Battling the Consequences of War

The Al-Kindi Teaching Hospital in Aleppo, where Dr. Fouad M. Fouad trained in surgery, now lies in ruin, an unfortunate casualty of a series of airstrikes that, over the past six years, partially or completely destroyed sixty of Syria’s hospitals.

Fouad fled the Syrian conflict in 2012 along with millions of his fellow countrymen. He put down roots in Lebanon and now heads the Refugee Health Program at the Global Health Institute at the American University of Beirut.

Ongoing conflict in the Middle East has yielded a wave of refugees seeking asylum in neighboring countries, Europe, and elsewhere. These travelers escaped the ravages of war, left behind their ancestral homes, and made sometimes treacherous journeys to their country of asylum. Their trauma is often compounded by the stress of starting over in an unfamiliar and often hostile new environment.

Refugee populations are at considerable risk of developing mental disorders, including anxiety, depression, and post-traumatic stress disorder, but mental health care is frequently inaccessible.

In September, the CUNY Graduate School of Public Health & Health Policy’s Center for Immigrant, Refugee, and Global Health (CIRGH) hosted an international panel of mental health experts to address clinical and empirical perspectives on Arab refugee mental health and discuss strategies for building capacity for culturally competent treatment and reducing barriers to access.

“Syria is the largest displacement crisis globally,” Fouad said. “Fifty-three percent of the Syrian population is now displaced and around 51 percent are under 18.”

The humanitarian aid system is not equipped to meet the mental health needs of these refugees, Fouad said. Displaced Syrians have high rates of clinic-reported psychosocial distress such as anxiety and depression, and admissions of Syrians into Lebanese psychiatric hospitals substantially increased after the war began in 2011.

Fouad said that unfortunately, many mental health programs and interventions for refugees focus solely on PTSD, ignoring preexisting mood and anxiety disorders and substance abuse.

“The trauma of war can exacerbate existing mental health disorders,” Fouad said.

“A lot of effort should be put towards recovery and prevention of long-term manifestations of trauma.”

Fouad warned that mental health providers working with refugees may overlook depression and anxiety in patients due to their cultural idioms of distress, or the way distress is verbalized in certain communities.

“Mental health providers need to be able to understand the patient’s culture to an extent and how they explain their symptoms.”

Dr. Ceren Acaturk, Associate Professor at Istanbul Şehir University in Turkey, worked with residents of a refugee camp near the city of Kilis to create a mental health intervention program tailor-made for Syrian migrants suffering from PTSD and depression.

Together with her colleagues, Acaturk conducted a study weighing the effect of eye movement desensitization and reprocessing (EMDR), a form of psychotherapy in which the patient is asked to recall distressing images while generating one type of bilateral sensory input, such as side-to-side eye movements or hand tapping, on participants living in the camp. During the course of the study, Acaturk and her team conducted one-on-one interviews with refugees about their struggles.

“We wanted to understand the problems they have and how they express them and what are the solutions they think would help them,” Acaturk said.

The research team then held focus groups with religious and community leaders and conducted cognitive interviews about the proposed treatment methods.

Finally, the researchers trained three psychologists in EMDR and, with the help of translators, they provided one-on-one individual sessions with patients with PTSD. The psychologists and translators were matched by gender with their patients, according to recommendations from the focus groups. Sessions were held near a daycare facility so participants’ children would be cared for during the sessions.

The researchers performed three assessments of the participants, one before the intervention, one after and one a month later. They found that after the treatment, the intervention group had significantly lower scores on the Harvard Trauma Questionnaire. Acaturk noted that the majority of Syrian refugees in Turkey reside in urban areas, not in camps, so the program will need to be adapted to accommodate patients in an urban setting.

Acaturk and her team have since signed on to two projects funded by the European Union’s Horizon 2020 Research and Innovation program: STRENGTHS and REDEFINE.

“We didn’t want to do the study, publish the paper and forget about it,” she said. “We wanted to continue our health strategy.”
The STRENGTHS project will train Syrian refugees to administer a mental health intervention called Problem Management+ (PM+), which was developed by the World Health Organization (WHO), to fellow Syrian refugees.

The REDEFINE project is unique in that it seeks to prevent the onset of mental disorders in refugees with psychological distress through psychological intervention. It will also be tailored to people who may not be able to attend in-person sessions.
“The WHO says—and I agree with them—that we need to target people who are difficult to reach,” said Acaturk. “So through audio recorded consultations and illustrated booklets we aim to reach more people.”

