International Journal of Mental Health & Psychiatry.ISSN: 2471-4372

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Review Article,  Int J Ment Health Psychiatry Vol: 6 Issue: 1

Concepts of Transgenerational and Genocidal Trauma and the Survivors of ISIS Terror in Yazidi Communities and Treatment Possibilities

Kizilhan J1,2* and Wenzel T3

1Institute for Psychotherapy and Psychotraumatology, University of Duhok, Zakho Street, Duhok, Iraq

2State University Baden-Württemberg, Friedrich-Ebert-Strasse 30, D-78054 Villingen-Schwenningen, Germany

3Medical University of Vienna, Universitätsring 1, 1010 Vienna, Austria

*Corresponding Author : Jan Ilhan Kizilhan, PhD
State University Baden- Württemberg, Friedrich-Ebert-Strasse 30, D-78054 Villingen-Schwenningen, Germany
Tel: +49 7720 3906-217
Fax:
+49 7720 3906-219
E-mail: [email protected]

Received: January 06, 2020 Accepted: January 20, 2020 Published: January 30, 2020

Citation: Kizilhan J, Wenzel T (2020) Concepts of Transgenerational and Genocidal Trauma and the Survivors of ISIS Terror in Yazidi Communities and Treatment Possibilities. Int J Ment Health Psychiatry 6:1. doi: 10.37532/ijmhp.2020.6(1).174

Abstract

After the attack of the terrorist organization ISIS in 2014 and the systematic attempt to destroy the religious group of the Yazidi, the topic of transgenerational, collective and individual trauma has become a focus of attention in regard to this group. Since the Yazidi have been victims of 74 genocidal attempts for more than 800 years, the theory and discussion of group and Transgenerational Trauma models will be important for both research and long term treatment planning. In general, models rest on the assumption that some ethnic and religious groups have in the past been exposed to mass trauma as a result of colonialism, slavery, war and genocide over longer historical periods. Due to collective traumatic experiences, the secondary and subsequent generations have passed on the trauma of their forbears to the following generations and, in doing so, repeatedly transformed it. Being passed down between generations, this traumatic experience is a trauma shared by all members of a group and made up of elements from the past and of the present. Even several generations after the original trauma, an increased level of psychological symptoms have been observed, though mechanisms of impact have not been identified with certainty in spite of numerous proposed models, including, most recently, epigenetic mechanisms. A proper understanding of the way transgenerational trauma can affect the present psychic health of ethnic or religious collectives may help to identify new paths to explore and new insights on how best to provide effective treatment for psychic traumas in groups exposed to repeated and severe violence and persecution. Our article aims at summarizing the different aspects and models of transgenerational transmission of trauma and their potential application to the Yazidi genocide, resulting treatment needs, and propose the category of genocidal environment to describe this and similar situations that are becoming more frequent in spite of comprehensive international human rights standards.

Keywords: Transgenerational; Genocide; Collective; Individual trauma; Ethnic/religious minorities; Trauma; Psychotherapy; War

Introduction

In general, trauma can be defined as the effect of a considerably stressful and unusual experience which puts the victim in a condition characterized by a feeling of a loss of control [1]. This feeling of being unable to take care of oneself can affect several or all areas of the identity of a traumatised person: the sense of control over situations and effect on actions, the ability to cope with stressful incidents as well as the ability to cultivate or nurture close personal relationships. Traumatised individuals are often also much more susceptible to the development of trauma related but unspecific disorders and reactions such as depression, and complications such as drug abuse, but also to trauma specific disorders such as post-traumatic stress disorder (PTSD) [2] or culture specific trauma reactions such as nightmare death [3] and other idioms of distress [4].

While a substantial body of research has documented this wide ranging sequels in individuals, impact on groups in general has been less explored so far. In addition to the individual trauma resulting from a traumatic incident, persecuted ethnic and religious groups and communities are under constant threat or have been exposed to an often large range of severe stressful factors such as discrimination, poverty, displacement or witnessing violence that in itself have been demonstrated to have an adverse impact on mental health for several generations independent from separate earlier traumatic events [1]. Psychiatric and psychotherapeutic treatment approaches with traumatised clients concentrate nowadays consequently mainly on the individual and gives insufficient consideration to the transgenerational and collective aspects [5,6] that can also be called “past collective” trauma as proposed by Rosler [7]. Brave Heart and DeBruyn [1,4], proposed the concept of a “ historical ” trauma, to describe the longstanding exposure to complex factors including multiple losses and discrimination experienced by Native American Indians. Sotero [8] proposed successive phases for “historical” trauma. In a first phase dominant culture afflicts devastation on multiple levels on a group. The second phase is characterized by the first generation and its symptomatic reactions which are manifested in social interactions, mental and emotional as well as biological processes. Finally, a combination of the social environment, mental as well as emotional aspects and continuous harassment and marginalization causes these symptomatic reactions to be passed down to the following generation.

