RESULTS
Responses must adapt quickly to changing, local needs
After the initial shock when a small demonstration in the town of Daraa transmuted
rapidly into a nation-wide war, SAMS responded by transforming itself from a consortium
for medical professionals of Syrian descent to a medical relief NGO to provide frontline
and long-term crisis relief and healthcare to all affected by the Syrian war. Similar
to other relief organizations, SAMS initially prioritized treating severe physical
injuries over mental health needs. As millions of Syrians were displaced or living
under sustained conflict, mental healthcare became essential.
The minimal mental health system in Syria prior to the crisis, coupled with large-scale
mental healthcare needs amplified by the war, made it impossible for SAMS and other
NGOs to begin programs with adequate formally qualified staff due to preexisting shortfalls
of mental health professionals. Shortfalls worsened after attacks targeted healthcare
professionals, medical hospitals, and psychiatric facilities.[1],[2],[6],[7] Consequently, provision of mental healthcare and psychosocial support (MHPSS) was
adaptive, relying on expatriate healthcare professionals, ad hoc and formally trained
nonprofessional personnel and refugees, and telepsychiatry for training, supervision,
and consultations with Arabic-speaking psychiatrists and neurologists.[1],[7] preexisting medical networks such as SAMS and the Syrian Expatriates Medical Association
could adapt quickly and flexibly with efficient communication networks that facilitated
rapid, effective mobilization of resources, for example, to provide MHPSS in besieged
conflict areas.[8] The first and main challenge was the scope of mental healthcare needs, as shown
here.
In 2012, Ghouta’s population of 500,000 was besieged. For six years, government forces
allowed no medicine or food to enter. Repeated bombardments caused numerous civilian
casualties. Residents were left to their own resilience and resources to deal with
the catastrophe. The SAMS MHPSS programs relied on a key individual; a charismatic
local woman in her 20s with no formal training in mental healthcare. She led a team
of 12 semiprofessionals to provide psychological support and social services, with
a psychiatrist consulting by telepsychiatry. She maneuvered their way through a complex
social system controlled by rebel groups to provide individual and group therapy to
children, adolescents, and mothers who were particularly isolated or vulnerable to
aggression or neglect. She did not go door-to-door generally offering “support.” Instead,
she sought out the most highly vulnerable: children wandering the streets, impaired
individuals who might be exploited to smuggle bread through checkpoints, those with
preexisting developmental and psychiatric problems, children and adolescents with
temperament problems, and widows lacking social support. The scope of care was focused
on those least capable of adapting to the catastrophe. The team focused on empowering
them by teaching them adaptive communication and social skills. Children were provided
with schooling and with meals to prevent sexual exploitation given that food was scarce.[1] Following the emergency evacuation of Ghouta in 2018, SAMS provided mobile clinics
and treatment at temporary IDP camps.[6] MKH
The second challenge was how to deliver socio-culturally appropriate mental healthcare
in a humanitarian emergency involving great loss of life and a collapse of social
and moral order. Consensus has emerged that to increase the scale of services and
logistical and cultural accessibility, mental healthcare in humanitarian emergencies
benefits from integration into primary care and systematic inclusion and training
of nonprofessionals and peer-refugees.[1],[3],[6],[7],[9],[10] Models for training primary care clinicians and nonprofessionals have been developed
such as the WHO mhGAP and Problem Management Plus programs, both of which were adapted
for use with Syrian refugees.[1],[3],[7],[10],[11] However, Western centrally developed models of service delivery and research are
sometimes rigidly structured and monolithic, with modifications for local populations
limited to language or idioms of distress. What is “best practice” in one setting
is not necessarily best practice, or feasible, in another. A bottom-up strategy for
service and research development can enhance relevance and efficacy, but this approach
is not yet prevalent.[8],[12] In the field in Syria, interventions often lacked context and relevance for the
population who was not necessarily consulted on their needs or the basic premise of
evaluation and treatment tools. In the gap between distant ideals and local needs
those who were trained to conduct day-to-day evaluations and treatment often adjusted
tools by omitting elements, “translating” them, or adding interpretations. Compared
with models of structured, frequent supervision, in the field supervision was unstructured,
infrequent, and unverifiable. To optimize relevance and efficacy, mental healthcare
providers and models must not only adapt to specific sites, cultures and needs, but
also arise from them.
Local and personal relevance
Syrian refugees typically have no prior exposure to mental healthcare and consider
psychological problems stigmatizing. Indeed, Syrians often experience Western, psychologized
terms and therapies as intellectual exercises foreign to their experience rather than
real support. Instead of superimposing frameworks of meaning and communication, it
is more helpful to ask and to respond to identified difficulties.[9],[11] In the case referred to later, refugees responded to beginning with an apology,
light social interchange, and asking them to identify their main “challenge”—a term
conveying personal agency and ability.
