Between Worlds

Between Worlds · essays on displacement, trauma and belonging

The Cost of Looking Away

Untreated trauma in displaced people doesn’t stay contained. What the evidence says it becomes — and why that’s a choice, not a fate.

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The story a society tells itself about trauma and danger almost always begins at the wrong end. It begins with the incident: the fight, the assault, the headline, the man in the dock. That is where attention arrives, because that is where the harm is loud. But by the time a nervous system reaches that point, it has usually travelled a long, quiet road — months or years of a wound left open, untreated, feeding on itself — and almost every step of that road was a place someone could have intervened and didn't.

This essay is about that road. Not to excuse what happens at the end of it, but to look honestly at what untreated trauma becomes when it is left alone, and at a claim that sits uncomfortably across the political spectrum: that the suffering of a traumatised refugee is purely private, a matter for them, with no bearing on anyone else. That is not what the evidence shows. Untreated trauma does have costs beyond the sufferer. The costs are real, they are sometimes social, and pretending otherwise helps no one. But — and this is the part both the people who deny the costs and the people who weaponise them tend to miss — those costs are produced by specific, identifiable conditions, they fall on a predictable minority rather than a whole population, and nearly every one of them is preventable. The harm is not in the person. It is in what we do, or fail to do, with the injury they arrived carrying.

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I. It does not fade on its own

Start with the assumption that quietly underpins most inaction: that time heals. Leave people alone, the thinking goes, let them settle, and the wounds of war will close by themselves.

They often don't. Post-traumatic stress disorder, and the deeper complex form that follows prolonged captivity, war and repeated terror (Herman, 1992; WHO ICD-11, 2018), is not a mood that lifts. Roughly one in three refugees and asylum seekers lives with PTSD or depression — around ten times general-population rates (Blackmore et al., 2020; Steel et al., 2009) — and while some proportion recovers naturally over years, a stubborn core does not. A brain locked in threat-prediction, replaying the worst night of a life on a loop, does not spontaneously relearn safety. Left to itself, it practises fear until fear becomes the default setting of a person.

Worse, the conditions a receiving country imposes after arrival routinely make the injury deeper rather than shallower. Immigration detention is associated with PTSD rates above 40% (von Werthern et al., 2018) — the processing system actively re-traumatising the people inside it. And the long limbo of an undecided claim does measurable, lasting harm: Hainmueller, Hangartner and Lawrence (2016) showed that each additional stretch of enforced waiting reduced refugees' later employment for years afterwards. We take a person whose nervous system is screaming for safety, predictability and purpose, and we give them indefinite uncertainty, enforced idleness, and nothing to do but wait and remember. Then we are surprised when they do not simply get better.

So the first honest point is the least comfortable one for a budget: untreated trauma in displaced people is not a problem that solves itself if you look away. Looking away is not neutral. It is a decision to let the wound deepen.

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II. The first casualty is the person

Before trauma costs a community anything, it costs the person who carries it almost everything — and understanding that inward collapse is the only way to understand what sometimes spills outward.

The most common route that collapse takes is self-medication. The symptoms of untreated PTSD — the sleeplessness, the hypervigilance that never switches off, the intrusive memories, the sheer exhaustion of being afraid all the time — are unbearable, and people reach for the nearest thing that dulls them. Usually that thing is alcohol or drugs. The comorbidity is not marginal; it is one of the most robust findings in the whole field. Lifetime rates of substance use disorder run at roughly a quarter to a half of people with PTSD, against perhaps 8–25% in the general population (Jacobsen, Southwick & Kosten, 2001). The direction of causation usually runs from trauma to substance, not the other way: the drinking starts as a way to quiet the symptoms (Khantzian's self-medication pathway, confirmed across the literature). And once the two are locked together, they feed each other — withdrawal sharpens the very symptoms the substance was meant to numb, so the dose climbs, and both conditions become more severe and harder to treat than either alone (Jacobsen et al., 2001).