Early attempts to conceptualise trauma transfer among different family generations were inspired by studies from the 1960s which examined continuous traumata experienced by family members whose parents survived the Holocaust. Continously since the 1960s, numerous studies have drawn attention to two main findings. First, a wide spectrum of symptoms indicating a trauma reaction is manifested in family members whose parents survived the Holocaust. Secondly, these family members perceive that they feel abnormal and considerably impaired due to what their parents had suffered. [9,10]. These aspects are subject of a controversial discussion among scholars. This controversy is mainly caused by study designs which do not pay enough attention to a methodology that meets the complex characteristic of trauma transfer among family generations [11].

The present controversy on the issue since the first publications on the holocaust and second/third generation impact can be separated into different key questions:

1) Is there an impact on indirect victims (those not themselves present in a catastrophic event)?

2) Is there a characteristic universal pattern (syndrome) that can be identified in the second or third generation?

3) Is there an increased prevalence of mental or physical health problems, indicating greater vulnerability in the second or third generation?

4) Is there a better resilience at least against some challenges in the second or third generation?

5) What are respective mechanisms and cultural, social and biological factors as outlined above and can they be integrated in a “universal model”?

Recent studies by Palestinians, Kurds, Russians, Cambodians, Afro- Americans and Native American Indians document that offspring of traumatised parents also display various PTSD symptoms or “trauma reactions” [4,12,13]. These symptomatic indications include different mental and emotional issues which become evident in the following behavioural patterns. Those who are affected consciously ignore external events. They show signs of depersonalisation and amnesia. They experience unpleasant and frightening dreams. They are extraordinarily watchful and alert. They shut down emotionally. They abuse drugs. They frequently occupy themselves with thinking about traumata and reflecting on death. Finally, they are preoccupied, trying to cope with feelings of guilt and grief [12,14-17]. Faimon [18] describes the transgenerational trauma experienced by a Sioux tribe as indescribable terror and the legacy of terror which still exists even after 140 years, as displayed by repression, dissociation, denial, alcoholism, depression, doubt, helplessness and devaluation of self and culture [18]. She also elaborates on the transgenerational sharing of sadness, embarrassment, guilt and the inability to trust . For seven generations, these feelings have been passed on. In this way, they are deeply entrenched in the group identity. The Aboriginal Healing Foundation (2004) defines historical trauma as a mental illness characterized by a collection and interaction of traumatic experiences. The symptomatic indications of historical trauma reflect a collective attempt to cope with traumatic experiences from the past. For that purpose, behavioural strategies were developed, incorporated into the cultural practices as well as traditions of the group and shared among numerous generations. However, these behavioural strategies are highly inflexible and non-constructive [19].

Studies on historical trauma are mainly characterized by a theoretical or qualitative approach. However, the scientific community needs a bigger pool of quantitative findings which it can refer to in order to elaborate on the connection between PTSD and collective trauma and transgenerational trauma. More quantitative studies are necessary to build on existing work and to connect historical trauma with PTSD results. As a concrete case study for many groups the historical and current traumata of the Yazidi could lead to a better understanding of transgenerational traumata.

In settings of continuous persecution and repeated massacres, trauma is not only historical. It might in this context be justified to speak about a “genocidal environment”, that includes the permanent threat of future repeated violence or pogroms, the continuous presence of loss by the unresolved fate of missing (possibly killed) family and community members [20,21], persistent discrimination, harassment, and efforts to eradicate the culture, institutions and independence of a specific group. This would imply, that not only transmission of memories, and the reaction to symptoms of parents, but also interaction with ongoing social and political stress factors that shape also what is often termed a “second generation” syndrome. In refugees, authors like Silove [22] have demonstrated the relative influence of present stressors related to factors such as insecurity, discrimination and displacement as compared to prior traumatic experiences [22]. The model could apply to a wide range of groups, including Kurdish groups, Armenians, Ismaili, Jews, Native American Indians and African Americans.

