Feelings of betrayal by the United Nations High Commissioner for Refugees and emotionally distressed Sudanese refugees in Cairo

Abstract

Thousands of Sudanese refugees have fled to Cairo, Egypt in the wake of Sudanese civil conflicts. Sudanese refugees were evaluated with respect to symptoms of depression, post-traumatic stress disorder (PTSD) and social stress. Four respondents (22%) indicated that their interactions with the United Nations High Commissioner for Refugees (UNHCR) in Cairo, Egypt were the worst experiences since war-related atrocities. Fourteen participants (63.6%) felt ‘extremely’ betrayed by the UNHCR on a four point scale. Greater feelings of betrayal by the UNHCR were associated with greater avoidance and arousal symptoms of PTSD, symptoms of depression and trait anger. This is the first study of which we are aware that examines the relationship between sense of betrayal by the UNHCR and symptoms of PTSD, depression and anger among asylum seekers.

Background

The Office of the United Nations High Commissioner for Refugees (UNHCR) was established on 14 December 1950 by the United Nations General Assembly. The agency is mandated to lead and co-ordinate international action to protect refugees and resolve refugee problems worldwide. Its primary purpose is to safeguard the rights and well-being of refugees. It strives to ensure that everyone can exercise the right to seek asylum and find safe refuge in another State, with the option to return home voluntarily, integrate locally or to resettle in a third country. Since its establishment, the agency has helped an estimated 50 million people. Currently, the UNHCR employs a staff of around 6,300 people in more than 110 countries helping 32.9 million people.

Tension between State interests and UNHCR autonomy has been ubiquitous since the latter’s inception¹. Many in international relations view the UNHCR as subordinate to State interests, citing the fact that the UNHCR is dependent on donor States for funding and on host governments for permission to initiate operations on their soil: ‘According to this view, UNHCR is in no position to challenge the policies of its funders and host governments and merely acts as an instrument of states’¹. On the other hand, it is noted that despite such potential restrictions, the UNHCR’s autonomy and authority has grown since its genesis and it has developed independent interests and capabilities¹.

Many Sudanese refugees fled to Egypt in recent years. They came to Cairo seeking safety, assistance from the UNHCR, and education and economic opportunities. The UNHCR estimated that Egypt was home to 23,000 officially recognized Sudanese refugees and asylum-seekers in January of 2009². Local sources estimated the total numbers of official and unofficial Sudanese refugees in Cairo to be much higher; one estimate puts it in the hundreds of thousands³.

Egypt has received international attention for its mistreatment of the Sudanese who fled to Cairo. One of the most flagrant and widely condemned examples relates to a protest beginning in September 2005. Sudanese refugees or asylum seekers camped in front of the UNHCR offices as part of a demonstration, demanding that the UNHCR remove them to a third country with better conditions. The protesters remained there for several months attempting to affect change. In December 2005, the Egyptian police used violence and water cannons to disperse the protest leaving approximately 25 Sudanese dead⁴.

There has also been international legal criticism of UNHCR practices in Cairo. ‘Refoulement’ is a concept of international law, defined as any measure that could have the effect of returning refugees to territories where their lives would be threatened or where they are at risk of persecution. It has been argued that the UNHCR office of Cairo, Egypt, committed refoulement⁵. Although Cairo’s UNHCR granted temporary protection to Sudanese refugees, this status does not grant any social services and denies the right to work, which some believe is equivalent to forcing repatriation: ‘limiting asylum-seekers to the current “temporary protection” regime during a long-term crisis, rather than granting fully-fledged refugee status, is tantamount to forcing repatriation and is therefore a failure of UNHCR to apply its mandate of protection for refugees’⁵.

We have worked with Sudanese populations for approximately 10 years, in locations including South Sudan, the Chad-Darfur border region and Cairo, Egypt. Previous work in Cairo includes a qualitative study with mental health needs assessment and measure adaptation, which took place in autumn 2006⁶. During that study we found a range of individual and interpersonal problems including legal, financial and social difficulties. Experiences with the UNHCR emerged as an important theme during this qualitative evaluation of mental health care needs among Sudanese refugees living in Cairo. Common emotional problems were depression and post-traumatic stress symptoms, as well as high levels of anger, family discord and violence. Upon review of our data and discussion with community members and local partners, we selected individual Interpersonal Therapy (IPT), delivered by trained community therapists, as the optimal intervention to address gaps in mental health care for the Sudanese refugee community in Cairo. The study discussed here represents the baseline data gathered as part of our pilot, Randomized Controlled Trial (RCT) of IPT for Sudanese refugees living in Cairo, which took place from April to August 2008.

