Tag: cultural competency

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Stakeholders & Grantors in Cross-Cultural Adaptation of a Trauma Assessment Instrument for Syrian Refugees

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Engagement of grantors and stakeholders in a research project can be vital to its success. In adapting the International Trauma Questionnaire (ITQ) to include cultural idioms of distress for Syrian refugees, grant funding would need to be secured in order to successfully carry through the development, testing, and initial study. Furthermore, partnerships with stakeholders are also important, as it is through their organizations and networks which participants may be gathered, may be a part of the research team itself, or may be members of the populations who will benefit from the research, such as mental health workers, other psychological researchers, the Syrian refugee community, policy makers, among others.

            Grant funders are more than just sources of money to complete a project. Ideally, they would also be partners, advocates, and endorsers, with an equal interest in seeing the project come to completion (Broussard, 2019). Typically, organizations, foundations, and government programs which award grants do so, at least in part, because they identify a need which aligns with their values and mission which usually helps society in some fashion (Grant Funding Expert, n.d.). For research which makes a substantial contribution to a field of study, this can also increase the reputation and notoriety of the organization providing the funding. In writing a grant proposal, one should pay close attention to the details of how the funds are meant to be used, and also the objectives and values of the grantors. The grant proposal application needs to clearly demonstrate the value of the research to society and to the grantor organization. Furthermore, funding agencies do not want their funds to be wasted, so defining a clear budget and purpose for funds awarded is necessary (Resnik & Elliott, 2013). While a funder who is actively engaged with the funds recipient throughout the research process shows a strong engagement partnership, it can also signal problems for researchers, whose research may then represent a conflict of interest or bias, even if unintentional, to produce results which please the grantor (Resnik & Elliott, 2013). A tip for engagement of grantors in increasing odds of being approved for funding is to make contact with them and learn about their goals, using a variety of modalities such as social media, emailing, calling, or having an in-person or virtual meeting to gain an insight into their perspectives (Wright, 2019). Grantmakers themselves should also seek to be involved with both their grantees and community stakeholders which can improve the success rates of the programs and research that they are funding (Enright & Bourns, 2010). For engagement with both grantors and stakeholders, meeting expectations is key – monthly reviews of the project progress and evaluation on which goals have been met and which are needing additional work or re-strategizing can help keep the project on track and maintain accountability.

            Researchers also need to engage with stakeholders. This includes “those involved in program operations,…those served or affected by the program,…[and] those who are intended users of the evaluation findings” (Centers for Disease Control and Prevention, 2012, par. 3), such as other researchers, community members, local leaders, organizations with interest in the research, thought leaders and experts, and others who may benefit from or be impacted by the research being conducted (Geo Funders, 2014). According to Boost Midwest (2020), stakeholders can be identified as being key stakeholders or secondary stakeholders, and it is recommended to create a stakeholder register and assessment. They state that the major benefits of engaging stakeholders are that they “can help provide an accurate sense of the needs and challenges facing the grantee. The more diverse your team’s list of stakeholders can be, then the easier the buy-in for the project and it’s goals will become and the more successful the implementation will be long term” (Boost Midwest, 2020, par. 12). Engaging with diverse stakeholders early in the research process and throughout its timeline, can increase the usefulness, relevancy, and credibility of the study (Preskill & Jones, 2009).

            There are a variety of strategies for engaging stakeholders throughout the research process, and beyond. Sharing updates and information on the project is essential, and a variety of methods can be used to do so. It will be important to consider each group or individual stakeholder and their ability to access such communications (for example, availability of internet service). The use of targeted experiences can be done through digital engagement, and includes sharing webinars, having Slack channels, podcasts, or informal meetups or chats (Young Entrepreneur Council, 2019). Meeting in person with stakeholders, even if infrequently (such as once a year) is also recommended, although talking on the phone may suffice if travel is not possible. Periodic updates can be sent out to stakeholders, through internet services like email newsletters, private emails, text or WhatsApp, or even through postal mail. Asking questions of stakeholders may bring in higher engagement, and also further collaborative efforts and allow stakeholders to share their expertise which may benefit the project.