Part of this ongoing traumatic stress are frequently efforts of denial of historical reality by perpetrators and the impunity of perpetrators that can be seen as a continuous attack on the identity of the victim group [23,24]. Some countries, such as Austria, have anchored the prohibition of denial of the holocaust in specific or even constitutional laws in the understanding that social and psychological peace cannot be achieved without truth. Countries like South Africa (truth and reconciliation commissions) [25-27] and Rwanda (Gacatcha courts) have taken steps to avoid the trap of denial of genocide. Several authors have explored the impact of this process on mental health [25,28-31]. The process is complex, part of the process of “transitional justice”, must be culture sensitive, and is not limited to the question of impunity [32,33], while still identification and prosecution of perpetrators can be an important step, though especially difficult in the case of “non-state” actors like ISIS. We will discuss this aspect later on in the context of “therapeutic justice”.

Further, groups and individuals are not always victims or passive “walls” exposed to past or new traumatic environments, but might develop coping strategies, or even “posttraumatic growth” [18,34] and improved resilience [25,35-38]. Some authors, such as Sagi-Schwartz in a recent prospective study have even observed increased life expectancy in holocaust survivors as compared to non-holocaust survivors, and underline the importance of later environmental factors [39]. The actual “state of mind” of individuals and society should therefore be seen as the result of a complex process and not solely in identification with the role of victim.

Examples such as even the present political dominance of the usually severely persecuted Alawi group of Syrian President El-Assads family demonstrate a possible move to control and dominance as a counter reaction to persecution [40]. Kurdish fighters with strong militant organisations such as PKK or Peshmerga could be seen as the counter-model or mirror of coping or resistance to efforts to destroy Kurdish culture by prohibition of language or by forced conversion from Yazidi to Alawit religion in Turkey and protect against cultural and physical genocide. Kosovar academics had to develop “underground universities” to maintain intellectual standards when their Universities were closed by Serb nationalist strategies as part of ethnic persecution of the Kosovar ethnic minority, contributing to a new and strong academic tradition in the country.

If both the individual and the collective are victims, they experience a hiatus in their daily routine which is handed down from generation to generation and which is in perpetual transformation [10]. Coping strategies and adaptation patterns are passed on to future generations, and as part of the culture can be integrated into religions and norms and communicated not only by word of mouth but can also be passed on through rituals and ceremonies. This process of propagating group behaviour patterns is carried out at both a conscious and at a subconscious level [41,42].

An increased risk of problems in handling violence can, but must not be an additional risk in groups exposed. This can be seen in numerous studies that examined children who had suffered abuse. These studies found that parts of the sample are at risk to become abusers [42].

The group psychoanalyst Vamik Volkan has explored the special aspect of chosen traumata in groups, - long distant negative events that are redefined as key identity of a group in order to encourage group regression that in turn can be used to instigate future violence [43]. The aspects of this “politics of memory” is important to understand the long term group processes in both victims and perpetrator groups [44].

In contrast to psychoanalytical theory, which concentrates on subconscious influences, the theory of social learning investigates the concrete aspects of the influence of parents on their children. Kellermann (2001) came to the conclusion that there can be four main types of parenting in survivors of the second generation: transference, affection, punishment and over-protection [45]. Kellermann’s study (2001) identified four types of parenting; second-generation survivors said that, as regards transference, the role of their parents had been of greater importance [45]. Based on the latest studies it can be assumed as accepted that parental traumatisation, at least regarding the concept of the transgenerational transmission of the traumatising potential, can also affect future generations who were not even born at the time of the traumatising experience [10].

In the opinion of some authors, the vulnerability to mental disorders is also transferred [35,45,46]. This occurs via mechanisms such as projection and identification [43] as well as at a psychophysiological level (Franklin et al. 2009). The effects of parental traumatisation on the following generation were widely researched, above all, in connection with the research into the holocaust [45-47].

In our context, historical traumata which occurred several generations ago seem to be significant regarding the psychological disorders in the offspring and this in particular is why we would like to shed more light on transgenerational trauma, despite, or perhaps due to, the lack of literature on the topic in the region and neglected groups such as the Yazidi.

Transgenerational trauma

Transgenerational and intergenerational trauma theories are based on psychosocial, political, economic and socio-ecological theory [48].

The psychosocial theory is based on the assumption that illness is linked to both physical and mental stress. Both types of stress are experienced because of the environment and coinciding social factors. In this respect, the combination of social factors and physical as well as mental stress causes individuals to be more susceptible to disease. At the same time, this combination pathologically influences biological processes in the human body in a direct [41]. Political and economic theory incorporates political, economic and structural phenomena which influence well-being or illness. This includes power imbalance and social injustice, for example [48]. The socio-ecological theory asserts that illness is caused by multi-level connections and interactions between past events and present-day situations as well as between aspects concerning the vicinity of an individual and places which are distant from the individual. According to this approach, these interactions are active throughout life [46,48].