Methods

This study of 22 subjects is an analysis of the baseline data gathered as part of a pilot RCT of IPT for Sudanese refugees in Cairo, Egypt. Participant selection criteria included: (1) Age greater than 18 years; (2) Absence of cognitive dysfunction which requires a higher level of care and/or interferes with ability to participate in IPT; (3) Absence of severe thought or mood disorder symptoms which requires a higher level of care and/or interferes with ability to participate in IPT; (4) Absence of drug and alcohol dependence; (5) Harvard Trauma Questionnaire (HTQ) average score of 2.3 or greater, on part 4, items 1–16; (6) Ability to attend bi-weekly therapy sessions for 3 weeks and (7) Ability to give verbal informed consent.

Study design and sample size

Given that the baseline data was gathered as part of a pilot RCT, in which pre- and post- measures of treatment effects were determined, it is inherently a quantitative study. The sample size is intentionally small in this pilot study. It is a small sample of convenience of Sudanese refugees with high symptoms of post-traumatic stress disorder (PTSD) (see below for recruitment information). This study was not designed to obtain results that can be extrapolated for the diverse Sudanese population in Cairo, in particular those with lower symptoms who were not seeking treatment (see limitations). We make no claim that this sample is representative.

Measures

Beck depression index (BDI)⁷

The second edition (BDI-II) is a 21-item instrument intended to assess the existence and severity of symptoms of depression as listed in the DSM-IV. The patient is asked to consider each statement as it relates to the way they have felt for the past two weeks. Each of the 21 items corresponding to a symptom of depression is summed to give a single score for the BDI-II. There is a four-point scale for each item ranging from zero to three. BDI has been used for 35 years to identify and assess depressive symptoms, and has been reported to be highly reliable regardless of the population. It has a high coefficient α, (0.80) its construct validity has been established, and it is able to differentiate depressed from non-depressed patients.

Harvard trauma questionnaire (HTQ)⁸

The HTQ is a checklist which has been used effectively with many refugee populations. It inquires about a variety of traumatic events, as well as the emotional symptoms considered to be uniquely associated with trauma. Part one asks about traumatic events. Part two is an open-ended question that asks respondents for a subjective description of the most traumatic event(s) they experienced. Part three asks about events that may have led to head injury. Part four includes 30 trauma symptoms. The first 16 items were derived from the DSM-IIIR/DSM-IV criteria for PTSD. The other 14 items were developed by the Harvard programme in refugee trauma (HPRT) to describe symptoms related to specifically refugee trauma. The scale for each question in Part four includes four categories of response, rated on a four-point scale ranging from one, ‘not at all,’ to four, ‘extremely.’ Part five is a 28 item torture history questionnaire. The total score is the sum of the PTSD item scores (Part four) divided by 16. Cut off scores for the HTQ Part four have been developed to identify cases/non-cases of PTSD (2.5). This cut-off has been validated against clinical algorithms in other populations^8,9. Some studies have suggested that liberalizing the HTQ cut-off to 1.88 maintains specificity and increases sensitivity¹⁰. We selected a higher cut-off score of 2.3 as a more conservative approach for determining PTSD case status.

Social problems and feelings (SPF)

This is a 38-item questionnaire developed during the first phase of the work in Cairo⁶, which measures the emotional distress resulting from severe damage to Darfur social, cultural and moral norms sustained during civil conflict and displacement. This measure includes an item asking the respondent to rate their sense of betrayal by the Cairo UNHCR on a four point scale.

State trait anger expression inventory (STAXI)¹¹

The revised 57-item STAXI-2 consists of six scales, five subscales, and an Anger Expression Index that provides an overall measure of total anger expression. The STAXI2-State is a 15-item scale and includes three subscales for assessing major components of State Anger (feeling angry, feeling like expressing anger verbally and feeling like expressing anger physically). The STAXI2-trait is a 10-item scale with two subscales: angry temperament and angry reaction. The angry temperament subscale of STAXI-trait measures the disposition of someone to express anger without provocation. The angry reaction subscale of STAXI-trait measures the disposition of someone to express anger when provoked. Factor analyses across multiple populations have supported the identification of these scales^12,13.

