just cause suffering, they cause “traumatisation”

Assumption 2:

There is basically a universal human response to highly stressful events, captured by western psychological frameworks

Assumption 3:

Large numbers of victims traumatised by war need professional help

Assumption 4:

Western psychological approaches are relevant to violent conflict worldwide. Victims do better if they emotionally ventilate and “work through” their experiences

Assumption 5:

there are vulnerable groups and individuals who need to be specifically targeted for psychological help…Assumption 6: Wars represent mental health emergency- rapid intervention can prevent the development of serious mental problems, as well as subsequent violence and wars” (Summerfield 2001, pp. 39–44)

Trauma, rather than describing a feeling, emotion or affect is a concept – an empty signifier, used mainly by Western psychologists, psychiatrists and counsellors, to group certain actions, thoughts and behaviors into one category. By assuming “trauma,” or indeed any of the other constructs psychology uses to frame certain experiences (“depression”; “anxiety”; “schizophrenia,” etc.) as fact, the practitioner not only limits themselves to pathologizing experience but also runs the risk of enacting a kind of conceptual imposition. This legacy of psychic coloniality is perpetuated through social, political and economic discrimination by pathologizing experience of those who live in camps through Western psychological discursive frameworks and practices (Quijano and Ennis 2000). Narratives in relation to practices, traditions, cultures, etc. are framed as Other (Silverstein 2005).

Most camps are located in sub-Saharan Africa. After Africans gained independence, language shifted from “primitive” or “backwards” to “developing” – where modernization implied the economic growth needed to change values, societies and the way they earned a living. Assembling groups in one place (for example in camps) meant this “learning or adaptation [is] a condition of their survival” (Harrell-Bond 2000, p. 2). Indeed, humanitarian practice in camps, either explicitly through mission statements and principles, or implicitly through the practices of the delivery of interventions, governs “right ways of living as a refugee” (Feldman 2015). Such “over coding” creates and strengthens structures of power and hegemony (Quijano and Ennis 2000), including through racialized practices where “refugeeness” is synonymous with discrimination. This institutes the primacy of whiteness in what has been called “the coloniality of migration” (Rodríguez 2018). Humanitarian practices in camps have been criticized for replicating colonial power agendas (Ngo and Hansen 2013) and psychological interventions are part of this category. Claiming to offer an intervention (whether that be curative, educational, correctional, etc.) that overrides someone’s usual way of understanding and imposes another assumes a hierarchy of legitimacy over subjective experience, in this context, is a kind of psychic colonialism. Albeit obvious, it is noteworthy that there are other frameworks of understanding, other ways to interpret and understand experience. In sub-Saharan Africa, for example, there is an enormous variety of cultural, social, religious, political and psychological frameworks of understanding (Dona 2010; Tribe 2011; Tribe 2013; Qureshi and Tribe 2013). It should first be asked by the person offering a psychological or psychosocial intervention: does the person share the notions and assumptions of the paradigms used to understand their experience?

Psychosocial Interventions: Evidence-Based Practice and Future Research

While there may be disagreement as to which theoretical approach might best inform interventions, there is general agreement in the field on one issue: that there is an overall lack of evidence-based practice for psychological and psychosocial interventions in the field, including within refugee camps (IASC 2014; Schauer and Schauer 2010; Wessells 2009). It has been argued throughout this chapter that frameworks of understanding (including narratives, stories, definitions, language, etc.) are resources with which we use to make meaning. Much of the contemporary literature psychologizing the “refugee experience” speaks of categories applied to individuals in vastly different cultural, economic, political and social circumstances. Homogenizing any kind of experience is contentious but even more so when discussing the “refugee experience” because of the diversity in contexts. Aside from oversimplification, psychologizing refugees positions the migratory experience within “Western” frameworks of understanding. Most modern “Western” psychological paradigms hold positivist epistemologies, which espouse that truth is knowable and discoverable. Psychology, from this perspective then, becomes about delineating causal explanations and providing curative interventions. These are administered on the basis of a pre-defined notion of the health-illness (or mental order-disorder) continuum. Such causal explanations of experience are not only culturally incompatible with most communities in camps, they enforce structures of control in a hierarchy of expert-recipient. The camp itself might be thought of as a systemic instrument of power within the neo-liberal context of globalization and the current status of psychological or psychosocial responses as psychically overcoding other ways of experiencing the world. Further research is needed so that the re-organization of structures and power relations can facilitate a “bottom-up” approach, so that the “benefactors” take the lead on shaping the services they receive.