Epigenetic causes have been the most recent mechanism suspected in trauma transmission [46]. In one of the key studies in this area, Yehuda et al. examined influential elements “of maternal and paternal PTSD on DNA methylation of the exon 1F promoter of the glucocorticoid receptor (GR-1F) gene (NR3C1) in peripheral blood mononuclear cells and its relationship to glucocorticoid receptor sensitivity in Holocaust offspring”. The authors reported that maternal and paternal PTSD effects were differentially associated with clinical indicators and GR-1F promoter methylation [46]. Still, present models must still be seen as speculative as they might be simplified in focusing on singular mechanisms such as methylation in specific genes, and recent research has proposed further epigenetic factors and more complex models [49-54] and even principal investigators like Yehuda have warned against simplified popularizing interpretation of published research.

In order to understand how and why certain ethnic groups are more susceptible to disease than others, the historical trauma theory offers a time frame at a macro level. At a certain point in time the “curriculum vitae” of an ethnic group confronted with trauma can be compared with an ethnic group which has not been confronted with trauma. A literature review reveals at least five assertions which support this theory:

(1) Based on a plan, a predominant and powerful group of people intentionally afflicts mass trauma on a particular group of other people.;

(2) Trauma must not be understood through a single devastating event but needs to be seen in the context of longer time period;

(3) Being echoed in a group of people, traumatic experiences are perceived by all people of a particular;

(4) Following generations themselves suffer mass trauma;

(5) The extent of the trauma experience significantly influences the extent to which the ethnic group can derail from its original beliefs and earlier coping strategies.

This, in turn, results in an inheritance of corporeal, mental as well as emotional, social and monetary as well as material disadvantages which run through the future generations.

The fundamental concepts of the approach can be described through the following three processes. In the first process, the group experiences the trauma. The second process is characterized by the reaction to the historical trauma. In the third process, the historical trauma is passed down among several generations. In many cases, trauma in connection to continuous suppression is an additional and crucial factor in this third process [4,6,10].

Up until the end of the 1990s, PTSD was almost exclusively described in terms of the serious and long-term effects of traumatic stress factors such as war, sexual assault, cruelty to children, road traffic accidents or natural disasters [55]. This has changed. Nowadays, more aspects are considered to understand PTSD. For example, PTSD is discussed in connection with chronic stress and also with links to physical health. These psychological factors might exacerbate chronic illnesses including diabetes and abnormally high blood pressure and diseases connected with the heart and blood vessels [56].

There is evidence which shows that reactions to a consciously evoked (“man- made”) mass trauma differ greatly from reactions triggered by accidents or natural disasters. Trauma that is caused by premeditated intention creates a deep feeling of distress. This feeling, in turn, causes those affected to perceive everybody who is not part of their ethnic or religious group as danger. Deliberate assault and intentional psychological cruelty extensively decrease an individual’s fundamental trust in a peaceful and fair world as well an individual’s belief in an unconditional value of every human being while significantly increasing one’s vulnerability [56]. A crucial characteristic of transgenerational trauma theory can be seen in the transmission of the mental and emotional effects of the trauma experience. This aspect is essential with regards to the expectations which the first generation communicates to the subsequent generation through the dynamics previously discussed. This has been described to develop an intergenerational cycle of trauma reaction [10,11,19,45].

Case Study: Historical Trauma in the Yazidi Population

The subjugation of the Yazidi due to flight, massacre and the violent conversion to Islam has already been described by many authors. For that reason, it will not be repeated here [1,57].

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Referring to Mithraism and its relationship to Yarsan and Zarathrustra, the Yazidi explain their membership in one of the oldest religions [58]. They have reportedly been exposed to cruel mass killing for a very long time. In 637 A. D., for example, they suffered massacres when the Arabs invaded the area which is nowadays called the Near and Middle East. The actions taken by the so-called Islamic State (ISIS) is a present-day example of the recurrence of events from the past. Frequently, mass killings took place in connection to forced conversion to Islam. As a result, they secluded themselves from the other social groups of the local population by moving to the hilly hinterland. Oral accounts given by priests are the traditional medium to pass down and convey their religious principles among the generations. There had not been a big number of written documents telling about the Yazidi history up until 50 years ago [59,60]. For these reason, the term “Oral History ” is used to describe the past events which shaped the development of the Yazidi.

In temporal terms, the Yazidi trace back their beginning to the 14th century B. C., to the Mithraic religion. The term ‘Yazidi’ cannot be found in any written historical document from the time prior to the 7th century A. D. The first mention of the term ‘Yazidi’ can be dated at about the turn of the century when members of the Moslem clergy and Moslem historian wrote down the term ‘Yazidi’ in their records and accounts [61].