This is the quiet catastrophe that unfolds long before any incident: a person who survived a war slowly disappearing into addiction, chronic illness, unemployment, isolation and, too often, suicidality. The body kept the score, as the clinician Bessel van der Kolk put it, and it keeps paying. If there were no social cost whatsoever — if the harm stopped entirely at the edge of one ruined life — it would still be reason enough for a decent society to act. But the harm does not always stop there.

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III. Then it spreads — and here honesty matters most

This is the section where it is easiest to lie in either direction, so let me be precise.

The harm reaches outward first and most reliably into the family. A parent trapped in untreated hyperarousal, emotionally numb one hour and volatile the next, cannot parent the way they want to. Rates of intimate-partner aggression are elevated where PTSD is untreated — the long-running US veterans research found roughly a third of men with current PTSD reporting partner aggression in the past year, against about one in eight without it (Jordan et al., 1992). And the wound can travel down a generation: Rachel Yehuda's work on the children of Holocaust survivors found altered stress-hormone profiles in people who never saw the camps, through a mix of epigenetic and environmental transmission (Yehuda & Lehrner, 2018). A child raised by a mother who cannot stop scanning the room learns, in their own body, that the room is dangerous. Untreated trauma in one adult shapes a household, and sometimes a lineage.

Then there is the question everyone circles and few handle honestly: violence against the wider community. Here the evidence is genuinely nuanced, and the nuance is the most important thing in this essay, so I will not flatten it.

PTSD on its own is a weak predictor of serious violence. In one of the largest studies of the question — Elbogen and colleagues' national survey of US Iraq and Afghanistan veterans (2014) — people with PTSD but no alcohol problem were not significantly more likely to commit severe violence than people with neither. Read that twice, because it demolishes the lazy equation of "traumatised" with "dangerous." What drove the risk sharply upward was a combination: PTSD plus untreated self-medication with alcohol. When the two co-occurred, the predicted probability of violence rose steeply. The mechanism runs through the hyperarousal and hostility that trauma leaves behind (Elbogen et al., 2016), amplified by the disinhibition of drink. The UK's own cohort study of military personnel found the same shape — combat-related PTSD linked to later violent offending, concentrated among the most symptomatic (MacManus et al., 2013, Lancet).

The one strong study on refugees specifically tells a consistent story. Couttenier and colleagues (2019), using every crime record in Switzerland over seven years, found that asylum seekers exposed to civil conflict and mass killing in childhood were substantially more likely to commit violent crime than otherwise-similar asylum seekers who had not been so exposed — the fingerprint of trauma, not of nationality. And the same study found the effect largely dissolved when those people were allowed to work.

So assemble it honestly. The risk is real. It is not evenly spread across a population — it concentrates in a minority defined by severe, untreated trauma, compounded by self-medication and by exclusion from work and purpose. It is not a property of being a refugee; it is a property of an injury left to fester in a vacuum. The overwhelming majority of traumatised people never harm anyone and are, as every serious review finds, far more likely to be victims than perpetrators. But the minority in whom trauma, addiction and idleness converge is where the social cost — the incident, the headline, the man in the dock — is actually generated. Deny that and you have no credibility. Exaggerate it into "they are dangerous" and you have a slander. The truth sits exactly in between, and it is far more useful than either edge, because it tells you precisely where to intervene.

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IV. The destructive choice is to do nothing

Notice what every link in that chain has in common: each one is a point of failure that was also a point of possible rescue.

The trauma could have been treated before it entrenched. The self-medication could have been caught before it became dependence. The person could have been allowed to work before idleness and hopelessness did their corrosive work. The family could have been supported before the strain hardened into harm. At every stage, the slide toward the worst outcome was not inevitable — it was permitted. This is why the language of "these people are destructive" is not just offensive but analytically wrong. The destructive force in the story is the untreated condition and the system that leaves it untreated. The person is the site of the damage, not its cause.