Finally, narratives on the psychology of individuals residing in camps, rather than being simplified to a psychosocial and trauma focused approach need to be more progressive and be evidence-based (Miller and Rasmussen 2014). In order to promote ethically sensitive ways of working, psychologists and psychosocial workers might in the first instance, consider their own values and the assumptions of their frameworks of understanding that color and bias their perceptions of others in an effort to radically interrogate and deconstruct their world view so that they might hope to remain more open to other ways of seeing and experiencing the world. Drawing upon other strands of psychology might also prove useful when adopting an open, flexible approach to working cross-culturally with people who have or are residing in a refugee camp. As an alternative to the most commonly referred to psychological paradigms (including psychopathology), liberation psychology, community psychology, and systemic psychology may have more to offer, notwithstanding abandoning any paradigm that is not appropriate or useful according to the people it intends to assist.

Conclusion

The concept of forced migration is prolific and familiar in the current Zeitgeist. The refugee camp occupies political, social, anthropological and psychological discourses. The sizable body of literature in academic fields reflects this interest. “Refugee mental health” is often measured against normative discourses on citizenship, pathology and wellness and all that is not expressed within these narratives becomes either subsumed or disregarded. It has been noted in this chapter, that when working with people who reside in migrant camps, there is a prevalence of psychological and psychosocial paradigms, which ground their assumptions firmly within Western concepts of mental “health” and “illness.” Such models often focus on identifying specific symptoms and provide associated interventions. Western psychology, with its implicit power when engaging with camp residents, plays a regulatory role as it classifies experience into pathologies and suggested ways of intervening. This is not to say that distress, for example, is not intensely lived and experienced as people negotiate events of life and death, but labelling these as “trauma” or someone “having” a disorder of the mind (e.g., PTSD) imposes classifications on experience with specific value judgments. It is in this way that difference becomes fixed. Psychopathology may be a useful way to understand experience in some contexts but should be used with caution and should not be the starting point – instead, the cultural, political, religious values and other ways an individual or community makes meaning, should be given priority.

It is also common for nonstatutory organizations to commission research in this area. How people who reside in migration camps are researched and understood often depends upon those who represent their voice. It is vital then, to scrutinize the many, complex interplaying issues which affect this representation; the values that underpin any paradigm employed to conceptualize the human condition; and the economic, political, social, and institutional structures that impact peoples experience. This chapter has also noted the tensions between, on the one hand, the economic architecture of aid, which often positions, in many ways, people as passive recipients and yet on the other, psychological interventions that aim to “make healthy” though imposing culturally inappropriate ways of conceptualizing the human condition. A paradigm shift would imply changes in both discourses and practices, moving away from “involving,” “supporting,” “empowering,” “giving voice to,” etc. and towards a relocation of the locus of power. This first requires an alteration in discerning the neoliberal subject through notions of “resilience” and “vulnerability.” Instead, there must be a recognition of the systems of oppression that give rise to global, national, local and community (including camp communities) unjust practices. This re-location of power might include but not be limited to considerations of agency, politics and social fabric. In general terms, how we processes experience, what it means, our expectations of the future, how comfortable we feel in ourselves, how our bodies feel, our relationship to emotions (including distress), our role in the community, our faith or cynicism, how we feel strong, and what makes us waver, are based upon the societal and cultural frameworks of reference in which we operate. It is only from this position that practitioners can begin to re-negotiate and co-construct new principles, narratives, and interventions for the individuals they serve.