After the demise of the so-called Ottoman Empire, a lot of Yazidi people had to flee to the area of what today is known as Armenia. They settled down in the Caucasian mountain parts of Armenia. Ever since the Yazidi homeland was divided into several parts between 1918 and 1923 (year when the state Turkey was founded), the Yazidi have predominantly been living in the hilly parts of Turkey, Iraq, Syria, Armenia, Georgia and Russia.

Based on ample evidence, it is estimated that the Yazidi people had to suffer 74 genocides initiated and implemented by Islamist groups and states within the last eight centuries.

According to conservative figures, approximately 1.8 million Yazidi people have had been forced to convert. About 1.2 million Yazidi people have been killed. Many fatwas have been used as a legitimizing foundation for inhuman and criminal actions (killing, abduction and looting) taken against the Yazidi people. Following the logic behind these fatwas which did not acknowledge Yazidi religion as real religion at all, perpetrators had a legal basis to use violence in order to convert Yazidi people to their understanding of Islam. Imitating this procedure by using a bogus explanations, ISIS has inflicted genocidal actions on the Yazidi people [13].

Ever since ISIS launched their offensive in August 2014, they have killed more than 7000 Yazidi people. Moreover, ISIS has held thousands of families hostage. This situation coincides with murder. If the Yazidi hostages refuse the conversion to ISIS’s understanding of Islam, they are killed. In addition to families, ISIS has kidnapped more than 5800 girls whom they enslave and abuse sexually. Moreover, these girls are seen as goods or commodities which are sold on Arab markets. As the Yazidi have been systematically persecuted and killed [62], there is a huge number of Yazidi refugees who flee to Syria (20,000), Turkey (30,000) and the Kurdistan region (3,60,000).

Transgenerational traumata and the consequences of the current traumatisation in Yazidi groups

The genocide of the IS together with the current traumatisation has brought back to mind the genocides and massacres of their ancestors. They experience a double or multiple traumatisation and come to the conclusion that they cannot defend themselves and will, again and again, be the victims of Islamic terror, as proposed in our model of a “ genocidal environment ” . The distance to Islam has become significantly greater. Fearing their Moslem fellow-countrymen they do not say anything, but they have lost their trust because once more they are subject to a collective massacre in the name of Islam just as they were in the 18th or 19th century.

We see similar types of behaviour as in those who experienced the Holocaust [63] (Bar-Tal, 2000). They are unsure, tense, are worried that their children cannot survive and have feelings of being powerless and helpless. They experience their individual traumata, were collectively traumatised on 3rd August 2014, and remember the transgenerational traumata of their ancestors.

Three types of trauma can be observed in the Yazidi. The genocides have been passed by narrative from one generation to another connected with fear and insecurity through stories, songs and prayers. The term “Ferman” is used for genocide. As soon as a Yazidi hears the word “Ferman”, memories of historical genocides are evoked. It was with this background that the Yazidi experienced genocide at the hands of the IS which began on 3rd August 2014, was experienced as a continuation of the collective historical trauma [1,59,60].

These negative, collective experiences shape the Yazidi group and its collective memory. Consequently, one can argue that these experiences destroy the Yazidi people. On the other hand, adopting a psychotherapeutic perspective, one can argue the following: These collective experiences can facilitate an approach to traumata experienced by individual Yazidis in the sense that they can strengthen resilience. This is important because helping survivors of terror to promote resilience is a crucial aspect when treating them psychotherapeutically [1].

A Framework for Historical Trauma

The framework for transgenerational trauma transmission illustrated here aims at showing the narrative of minorities which have been subject to trauma experiences over generations. It describes the physical, psychological and social aspects which link transgenerational trauma to the prevalence of illness and health disparities (Figure 1). We have omitted epigenetic factors due to the yet too speculative nature of present models in this area.

Figure 1: Three types of Trauma.

The model postulates that a transgenerational trauma arises when an ethnic and/or religious group experiences the collective violence of a dominating group. A collective trauma arises (Figure 2).

Figure 2: Conceptual Model of Transgenerational Trauma.

(1) by overwhelming physical and mental violence,

(2) forced displacement, flight, living in refugee centres in the mountains etc. (and this for generations),

(3) economic disadvantages extending to exploitation and

(4) cultural expropriation extending to deformation. A genocidal environment might have a persistent influence on this process.

Methods of oppression by the ruling group can include various means including military force, biological warfare (as in Iraq against the Kurds in 1988), deprivation of rights and oppression by a state, expulsion and displacement, imprisonment, enslavement and/or legal measures restricting mobility, commercial activities and the practice of cultural traditions [6,64].