In conducting research to develop an adaptation of the ITQ for Syrian refugees, it is expected that a number of stakeholders would need to be involved, in addition to one or more grantors. The development, pilot testing with feedback, and pilot testing for validity and reliability checks would best be done in a location close to potential participants and related stakeholders – Jordan was chosen as an appropriate country with high numbers of Syrian refugees while being a safe location to conduct research. Some permissions would likely need to be granted by governmental or organizational groups overseeing research with human subjects. Forming relationships with these groups could be mutually beneficial. Furthermore, stakeholders would ideally also be leaders within the Syrian refugee community, as well as with local mental health or psychology organizations which could provide input on the development of the assessment and would also benefit from being able to see or use the results in providing more comprehensive support or care for Syrian refugees. A cultural expert would also be needed to help broker local needs, as well as provide insight on cultural specificities in both working with and communicating with regional partners and participants, and also practical needs of conducting research such as assistance in renting an office space. Many secondary stakeholders could also exist from international organizations who hold interest in the research, however, too many could overwhelm the project’s immediate scale. A balance of input and output should be sought, and stakeholders could be assessed for their skills type and level of contribution that will improve but not hinder the research process (Preskill & Jones, 2009).


References

Boost Midwest. (September 24, 2020). Grant management: Building stakeholder engagement. https://www.boostmidwest.com/post/grant-management-stakeholder-engagement

Broussard, D. (February 13, 2019). Engage grant funders to be advocates and endorsers. Dickerson Bakker. https://dickersonbakker.com/engage-funders-to-be-advocates-and-endorsers/

Centers for Disease Control and Prevention. (2012). Program evaluation for public health programs: A self-study guide. CDC: Program performance and evaluation office. https://www.cdc.gov/eval/guide/step1/index.htm

Enright, K.P. & Bourns, C. (2010). The case for stakeholder engagement. Stanford social innovation review. https://ssir.org/articles/entry/the_case_for_stakeholder_engagement

Grant Funding Expert. (n.d.). Why does the government give grant money. https://www.grantfundingexpert.org/why-does-the-government-give-grant-money/

Preskill, H. & Jones, N. (2009). A practical guide for engaging stakeholders in developing evaluation questions. Robert Wood Johnson Foundation.

Resnik, D. B., & Elliott, K. C. (2013). Taking financial relationships into account when assessing research. Accountability in research, 20(3), 184–205. https://doi.org/10.1080/08989621.2013.788383

Wright, J. (September 27, 2019). Grant seeking 101: A step-by-step guide to finding and winning grants. sgENGAGE. https://npengage.com/nonprofit-fundraising/grant-seeking-101/

Young Entrepreneur Council, Expert Panel. (September 19, 2019). Five effective methods for     keeping stakeholders engaged. Forbes.             https://www.forbes.com/sites/theyec/2019/09/19/five-effective-methods-for-keeping-stakeholders-engaged/?sh=3cff4a6635b2

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Adaptation of Adult Trauma Assessment Instruments for Children & Adolescents

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Adapting a trauma assessment for children and adolescents can be done based on an existing assessment for adults. Certain considerations need to be made for how children and adolescents understand and experience trauma in ways which are different from adults. Steps which outline how to do this can serve as useful guidelines. Assessment for trauma also can limit the long-term impacts of trauma, such as other psychiatric disorders, impaired functioning, and physical health problems (Berliner et al., 2020).

In some respects, adapting instruments meant for adult assessment to screen for trauma in children is similar to doing cross-cultural adaptations of instruments. Language needs to be understood and relevant for children (Grace et al., 2021), just as terms translated to other languages need to impart the same meanings within differing cultural contexts. Trauma assessments have typically focused on broad age ranges for children and adolescents, such as ages 6 to 17 for the Child Trauma Screen (Lang & Connell, 2018). However, there are dramatic developmental differences between children of different ages, and especially between children and adolescents (Grace et al., 2021). Many prior screens do not account for this, and also “did not report collecting data from children and adolescents on how to better articulate the screening items for them” (Grace et al., 2021, p. 2). Additionally, symptom presentations in children with PTSD are frequently left out of assessments, including somatic symptoms (often stomachaches and headaches), separation anxiety or clinging, regression of developmental skills (such as bedwetting), reckless behaviors, old fears suddenly reemerging, as well as symptoms which overlap with and may be misdiagnosed as attention deficit hyperactivity disorder such as hyperactivity, impulsivity, distractibility, and loss of focus and concentration (Kaminer et al., 2005). In their outline of steps to adapt an assessment cross-culturally, Sousa and Rojjanasrirat (2011) list the crucial fifth step as conducting a pilot study with the intended population, who then give feedback and rate the assessment questions, instructions, and items for their clarity and relevance. This step seems to be largely ignored when adapting assessments to children and adolescents, although it seems to be incredibly important to developing an accurate measure.