Measure translation and adaptation

Measures were translated and adapted during the first phase of this research. The translation team consisted of four men from Sudan. One man was from Khartoum, one from Darfur and two from northern Sudan. They all had extensive experience with Sudanese refugees in Cairo through their involvement with psychosocial work and their informal social networks. Two of the team members were certified translators and interpreters from the American University in Cairo. One worked as a full time interpreter and provided the interpretation for the focus groups and interviews during the mental health care needs assessment. One of the team members was the current Zhagawa community leader in Cairo (one of the two largest Darfur tribes).

We used a standardized method of instrument adaptation and translation¹⁴. As discussed above, a bilingual group of experts was established. The conceptual structures of the instruments were examined by the experts. The instruments were translated from English to Sudanese Arabic separately by two team members. For each item, two team members were asked to comment on (1) appropriateness of the question for the Sudanese refugee community of Cairo and (2) relevance to the Sudanese refugee community of Cairo. The translation products were compared between the two members and discrepancies were addressed and debated. The completed Sudanese Arabic instrument was then given to the two other translation team members, who separately back-translated the instrument from Arabic to English. The two resulting English versions of the measure were discussed by the entire four member team. Discrepancies between the two English versions and the original English measure were addressed. The appropriateness and relevance for the community was discussed. With the aim of producing a measure translation that could be read to and understood by adult Sudanese in Cairo, the Arabic was reviewed and revised to ensure that the language was accessible for all education levels.

Research partner

The Cairo-based partner for this work was the Ma’an Organization. Ma’an was founded and is run by Sudanese. Its aim is to raise the health, social and legal awareness of Sudanese refugees in Cairo through programmes that address youth and adolescents, men and women. Ma’an has been working exclusively with Sudanese refugees in Cairo for 10 years and has extensive expertise with skills training in the community. Specific examples of their work include their recent occupational skills training of Sudanese refugees, funded by the Ford Foundation.

Recruitment

Study subjects were recruited through the Ma’an psychosocial team and community leaders. Study personnel were recruited through previous contacts with the Sudanese community of Cairo, as well as the Ma’an Organization, with which this study partnered. Study personnel administered baseline measurements in a private room at the Ma’an offices. Study participants provided verbal informed consent prior to beginning any screening procedures or baseline measurements. Study subjects were informed that their participation was voluntary and that they could decline to answer questions or request a break at any time. Participants were compensated for their travel expenses and time according to the daily labour rate in Cairo (~$6 USD/day).

Measurement administration

All measurement items were read to the study participants by study personnel and their responses were recorded. All individuals underwent the same baseline measurements including adapted and translated instruments that measured traumatic stress, depression, trait anger and social stressors. Part four, items 1–16 of the HTQ, were completed as part of the eligibility screening. During baseline measurement, the remainder of the HTQ was completed. Part two of the HTQ consists of a ‘Personal Description’ narrative section in which the respondent is asked two questions: (1) Please indicate what you consider to be the most hurtful or terrifying events you have experienced, if any. Please specify where and when these events occurred and (2) Under your current living condition (that is, country of resettlement, awaiting resettlement, awaiting other opportunities) what is the worst event that has happened to you, if different from above. Please specify where and when these events occurred.

Data analysis

Narrative data were coded in bivariate format according to whether or not the responses indicated that the UNHCR was directly involved in the worst experience in displacement. Frequencies of the resulting variable were calculated. Frequencies of the sense of betrayal by the UNHCR were calculated according to the four point scale of the measure. Correlations between UNHCR worst event of displacement, sense of betrayal, total PTSD symptom scale scores, PTSD subscale scores and depression and trait anger symptom scale scores were also calculated.

Results

Participants

There were 22 participants in this pilot study of interpersonal therapy. Seventeen participants were women and five were men. Age of participants ranged from 21 to 42 years. The mean age was 31.2 years. Forty-one per cent of the participants were from Darfur and 59% were from other conflict areas of Sudan. Study inclusion criteria required that participants meet or exceed an average score of 2.3 on the first 16 items of part four of the HTQ. Eighty-five per cent of individuals screened were enrolled in the study. Four individuals did not meet the HTQ score cut-off and one individual was found to be in need of a higher level of mental health care.