This all-embracing experience of oppression and discrimination, extending to collective violence, represents a significant physical and mental trauma for the affected group.

Many survivors who had to witness the death of numerous people and have experienced brutality, hunger and disease suffer from physical injuries, malnourishment and a high rate of infectious and chronic illnesses [57]. Their physical and emotional reactions are based on violence, severe stress, ubiquitous hardship and the “unrelenting”, incessant grieving for their murdered family, the deprivation of their homeland and customs [65]. The reaction to trauma in first generations is characterized by PTSD, signs of depression, selfdamaging behaviour, a mental state considerably and extensively influenced by fear and panic , feelings of guilt, enmity, embitterment, and permanent grief [57]. Mental and emotional disorders can easily contribute to the development of physical illnesses and vice versa [6,66].

Second and subsequent generations are impaired by the original trauma in different ways. The subsequent generation, subjected just like the previous generation to extreme traumata such as massacres and genocide, is in many respects affected by the traumata of their ancestors as well as their own more recent experiences. This influences the behaviour, the emotions and the cognition of the survivors who, through narratives/stories, religious ceremonies, music etc., can become part of the “new trauma culture”. Extreme trauma can also lead to a subsequent impairment in parenting competence [66]. As noted before, disorders such as mental illnesses, depression and PTSD might be also transferred by genetic and epigenetic mechanisms to second and subsequent generations [67].

Maladaptive behaviour patterns (drug misuse, corporeal as well as sexual abuse, committing suicide) and social problems of the survivors of the first generations play a crucial role in two ways. First, they immediately traumatize the following generation. Secondly, the following generation learns these behaviour patterns through model learning. In this way, the patterns and problems are transmitted in an indirect way. This transmission exacerbates the trauma cycle created by the interaction between the generations. This interaction primarily takes place through oral accounts (narratives in story-telling, songs, ...) and is manifested in the social memories which, in turn, shape the collective memory. Together, they cause subsequent and later generations to perceive so-called “vicarious traumatization” [11]. In this context, the subsequent generation is always shown how to participate in the suffering experienced by the ancestors. Consequently, the subsequent generations might perceive difficulties in trusting other parts of the society, start feeling persecuted and develop a deep sense of grief [11]. In addition, it is likely that they experience a primary trauma, realizing that their cultural traditions, customs and important identity elements, such as language, have been taken away from their group. Moreover, phenomena which the subsequent generations experience themselves are likely to aggravate the traumatic experience. These phenomena include social inequality, poverty, discrimination, injustice. From their point of view, experiencing these phenomena first-hand confirms what they have learned through oral traditions and the collective memory which are shaped by the historical trauma. In this way, these first-hand experiences perpetuate the historical trauma experience and the coinciding reactions [66].

The accumulation of these mechanisms and its ultimate impact on the traumatized collective becomes evident in an excess of social and corporeal illnesses which are only suffered from that particular (traumatized) group. This situation means injustice because, frequently, the traumatized group does not have any access to treatment options for their largely unprocessed psychological trauma while it is exclusively them who suffer that illness and the symptoms. As the excess and rise of social and corporeal illnesses coincide with a weaker immune system over time and over the subsequent generations, one can consider historical trauma as ‘disease of time’.

Therapeutic justice

An important aspect of increasing importance is the already mentioned discussion of the influence of socio- legal factors, especially the impunity of perpetrators, lack of redress, and intentional distortion of history negating the reality of a genocide or blaming victims [68-71]. Three key points (confirmation that an event has actually happened, that is was injustice, and it should not be permitted to happen again) have been proposed as important to the emotional wellbeing of victims [71]and indicate that social, including legal interventions are of importance besides individual and group therapy of trauma. The responsibility of national and international legal systems not only for justice, but also for the well-being of victims or survivors has been confirmed by inter alia the EU victims of crime framework. The European court has taken a milestone decision to confirm the psychological needs and right to redress of indirect victims, in this case of “disappeared” victims of the Turkish invasion in Cyprus 1974 (operation “ Attilas ” ), that were seen as suffering emotional pain even decades after the event because of the lack of the Turkish government to conduct an investigation. In the same ruling the court also confirmed that Turkey violated a number of further rights (also characteristic for genocidal and ethnic cleansing situations) like loss of ownership rights; eradication of Greek-language in a secondary schools in north Cyprus, censorship of primary-school books; restriction of freedom of religion [72]. This shows that an interdisciplinary approach is required to address large group violence and genocide impact, confirming the responsibility of perpetrators, suffering, and re-establishing basic rules of human rights and human behaviour to provide a feeling of safety in victims and communities as outlined in recent “transitional justice models [72]. In the case of Yazidi and non-state actors like ISIS groups, this constitutes a special challenge.