The first time I went to Lebanon to see what I could do to help, I found a program
already operating. The staff were not sure of how to help those they reached out to.
They had been told to go to tents and give people questionnaires. The questionnaires
asked up to 90 seemingly arbitrary questions translated from English on symptoms and
personality traits. One day, I took the team to visit a tent where we found two women.
I apologized for our intrusion, introduced myself as an SAMS member—I never introduced
myself as a “mental health worker”—and said we were there to ask how we could best
help them. After light conversation, the two left and returned with other women. I
asked them, “What is it like to not have a home? What is the biggest challenge?” All
of them said that what was most difficult was dealing with the children. They said
that the children want to play, and they cannot stay in a tent, but they are in a
place they do not know, where police monitor them and target them for illegal status,
so they have to stop the children from leaving the tent. I asked, “How can you control
your children?” They said that beating was the only way. One mother described having
different types of sticks for different types of offenses. She had to hide the sticks
because the children started stealing them and throwing them away. In Syria, she lived
in her own house. Now she lived in a tent. She worked because of her husband’s illness,
woak up at dawn, treated him with a traditional remedy, and cleaned the tent, only
to find that her boys had wet their bedding. She would lose control and start beating
them like a mad person. One day, she ran to the border checkpoint, grabbed a guard’s
rifle, pointed it at her head and begged him to shoot, screaming, “Are you not a man?
I am an illegal Syrian, can’t you see? No one will blame you! Just do it!” How could
I counsel this woman? She said that she did not have a “psychological problem.” Her
initial response when offered support was, “You want to help me? Just take me back
to my house.” Only when I reminded of her of never hitting her children before, of
how she had changed, and of the guilt she felt due to her violence toward them, only
then there was a window to her pain and suffering. As she narrated her story, other
women began to realize how they were treating their children. Many cried and narrated
how their husbands, many of whom had been tortured, did the same to them. A Syrian-American
psychiatrist
Trauma propagates horizontal violence
Horizontal violence is a substantial problem for Syrian refugees, as for other victims
of collective trauma, and it needs to be sensitively explored. Domestic violence by
mothers against children is elevated in Syrian refugee camps, with mothers’ exposure
to war trauma associated with poorer maternal mental health and greater use of harsh
punishment, an effect decreased by having greater social support.[4],[13] Syrian parents keenly wish to parent their children as best possible under extraordinary
conditions and benefit from locally developed community education on parenting and
behavioral symptoms in children.[1],[14] As in other conflict-affected populations, domestic violence by men is elevated,.
Evidence-based services to men include anger management and positive parenting.[9] Women and children are among the most vulnerable of refugees, experiencing domestic
violence, gender-based violence, forced or child marriage, confinement, harassment,
survival sex, and child labor.[4],[9],[15],[16] Sexual and gender-based violence increased substantially during the Syrian war and
those known or thought to have experienced it can be highly stigmatized.[9] Men and women may avoid disclosing intimate, stigmatizing experiences to a male
practitioner. Having choice of a male or female practitioner can ease sensitive disclosures.[9],[15] In Syrian IDP camps, 15.8% of males over age 14 had been detained or kidnapped and
11.3% tortured or beaten.[17] Torture survivors present with complex emotional, social, physical, and identity
problems that are not well served by multiple diagnoses, but symptom reduction in
one area can beneficially affect others.[9] Torture survivors can have difficulty trusting medical authorities. Mistrust in
authority arising from political oppression is widely felt among conflict-affected
Syrians and projected onto healthcare systems, especially mental healthcare, which
attempts to uncover thoughts and feelings.
Humility in professionals
The assumption that people exposed to violence, atrocities, or displacement are targets
for one’s “support” or “therapy” can be offensive to conflict-affected Syrians. Using
professional jargon such as “psychological,” “mental health,” and psychiatric labels
(e.g., “depression”) can exacerbate stigma and distrust. Universal terms such as “suffering”
are more acceptable. Patients often express distress indirectly or through somatic
complaints (e.g., “I’m so tired”), which may reflect the Islamic understanding of
the body and soul as interdependent, interwoven entities and experiences. Cultural
resources for non-Arabic-speaking mental healthcare professionals include close collaboration
with Arabic-speaking colleagues to avoid cultural and linguistic missteps, and guidance
on cultural frameworks, idioms of distress, explanatory models, and social and historical
context of the Syrian conflict.[9] It is important to avoid being directive or assertive in the clinical encounter.