Moreover, other suggestions for cross-cultural adaptation would be very useful. Raghavan (2018) describes multiple considerations in this regard. Two of these stand out as particularly important additional considerations when adapting adult assessments for children and adolescents. Firstly, is the understanding of cultural idioms of distress. In this case, understanding how children express themselves and communicate amongst each other is valuable. This would mean that assessments may need to be reviewed every few years to ensure it is matching the current trends of how children and adolescents communicate and the terminology that they use. Another point made by Raghavan (2018) is the impact of interpreters. In this case, it would be the impact of the researcher, clinician, or administrator of the assessment. Considerations on this should be explicitly outlined in the assessment instructions by the development team. For example, a teacher administering an assessment may get a very different response from participants than a stoic but impartial researcher who is a stranger to the child, and also differing from a counselor who specializes in working with children and, even if a stranger, may know how to build safety and rapport with the child in the span of a few minutes.

Another consideration is that children may have trouble rating items on a Likert scale, as their memory and concepts of time differ from adults, so the use of Yes/No questions is preferable (Grace et al., 2021). Assessments which allow the child to self-report rather than relying solely on caregiver reports are more accurate (Sacher et al., 2017), although the use of caregiver reports or interviews can also provide important observations in a variety of contexts from someone who knows the child well (Berliner et al., 2020). It should be noted, however, that children and adolescents are particularly subject to suggestive statements, so assessment items which use first-person statements may lead them to be more likely to agree with those statements even if they do not accurately reflect the child’s experience (Grace et al., 2021).

 An important ethical consideration is if the assessment is being given within a clinical setting. If it is not, such as within a school, assessments which ask about a child’s traumatic exposure may cause distress or traumatization. However, for most children, assessments do not increase distress, although it has a higher likelihood of doing so in children who are having symptoms related to trauma (Berliner et al., 2020). Still, it must be considered if there is availability and access (including parental consent and financial resources) to initiate immediate treatment for a child who screens positively for trauma, as without such services, a trauma screening has the potential for harm (Grace et al., 2020). One other point is that there may be a tendency of assessments to not consider the child’s cultural context, such as those who live in dangerous communities, for whom what might appear as a high symptomology of hypervigilance is, in reality, a critical survival skill in their current situation (Grace et al., 2020).

Furthermore, it must be considered if the child’s family is the source of interpersonal trauma, in which case, an assessment could create intense fear and ramifications for the child at home (Berliner, 2020). This does not mean that such potential children should not be screened at all – in fact, early assessment and treatment is vital to ending abusive situations and providing healing for the child. Rather, that when doing an assessment, a plan should be in place in how to handle such situations. This includes the administrator’s familiarity with mandated reporting laws and procedures in the location the assessment is taken (Berliner, 2020). The context of the family can both be an exacerbator of trauma symptoms or a vital support network and conducting and development of assessments should take this into account, although its most valuable use is for clinicians who are treating traumatic symptoms in a child in working with the family.

References

Berliner, L., Meiser-Stedman, R., & Danese, A. (2020). Screening, assessment, and diagnosis in children and adolescents. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Foa, E.B., Asnaani, A., Zang, Y., Capaldi, S., & Yeh, R. (2018). Psychometrics of the Child   PTSD Symptom Scale for DSM-5 for trauma-exposed children and adolescents. Journal of Clinical Child & Adolescent Psychology, 47(1), 38–46.

Grace, E., Sotilleo, S., Rogers, R., Doe, R., & Olff, M. (2021). Semantic adaptation of the Global Psychotrauma Screen for children and adolescents in the United States. European journal of psychotraumatology, 12(1), 1911080.         https://doi.org/10.1080/20008198.2021.1911080

Kaminer, D., Seedat, S., & Stein, D. J. (2005). Post-traumatic stress disorder in children. World psychiatry : official journal of the World Psychiatric Association (WPA), 4(2), 121–125.

Lang, J., & Connell, C. (2018). The Child Trauma Screen: A follow-up validation. Journal of Traumatic Stress, 31(4), 540-548.

Sachser, C., Berliner, L., Holt, T., Jensen, T.K., Jungbluth, N.J., Risch, E.C., Rosner, R., & Goldbeck, L. (2017). International development and psychometric properties of the Child and Adolescent Trauma Screen (CATS). Journal of affective disorders, 210, 189-195 .