Consequences for a trauma therapy

It seems that a new understanding and new approaches are necessary if specialists want to treat patients with an individual and collective, plus a transgenerational trauma. For this reason, it is important to develop an intervention program which integrates recent models of transgenerational trauma and the community capacity and community empowerment (Figure 3).

Figure 3: Model for the treatment of transgenerational, collective and individual traumata [1].

Our concept is based on the knowledge of transgenerational trauma and its effects on common culture and health and is developed on a holistic, culturally-relevant point of view which respects ethnic and religious minorities. Symptoms of a transgenerational trauma-like perspective are described in an innovative way because, unlike earlier and conventional health programs, this framework is not based on Western belief systems. Consequently, inherently dominant Western cultural concepts are not imposed on those who must be treated. [4,66]. Trauma-work with minorities who have been confronted with prosecution, war, flight and genocide for generations offers a model with which transgenerational trauma can be understood and a concept for trauma therapy developed.

The connection between past events and present-day situation characterize plenty of cultures and their customs.

Connecting the past with the present is inherent in many cultural traditions. A framework for transgenerational trauma and the coinciding dynamics contextualizes temporal and spatial aspects. Traumatized groups and those who are affected can benefit from this in two ways. First, the framework acknowledges their perception, their accounts and their understanding of the world by reflecting them. This, in turn, is the foundation for external atonement to which the framework attributes a lot of importance. [72]. In this way, it allows those who are affected to mentally and emotionally extricate themselves from structures and dynamics which caused them to feel guilty about their origin and their health situation. This, in turn, empowers individual members of a group and the group as a whole entity to fight the reasons for low education as well as isolation from the world and to conserve tradition and culture as a way of surviving since the original trauma [73].

In general, the idea of post-traumatic stress disorder (PTSD) is adaptable to every ethnicity. However, the various perceptions of health/illness and the variety in conventional medical treatment in dealing with traumatic experiences, which depends on each culture, require alternative approaches or supplements [74]. Addressing these points, researchers have proposed a specific idiom of distress as trauma reaction for Yazidi people [75].

In the case of the Yazidis, among others, the following five phases of trauma must be taken into account during any treatment:

Phase 1: The siege of Sinjar (Shingal) and the start of the terror (from August 2014)

Phase 2: Deportation, being held hostage (captivity), executions, rape, separation of parents and children, child soldiers

Phase 3: Liberation

Phase 4: Life in refugee camps (up to 28,000 people can live in one refugee camp)

Phase 5 (in case of living in Migration): Life migration (this is the most important phase in the healing of traumata)

Based on our practical experience with traumatised Yazidi women, it is not necessarily and not always the degree of seriousness of the first two trauma phases which are decisive for their long-term “mental health” but rather the post-trauma care, in other words the treatment in the refugee camps or after fleeing to the host country.

A basic prerequisite in any case is a secure environment in which the person does not feel the threat of persecution or other dangers. It is only with this security that the woman is able to speak about the critical experiences in her life and to accept the therapy and the therapist.

The scale of each point must be seen as extreme. Cetorelli found for example that “estimated 2.5% of the Yazidi population was either killed or kidnapped over the course of a few days in August 2014, amounting to 9,900 (95% CI 7,000-13,900) people in total. An estimated 3,100 (95% CI 2,100-4,400) Yazidis were killed, with nearly half of them executed-either shot, beheaded, or burned alive-while the rest died on Mount Sinjar from starvation, dehydration, or injuries during the ISIS siege. “The authors estimated the number kidnapped at 6,800 [76]. A number of recent studies have documented the severe mental health impact especially on women and even in those who had escaped to third countries(40-52) that underlines the need for adequate treatment strategies.

Trauma confrontation is often an additional problem during treatment [77]. Even if we assume a fundamentally positive effect of a confrontation in trauma therapy, a secure environment is still a basic prerequisite. This environment is characterized by an atmosphere, in which the person does not feel persecuted and threatened or afraid of being deported to the country of exile. This feeling of safety, in the first place, enables the woman to speak about the critical experiences in her life and to accept the therapy.

The Yazidis, for instance, come from an oral and collective society and are familiar with narration, relating stories of disasters and this can be very useful as a resource. The traditional exposure therapy is not always effective with these survivors, particularly with the older women who have been through the socialisation process in the collective society up until adulthood [77,78]. It can even be counterproductive and can both reduce compliance and increase the drop-out rate. For this reason, it is also necessary to discuss whether suppression and avoidance would possibly be a better strategy enabling the individual to cope with the situation. A lot of cultural environments consider this an effective way of coping with traumatic experiences. That particularly applies to collective societies. They attribute much importance to harmonious family relationships [74]. Here, in particular, the cultural and social context significantly influence the healing process. This means the psychotherapist must particularly pay attention to that the victim does not suffer any “loss of face ” . This particularly important when the survivor suffered politically-motivated violence [78].