And here is the part that should concentrate the mind of anyone holding a budget: the costs of doing nothing do not disappear. They are deferred, at interest. They arrive later, larger, and harder to reverse — as emergency psychiatric admissions, the most expensive care there is; as tenancy breakdowns and homelessness; as children taken into care; as addiction services and A&E visits; as the small but real slice of violence the evidence quantifies; and, if the intergenerational findings hold, as a second bill that lands on services fifteen years from now, long after anyone connects it to its cause. A society that declines to spend a little, early, on treatment and integration does not save the money. It spends far more, late, on consequences — having also allowed a great deal of avoidable human wreckage in between. Inaction is not the cautious option. On the arithmetic, it is the reckless one.

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V. The chain can be broken — this is the good news, and it is strong

If the essay ended there it would be a counsel of despair, and it should not, because the most important finding in this entire field is the most hopeful: every link in the chain can be cut, and cheaply.

The core injury is treatable — often remarkably so, even under the hardest conditions. Narrative Exposure Therapy, a short structured treatment built for war and torture survivors, was tested on Sudanese refugees still living in a settlement, about as far from a comfortable clinic as therapy has ever been attempted. A year later, roughly 71% had recovered from PTSD, against the large majority who had not in the comparison groups — and they stayed recovered (Neuner et al., 2004). A handful of sessions, and the wound that drives the whole cascade closes. Treatment this effective, delivered early, breaks the first and most important link.

The self-medication link breaks when the trauma underneath it is addressed rather than ignored — which is precisely why treating the two together, rather than waiting for someone to "get clean" before anyone will look at the trauma, is now best practice. And the exclusion link — the one Couttenier's data showed dissolving the excess violence risk — breaks with the most ordinary things imaginable: the right to work, language, routine, a reason to get up, a place in a community. These are not soft extras bolted onto clinical care. Neurologically, they are how a threat-locked brain relearns that the world is safe: through repeated, lived evidence that tomorrow is predictable and that you have a place in it. Belonging is not the reward for recovery. Belonging is part of the treatment.

Which means the whole bleak chain in this essay is, read the other way, a list of interventions that work. Treat the trauma early. Catch the self-medication. Open the door to work and language. Support the family. Build belonging from day one. Do those things and the destructive end-point most people fear does not arrive, because the conditions that generate it never assemble. Fail to do them — leave the injury alone and call it respect, or leave it alone and call it toughness — and a minority will slide, predictably, toward outcomes that harm them first and others second.

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VI. What looking away actually costs

Return to where we began: the incident, the headline, the man in the dock. By the time a society is looking at that, it is looking at the one visible ruin at the end of a long chain of invisible, preventable failures — and then, too often, it draws exactly the wrong lesson. It concludes that the people are the problem, and reaches for exclusion, detention, deterrence: the very measures that, on all the evidence, manufacture the risk by deepening the trauma and widening the vacuum. It is a policy of looking away dressed up as a policy of control, and it is expensive, cruel, and self-defeating in equal measure.

The alternative is not softness and it is not denial. It is to see the chain clearly and cut it early — to treat the injury as an injury, which can be healed, rather than a character, which cannot be deported out of a person. That is the harder-headed position, not the softer one. It costs less, it prevents more harm to the community, and it happens to also be the humane thing to do — one of those rare cases where the decent choice and the shrewd choice are the same choice.

Untreated trauma does not stay contained. But it was never fated to spread. Whether it does is decided, every time, by what a society chooses to do with the wounded people who arrive at its edge — and that is a choice we keep getting wrong, at a price we keep pretending not to pay.

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Author's note: Between Worlds is committed to evidence first. Every claim above is drawn from peer-reviewed research or established clinical literature, cited below; where the evidence is nuanced — as with the link between trauma and violence — we have reported the nuance in full rather than the convenient half. Our position is not that displaced people are dangerous, nor that untreated trauma is harmless, but that its costs are real, concentrated, and preventable through early, structured, trauma-informed support and integration. That conviction is why we build Settle — a multilingual orientation, learning and one-to-one support programme designed to cut exactly these chains early, before the cost of looking away comes due.

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