On the narrative section of the HTQ, respondents were asked to describe the worst event they had experienced under their current living conditions. Four participants (22%) of the Sudanese refugees in this study reported direct experiences with the UNHCR as the worst experience under their current living conditions. Table 1 presents frequencies for severity ratings of feelings of betrayal by UNHCR. Fourteen participants (63.6%) of Sudanese refugees in this study reported that they felt ‘extremely’ betrayed by the UNHCR.

Table 1.

Severity of feelings of betrayal by the UNHCR.

Severity of feelings of betrayal	Frequency	Per cent	Cumulative per cent
Not at all	0	0	0
A little	2	9.1	9.1
Quite a bit	6	27.3	36.4
Extremely	14	63.6	100.0
Total	22	100.0

Table 2 presents a matrix of correlations between variables. We found that greater feelings of betrayal by the UNHCR were associated with greater levels of avoidance and arousal symptoms of PTSD (r = 0.51 and r = 0.44, p < 0.05), depression (r = 0.62, p < 0.001) and trait anger (r = 0.52, p < 0.05).

Table 2.

Intercorrelations among study variables.

Study measures	1	2	3	4	5	6	7	8	9
1. Age	–	0.11	−0.27	0.39	0.30	0.15	0.09	0.36	0.38
2. Gender		–	−0.32	0.12	−0.07	−0.24	0.25	0.16	0.34
3. UNHCR worst event in displacement			–	0.17	0.33	0.30	0.29	0.43	−0.08
4. Severity of feelings of betrayal by the UNHCR				–	0.36	0.51*	0.44*	0.62**	0.52*
5. PTSD re-experiencing symptoms					–	0.34	0.19	0.67**	0.46*
6. PTSD avoidance symptoms						–	0.49*	0.44*	0.11
7. PTSD arousal symptoms							–	0.35	0.32
8. Depression symptoms								–	0.61**
9. Trait anger									–

^*p ≤ 0.05,

^**p ≤ 0.01,

^***p ≤ 0.001.

Discussion

Displacement is a notoriously stressful experience for refugee populations, but there is limited data explaining the source of the stressors^15–21. Our study is the first of which we are aware that examines refugee attitudes toward their local UNHCR office as a source of current stressors in the asylum community. Almost one quarter of the refugees in this study report that their experience with the UNHCR was their worst stressor since armed conflicts in Sudan. In our study of 22 Sudanese who fled to Cairo selected for substantial symptoms of PTSD (HTQ score of 2.3 or greater), we found that 14 people (63.6%) felt ‘extremely’ betrayed by the UNHCR.

In this study, greater feelings of betrayal by the UNHCR are highly correlated with arousal and avoidance symptoms of PTSD, symptoms of depression, and trait anger, in our sample of Sudanese refugees with high symptoms of PTSD. Causality cannot be determined from these cross sectional associations. It is possible that feeling unsupported by the UNHCR increases feelings of hopelessness and exacerbates symptoms of PTSD, depression and anger. However, it is also possible that those who have higher levels of PTSD symptoms score higher on a betrayal scale simply because their general level of distress is higher. If this were true, higher symptom scores on every PTSD subscale, including re-experiencing, would be expected. Instead, we found that sense of betrayal correlated only with the avoidance and arousal cluster of PTSD symptoms, suggesting that sense of betrayal is not a product of general distress. Alternatively, those with greater PTSD symptoms may have had prior traumatic experiences in Sudan that led to a greater generalized view of distrust of those in authority. A view of the world as dangerous, uncontrollable and unpredictable with a breakdown of trust in authority is a frequent post-traumatic belief in diverse traumatized populations including rape victims and war veterans^22–26. Rage at the source, that is, anger towards anyone or any institution with real or symbolic relationship to the original trauma, in this case the genocide in Darfur, is a theme identified by Horowitz and coworkers in their study of trauma survivors²⁷. Displacement of anger originally directed at authorities in Sudan towards those in authority in Cairo may in part explain our findings.