This model is based on the foundations of general psychotherapy, biography work and narration in medicine. It must be seen as an extension of the psychotherapy of survivors of collective and individual traumata who, among other things, are still under the influence of the transgenerational traumata suffered by their ancestors.

In order to cope with trauma stability, feelings of security, orientation, self-esteem and intimacy are essential for all people. The “trauma story” itself is to be treated from an individual, collective, socio-cultural and political point of view.

A correct use of this narration requires the following steps. The psychotherapist must pay attention to the relationship with the patient in order to support him/her in a social way. Moreover, the narration must be connected to the social structures. In this way, the psychotherapist can engage patient to work with the narration, which, in turn, allows the patient to perceive the narration as beneficial. Narration, for example story-telling is frequently used in traditional societies and people from the orient as mental and emotional aid [79].

Furthermore, therapeutic justice – solutions to recognition of events, responsibility and protection against recurrence and against impunity, using transitional justice models will be important to the group and individuals. Family-orientated societies often tackle traumatic experiences via Expressions of pain [79]. From a psychodynamic perspective, somatisation offers people with severe traumatic experiences a chance to divert feelings of exclusion, social effrontery, guilt and feelings of inferiority from the conscious experience down to the corporeal dimension. They pursue two goals, following this procedure. First, they can preserve their self-worth. Secondly, the physician and doctor can provide immediate help by being able to concretely identifying the problem [77].

There are universally crucial aspects which do not depend on a particular cultural environment or ethnic group. . From a diagnostic point of view, the therapist must understand classify the illness correctly. This allows the practitioner to formulate a treatment plan. The therapist must communicate both steps to the patient. The practitioners’ explanations must be adapted to the patients’ level of education and cultural background. In this way, the patient can understand his or her illness and can develop a willingness to engage in psychotherapy.

However, a lot of manifold individual as well as collective worries and difficulties (e.g. war for many generations in their country of origin, sex-specific and societal disadvantages, detention or disappearance of family members etc.) can be additional reasons reasons why patients may not understand the exact causes of their mental illness (e.g. physical pain due to inner psychological conflicts) and may not be able to integrate these within their perception of illness

Conclusion

Empirical interdisciplinary research is needed to holistically grasp , operationalise and verify the theoretical framework of transgenerational trauma. Moreover, additional research must be conducted in order to connect the key characteristics of transgenerational trauma to trauma spectrum disorder outcomes, or in general, health outcomes. The majority of research on transgenerational trauma about the indigenous people in America, the Jewish Holocaust or Armenia Aghet during the Ottoman Empire has been conducted with the survivors until the fourth generation and is to a substantial part qualitative. Most of these studies are more focused on the first generation which faced a trauma and the impact on the next generation. The impact of Traumata on following generations in groups like the like the Yazidi, who have faced 74 genocides in the last 800 years, or in many African Countries who have faced many traumata since slavery, and interaction with present conditions are still missing.

Future directions in transgenerational trauma research would benefit from ample empirical evidence in two ways. First, empirical findings can help explain why transgenerational trauma is prevalent and manifested among indigenous groups. Moreover, they can describe the dynamics, explaining how trauma is transferred within one generation and passed down among several generations. In addition to that, empirical data can provide answers to the important question of the extent to which individual therapy or therapeutic justice and other community-oriented approaches can prevent the impact at this different level., In order to provide answers to this question, especially systematic studies with individuals, larger collectives or communities on intervention outcomes in transmitted trauma related syndromes must be conducted. In the treatment of survivors with a background of transgenerational trauma, it is important to take into account cultural and socio-political aspects, the perception of illness and dealing with it, transgenerational, collective and individual traumata as well as the structure of relationships. In addition, alternative therapeutic approaches with an interdisciplinary and culture-sensitive focus are particularly important but these must also be examined for their effectiveness.

The conceptual model of transgenerational transmitted trauma presented here is designed to help psychiatrists, psychotherapists and other specialists such as refugee workers and researchers to view transgenerational trauma from an extended perspective and to develop new approaches for the improvement of the state of health of ethnic groups. We think that the term of “genocidal environment” is helpful to better conceptualise the importance of continuous persecution and threat besides isolated late effects of historical earlier trauma.

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