Assertive manner, claiming expertise, and predicting outcomes—all common in Western
medical cultures–may offend the spiritual and cultural worldview of Syrians because
only God has ultimate knowledge.[9] One needs to listen closely to the views of patients who are already hyperaware
of insults to their agency and dignity in the midst of conflict and displacement.
Case: The power of humility
A 25-year-old woman of high social status lived in a suburb where male residents were
systematically humiliated. Men were taken to nearby fields and forced to stand for
days with no food or water. Many died. Many were forced to sign documents stating
they were terrorists and giving up ownership of homes. She now lived in a tent, her
husband psychologically paralyzed, with her mother-in-law directing her daily on cleaning
the tent. She was referred to me by the medical clinic she visited daily for unremitting
headaches asking, “What is wrong with my head?” I interpreted her psychological trauma,
loss of status, the pain of lacking her husband’s support, and being under the merciless
critique of her mother-in-law. She smiled sarcastically and said that I was doing
the same as all doctors, “Every doctor thinks that their explanation is the one. Some
tell me it is migraine. Another tells me it is my sinuses. Some say I need a CT scan,
and now you are saying I am crazy.” It was then that I realized what she was trying
to say - that no one understands, that no one will ever find a solution, and all are
empty promises of things getting better. I apologized to her for “daring” to simplify
things in an insulting way. She took that well, and to my surprise accepted an antidepressant.
A Syrian-American psychiatrist
Mental illness in sustained conflict and trauma
Exposure to trauma is high in Syrian refugees and occurs at all stages of the journey.
Among refugees in Greece, 31–77.5% experienced at least one violent event in Syria
(mainly bombings), 24.8–57.5% during the journey to Greece (mainly beatings), and
5–8% in the Greek settlement (mainly beatings).[18] Among Syrian refugees in Turkey, 72.7% had experienced or witnessed the death of
a close friend, family member, spouse or child; 48% had experienced or witnessed the
abduction of a close friend or family member; 42% had experienced or witnessed a close
friend’s or family member’s torture; and 50.6% had touched or seen dead bodies.[19] Among IDP Syrians, 31.7% overall, and 9.8% of children younger than 15 years experienced
at least one violent episode within the past year, in most cases witnessing atrocities
(floggings, executions, and public body displays).[17]
Case: Trauma exposure in a Syrian child
A young girl witnessed militants execute her father and then repeatedly rape her mother
until she died. The next day, they took her to her school, ridiculed the teachers,
and beat her and her classmates. When a male teacher came to her aid, they tied two
ropes around his neck and pulled until he died. When a female teacher tried to help
the children, they poured gasoline on her and burned her alive. This girl is now orphaned
and lives in the unstable environment of a refugee camp.
Sixty percent of Syrian schoolchildren aged 8 through 15 have at least one probable
psychological disorder, most commonly PTSD (35.1%), followed by depression and anxiety.[20] One-third of Syrian adolescent refugees in Jordan have moderate-to-severe PTSD,
with risk elevated for females and adolescents with one or both parents deceased.[21] Among adult Syrian refugees, approximately 30-40% have PTSD, which is often comorbid
with depression and anxiety.[19],[22],[23] Assessment of function is important because self-report and symptom scales used
in conflict-affected populations can overestimate prevalence by 1.5 to 2 times,[3] and because function is part of resilience.[12] Among IDP Syrians, 37.7% of household members over two years old were so distressed
that they were completely or almost completely inactive because of these feelings
in the two weeks preceding the survey. 14.4% felt so hopeless that most of the time
they did not want to carry on living. Among children aged 5–12 years, one-fifth had
frequent bedwetting, a common sign of trauma and distress in this age group.[17]
As observed by SAMS mental health specialists, early in the conflict many Syrians
experienced mental health symptoms consistent with established mental health disorders
of anxiety, depression, and PTSD. The confluence of past and ongoing complex trauma
over nine years of diminishing dignity, well-being, and hope while continuing to experience
violence, displacement, and humiliation has pushed mental distress beyond traditional
PTSD.[1],[11] For individuals with severe mental illness, treatment and illness course can be
profoundly affected by conflict.
A therapist’s account from Idlib (Names have been changed)
When Ahmed entered the clinic he examined everything obsessively with his eyes. He
said, “I look in the mirror for hours and ask my mother, ‘Do you see on my face or
hands white spots?’ I despair from checking my hands and my body.” I asked, “Can you
remember the beginning of your suffering?” He said, “I stayed in Aleppo for six years
alone in a building where only cats and an elderly neighbor remained. Days were miserable
and dark. We only saw at night by the glow of missiles. My brother Ami…went missing
in Aleppo. My beloved left me for Turkey…I was cut off from all my friends…I feel
bad for my brother Tariq more than anything. He has not left the house for two years.