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Cross-Cultural Adaptation of Trauma Instruments

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The seven steps provided by Sousa and Rojjanasrirat (2011) for the cultural adaptation of health care assessment instruments primarily focuses on translation. This does include some cultural considerations as well, and they suggest it best to use translators who are not only fluent in both languages, but also from the culture in question, in order to capture meanings accurately rather than a direct word-for-word translation.

The seven steps are:

  1. Initial translation from the original language of the instrument into the language sought for adaptation by two translators. One of translators should also possess fluency in the scientific terminology of the discipline being used, while the other should not be, but still familiar with common expressions related to the discipline.
  2. Initial synthesis – comparing both the original and translated instruments by a separate translator for accuracy of meanings. Any discrepancies would be handled by a meeting between all translators to decide on the best meaning to use.
  3. The newly updated translated instrument from the previous step is then back-translated to the original language by two other translators who have never seen the original instrument. These translators should possess similar qualities to the initial two translators.
  4. Secondary synthesis – The two back-translated instruments are compared, and any discrepancies are similarly resolved as the initial synthesis by consensus, and all versions of both the translated versions and back-translated versions are compared.
  5. Pilot test the first draft of the instrument with individuals who speak the target language only and are not bi-lingual. The participants rate the questions, instructions, and items on the assessment itself for being clear or unclear. The use of an expert panel who are within the discipline or have knowledge of it is also recommended for this step to evaluate the clarity.
  6. Preliminary stage testing with participants who are bilingual. This often is skipped over in testing instruments, but it can be a valuable step if it is incorporated.
  7. Complete full testing with the final draft of the translated instrument using a sample from the target population. This test can help to iron out any final inconsistencies or issues, and can be used to determine the general validity and reliability of the instrument.

Raghavan (2018) shares recommendations when conducting assessments for survivors of torture, but, these suggestions are also highly useful to consider for any cross-cultural adaptation of assessments and instruments. These recommendations are based in the premise that cultural contextual factors are critically important to understanding, assessing, and treating how individuals from differing backgrounds express, conceptualize, and experience mental illness. Some researchers believe that inconsistencies in assessments and instruments cross-culturally are not due to actual differences in the rates and underlying symptomology of a mental illness, but rather that the measurement tool does not accurately portray definitions or options which reflect the cultural viewpoint of those being assessed.

These strategies include:

  1. Cultural idioms of distress. How mental illness manifests within a culture, how it is commonly understood and described, and experienced. Many collectivistic cultures use somatic symptoms to express mental distress, for example.
  2. Impact of Interpreters. When clients or participants must use an interpreter to communicate with a provider or researcher, the true meaning of what they try to convey may be misconstrued or lost. Furthermore, the skills and bias of the interpreter may alter both the meaning of the client/participant and the clinician/researcher, and the interpreter may suffer from secondary trauma. It would be best to use a researcher/clinician who is already fluent in the client’s language, but, if this is not possible, using an interpreter is still a better option than not using one.
  3. Cross-cultural equivalence of measures. Five criteria are proposed to determine if measures are equivalent in differing cultures, such as being contextually relevant, differences in the cultural understanding of constructs, or if the method of data collection itself creates a response bias, or is inaccessible to some.
  4. Adaptation and Translation of Measures. Here Raghavan (2018) seems to agree with the steps of translation proposed by Sousa and Rojjanasrirat (2011).
  5. Use of culture-specific normative data. This consists of the baseline sample to which the assessment would be comparing. For example, the normative data would be the general rate of PTSD among community members in Guatemala, but the assessment would be measuring rates of PTSD of Guatemalan refugees. Rather than comparing to PTSD rates among worldwide populations, this ensures that there is accuracy within a cultural framework.

In reviewing a study by Oe et al. (2020), the researchers did make use of the above steps by Sousa and Rojjanasrirat (2011) and recommendations by Raghavan (2018). They used a Japanese-developed trauma screen, the TEC-J, and compared this with the Global Psychotrauma Screen (GPS) which was developed elsewhere and then modified/translated for use in Japan using the guidelines by Sousa and Rojjanasrirat (2011). The use of the TEC-J is important because it was developed internal to the culture in question, and therefore included culturally relevant considerations in its design (Oe et al., 2020). However, this may be outdated, as the TEC-J was developed in the 1990s and therefore avoided asking about highly taboo topics in Japan such as childhood sexual abuse. It is unclear whether this would still be such a taboo today to the point that it would be avoided on an instrument all together. In their analysis, Oe et al. (2020) consider cultural factors which may have impacted the scores particularly on the GPS, including response bias as mentioned by Raghavan (2018). One limitation, which is mentioned by the authors (Oe et al., 2020), is that the sample was skewed to those with severe trauma and who were seeking help; in other words, no normative data for comparison (Raghavan, 2018).