There are a number of possible reasons for the sense of betrayal felt by Sudanese toward the UNHCR. First, as discussed above, outside observers have questioned the policies of the UNHCR in Cairo, particularly with regards to the ratio of temporary protection to grants of refugee status for Sudanese nationals. It is argued that this policy fails to provide adequate protection. Visa status, specifically the designation as temporarily protected versus refugee, has been linked to mental health in previous studies^{15–17,28–30}. The length of time spent without full refugee status protection correlates with a worsening of asylum seekers’ mental health.

It is important to consider the potential cultural differences between the Sudanese refugees in Cairo and the UNHCR administration. Many rural Sudanese, particularly those from the Darfur region, are accustomed to a hierarchical social structure, headed by community leaders or elders. Such leaders traditionally handle community members’ problems, identifying those who need assistance and providing both guidance and access to resources. Given this custom, it is not surprising that Sudanese arriving at the UNHCR offices in Cairo may have expected more comprehensive and nurturing outreach from a newly designated ‘leader’ for the Sudanese community of asylum-seekers. From this perspective, the requirement for self-advocacy and self-directed help-seeking at the UNHCR may have been culturally dissonant for Sudanese. Elevated expectations could have primed Sudanese emotions toward a sense of disappointment and betrayal when they did not feel their requests were responded to adequately.

The sense of betrayal Sudanese in Cairo feel towards the UNHCR is consistent with qualitative findings which show that Iraqi refugees in Cairo and Jordan feel a lack of support from governmental and non-governmental sources (Cairo) and suffer abuse and threats from authorities (Jordan)^31,32. As mentioned above, this research focused on attitudes toward the UNHCR because our previous qualitative work indicated that, for Sudanese refugees in Cairo, the UNHCR was associated with particularly strong negative emotions⁶. This may be related to the uniquely negative experience that Sudanese refugees had during the 2005 protest at UNHCR offices in Cairo.

Limitations

As discussed above, this is a small convenience sample of Sudanese in Cairo who had high symptoms of PTSD and were seeking treatment. Although 85% of those screened met the PTSD symptom cut-off, it cannot be assumed that the report of negative experiences with the UNHCR or the sense of betrayal by the UNHCR is representative of attitudes in the general population of Sudanese refugees in Cairo. The four point rating scale of sense of betrayal by the UNHCR includes the following choices: ‘not at all,’ ‘a little,’ ‘quite a bit’ and ‘extremely.’ The fact that three of the four possible answers for this question convey some sense of betrayal could create a response bias toward over-reporting betrayal. As discussed above, the questionnaire which includes this item was based on previous qualitative studies evaluating emotional distress among Sudanese refugees in Cairo⁶. The question was designed based on the format of psychological tests, which traditionally include Likert scales including one negative option and multiple positive options, in order to discriminate between varying levels of positive symptoms^8,33–37.

Conclusions

This is the first study of which we are aware that examines the relationship between sense of betrayal by the UNHCR and symptoms of PTSD, depression and anger among asylum seekers. Although the cross-sectional data does not allow for determination of causation, previous longitudinal studies suggest that the refugee experience with the UNHCR plays a role in the community’s mental health¹⁸. There are many variables in the Sudanese population which may contribute to the negative experiences with the UNHCR and their sense of betrayal, including Sudanese expectations, cultural assumptions and pre-existing PTSD symptoms. Those with PTSD from their brutal experiences in Darfur may displace the anger originating in feelings of betrayal by those in authority in Sudan who failed to protect them, or committed atrocities, to those in authority in Cairo. At the same time, there may also be assumptions, attitudes and practices of the UNHCR that could be changed to improve the experience of asylum-seekers.

At a clinical level, this study implies that work with traumatized refugee populations should take into consideration the stressors associated with displacement, including experiences with the UNHCR. The exact clinical intervention cannot be delineated at this stage of research, given the need for a more thorough understanding of the directionality of the relationship between PTSD and sense of betrayal by the UNHCR. At the level of policy, becoming aware of the impact of UNHCR practices on asylum-seeking populations is the first step toward changing the system to minimize retraumatization. This study suggests that the impact of UNHCR processing on traumatized refugees should be further evaluated, with the goal of changing those policies confirmed to exacerbate negative emotions among refugees.