He is schizophrenic, that’s what they told me. God doesn’t bless the officer who beat
him and put him in prison…for 52 days. And he was tortured, beaten, berated, and he
finally came out of the prison as a mentally ill patient, helpless…My hair is falling
out. I have dropped my studies. I can’t work. Most of my time is spent in my room.”
He wept. Ahmed saw me for five months and was excited about psychotherapy. It was
a long time until he returned so I knew he was displaced again. He promised me a surprise
on the next visit. He said, “I will bring you Tariq.” For the first time in two years,
Tariq will come out of the house. Told by telepsychiatry to MKH.
Mental health provider dilemmas
Mental healthcare providers may struggle to maintain equilibrium while carrying vivid
knowledge of the trauma, losses, and psychological wounds of their patients.[1] They themselves may have undergone trauma from war violence and displacement. Self-care
can be difficult or infeasible under Syrian conflict conditions and burnout can occur.[1] Psychosocial support for healthcare providers in Syria is minimal.[24] Programs for well-being, training, and supervision are critical for healthcare workers
to aid them while coping with danger, stress, and moral distress while working with
conflict-affected Syrians.[7],[25]
Psychiatrists and other physicians in Syria risk arrest and torture by the Syrian
government, which criminalized the provision of healthcare to whomever it considers
opponents, in violation of the Geneva Conventions.[24],[25] Opposition militias may endanger and interfere with healthcare provision. Mental
health assessment and treatment is complicated by Syrian law, which deems attempted
suicide a crime. Some refugee host countries require clinicians to report attempted
suicides.[9]
Religion, fate, and resilience
Acceptance of fate when suffering is a characteristic of Islam that IA found had a
fundamental role in the therapeutic alliance. For many Syrians, faith and reliance
on God’s strength supports hope, transforms healing, and enables moral transcendence
over otherwise intolerable experiences. When dealing with trauma in conflict-affected
Syrians, rather than focusing exclusively on signs and symptoms of illness and distress,
accepting a patient’s view of the supreme power of moral victory can support their
resilience and healing.
Case: Acceptance and resilience
I was introduced at the refugee camp to a woman who had lost five of her children.
They had all volunteered for the Free Syrian Army and died within months. I asked
how she was doing and she answered with an expression of peace on her face, “Praise
to God.” (In Arabic, the rest of the phrase is “God is the only one we praise for
bad things.”) I literally did not know what to say. The next day, in the government-controlled
area of Syria I met an acquaintance who was now a medical officer in the Syrian Army.
I asked how he was doing. He looked miserable and exhausted. He complained about his
income and how “those opposition fighters” ruined the country. He declared, “We are
victorious. We will take back the country.” Inwardly, I compared the misery on the
face of the officer who was “victorious” with peaceful look on the face of the woman
who lost her children, who lived in a tent, and who had to work a whole day for one
dollar, but praised God. I asked myself, “Is trauma an illness of the perpetrator
or of the victim? Whom should I treat?” A Syrian-American psychiatrist.
Resilience in conflict-affected environments is affected by the phase of conflict,
gender, age, intraindividual variables, and sociocultural context. Resilience promotion
should be tailored to these specifics, with more focus on strengths and agency than
on deficits and symptoms.[11],[12] Religious identification, which is diverse in Syria and does not necessarily indicate
that an individual is devout, can be part of an individual’s framework for spiritual,
moral, cultural, socially affiliative and politically affiliative relationships with
self, others and existential meaning. Prayer is a common, important way to reduce
tension and stress among Syrians. Adolescents have reported that thinking of former
good times and reading the Quran are helpful coping practices.[9]
Mental healthcare capacity and stigma
Mental health services in Syria were scarce and disorganized before the war with fewer
than 50 psychiatrists, no other licensed mental health disciplines, and no mental
health code. The war decimated Syria’s mental healthcare capacity by triggering an
outflow of healthcare professionals,[1],[2],[6],[7] by extensive damage and temporary closure of Syria’s two public psychiatric hospitals
after targeted bombardment, and by the complete destruction of Syria’s two private
psychiatric hospitals.[2] Mental healthcare before the war was limited in part by low public acceptance of
mental healthcare and stigma. Shared wartime experiences of extreme stress and distress
from violence, loss, and displacement have decreased stigma, increased recognition
of the value of mental healthcare, and shifted explanatory models of mental illness.
Recognition of the psychological impact on children and adolescents of war-associated
loss and trauma has resulted in some school-based mental health programs to improve
teachers’ understanding of students’ mental health needs and means of addressing them.[2]