Many refugees in the Middle East and Africa are finding their way across the Mediterranean or by land to European destinations. Dr. Charles Cange, Assistant Professor of Public Health in the Department of Health Sciences at Lehman College and member of CIRGH, presented on the convoluted routes asylum-seekers commonly take to arrive safely and legally in their destination countries.
“There are different stages of trauma,” said Cange, a co-organizer of the event. “A lot of times folks are coming into this journey with a trauma from home. It might be sexual abuse, it might be torture, it might be something else. Sometimes they don’t have trauma initially, but the journey itself can become a trauma.”

Crossing the Mediterranean from Northern Africa to Europe is treacherous, Cange said. The International Organization for Migration reports that 3,100 people died attempting the journey in 2017, but Cange’s own research puts the number closer to 5,000.

Trauma-informed services may help these refugees better integrate into their asylum countries and encourage feelings of acceptance, Cange said.

“They feel alone,” he said. “There’s a lot of loneliness. A lot of times they’re coming by themselves and they feel lost and they feel hopeless and they feel alienated.”

Over the course of his research, Cange has been exploring how refugee service providers respond to trauma in migrants and the prevalence of trauma-informed mental health services in Italy and France. He found that trauma-informed psychological services for refugees is prevalent in Italy but lacking in France.

Both countries could benefit from more federal funding for refugee service-focused programs, Cange said. He recommends that both countries train refugee service providers on trauma-informed care and the types of trauma their clients are likely to have.

LGBTQ migrants are an often-overlooked subset of Arab refugees. For the past few years, Calle Brunell, a clinical psychologist, has been working with asylum-seeking LGBTQ migrants from the Middle East and Northern Africa at the Mansmottagning sexual health clinic in Stockholm, Sweden.

All over the world, LGBTQ people are targets of violence, discrimination and persecution. “Instead of a single catastrophe, many report a life characterized by violence,” Brunell said.

He told the story of a patient, “Niki,” a transgender woman from Egypt. The abuse started for her at an early age. Growing up in Cairo, she was verbally, physically, emotionally and sexually assaulted, predominantly by members of her own family.

“When harassment takes place at home, in school, in the religious community and at work, the individual is left without professional support from healthcare or juridical systems, nor can they find more informal emotional support amongst family and relatives,” Brunell said.

Brunell’s clients have often made arduous journeys through many countries to reach Sweden, facing harassment and abuse along the way. Once arrived at their destination, they’re often met with racism and islamophobia as well as homophobia or transphobia. The uncertainty of the asylum process only adds to his patients’ stress, he said.

“The asylum process can itself be seen as ongoing trauma,” Brunell said. “The longer you stay in it, the worse it gets. My patients have to be sheltered sufficiently from its effects.”

The clinic offers safe spaces in collaboration with NGOs, but more importantly, Brunell says, opportunities to process their experiences through therapy.

Through her work with Dr. Brunell, Niki was able to put aside her trauma and focus for the first time on her trans identity. She had always felt “different” but lacked the terminology in Arabic to express her feelings. Through therapy, Brunell says, Niki was finally able to find words to describe her experience and to place her identity in a wider context. She transitioned from a gay man to a transgender woman within a few months.

“It was like watching that sudden and delicate blossoming of cherry trees down by the opera house in May,” Brunell said.

Refugee mental health service providers, academics and migration authorities should show more concern for LGBTQ migrants, Brunell said, as they have suffered incomprehensibly in the pursuit of a better life and the realization of their true selves.

For Niki at least, her desires weren’t too different from those of the majority of the world’s refugees. “She just wanted to lead a safe life, she told me, to work and to love,” Brunell said. “That’s all.”

Dean Ayman El-Mohandes congratulated the presenters for going beyond the headlines to bring an evidence-based public health approach to the plight of refugees.

“It has been an honor for us to bring this international group of academics and clinicians to share the insights they have gained through their hands-on work with refugee populations,” said El-Mohandes, noting that this forum reflected CIRGH’s mission to advance scholarship, practice and understanding of the transnational policies, programs, institutions and ethos that influence global health.

“We are continuing to work with Dr. Fouad and the other presenters to bring their deep experience with refugee communities into our classrooms.”