References

Raghavan, S. S. (2019). Cultural Considerations in the Assessment of Survivors of Torture. Journal of Immigrant and Minority Health, 21(3), 586-595. http://dx.doi.org/10.1007/s10903-018-0787-5

Sousa, V.D. & Rojjanasrirat, W. (2011). Translation, adaptation and validation of instruments or scales for use in cross-cultural health care research: A clear and user-friendly guideline. Journal of Evaluation in Clinical Practice, 17, 268–274. 

Oe, M., Kobayashi, Y., Ishida, T., Chiba, H., Matsuoka, M., Kakuma, T., Frewen, P. & Olff, M. (2020). Screening for psychotrauma related symptoms: Japanese translation and pilot testing of the Global Psychotrauma Screen. European Journal of Psychotraumatology, 11(1). 

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Sway Presentation: Traumatic Stress & Syrian Cultural Conceptualizations

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International Psychology & Division 52 video

In this video, I explain my understanding of why international psychology is important and what it means to me, and what drew me to join APA Division 52, and what other students may gain from joining the division.

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Humanitarianism Papers, Docs, and Essays

Providing Mental Health Services in Humanitarian Aid to Syria

Syria has been engaged in a devastating civil war, between multiple groups including the government regime, civilian militias, and terrorist groups for almost a decade (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). This has been devastating to the population of Syria, destroying infrastructure, historical places, schools, hospitals, and demolishing whole communities. Prior to the war, Syria’s health system was already lacking, despite improvements to life expectancy and overall health (Hendrickx, Woodward, Fuhr, et al., 2019). Mental health services were extremely limited. Only 2% of the health budget was allocated for mental health, primarily for in-patient hospital settings. Community mental health settings were exceedingly rare, as was the availability of counselors, psychiatrists, psychologists, social workers, and other mental health professionals. Additionally, the system faced problems due to “inequity, poor transparency, lack of standardized quality care, inadequate numbers of health staff, and uneven distribution of services in the regions due to an uncontrolled expansion of private services” (Hendrickx, Woodward, Fuhr, et al., 2019, p.1) for general healthcare. The government military has deliberately attacked health clinics and hospitals, including psychiatric hospitals, creating an even larger disparity in access to mental health services (Hendrickx, Woodward, Fuhr, et al., 2019). This means the majority of MHPSS services are delivered within Syria by humanitarian organizations, both national and international.

Since the onset of the Syrian Civil War in 2011, more than half of all Syrians have been forcibly displaced, split nearly evenly between internally displaced persons and international refugees (Hendrickx, Woodward, Fuhr, et al., 2019). There are also many non-displaced persons within Syria who are in need of humanitarian assistance and mental health and psychosocial support (MHPSS). It is common for Syrians to be displaced multiple times as the conflicts zones continue to shift, and more than half of those displaced are children (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Known risk factors contributing to mental illness have been experienced by Syrians as a result of the conflict, such as “exposure to traumatic events, forced displacement and ongoing stressors such as unemployment, impoverishment, social dislocation and loss of social support” (Hendrickx, Woodward, Fuhr, et al., 2019, p. 1). Human rights violations towards civilians are rampant within Syria, “including massacres, murder, execution without due process, torture, hostage-taking, enforced disappearance, rape and sexual violence, as well as recruiting and using children in hostile situations” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 12). The Universal Declaration of Human Rights and International Human Rights Law (Weissbrodt & De La Vega, 2007) have been completely disregarded within Syria since the outbreak of the conflict.

One aspect that is particularly challenging for humanitarian organizations is the disregard for their protection – and even specified targeting – by actors in the conflict (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). About 4.8 million people live in remote or difficult to access areas, and another 440,000 are trapped in active conflict zones at any one time, further complicating the ability of humanitarian organizations to deliver aid, supplies, or services.

A systemic review of the literature on the burden and access to mental health services in Syria and neighboring countries (Hendrickx, Woodward, Fuhr, et al., 2019) found large variations in rates of mental illness, such as between 16 to 80% for post traumatic stress disorder, 11 to 49% for depression, and 49 to 55% for anxiety. The most common risk factors for mental illness were being exposed to traumatic events and a history or family history of mental illness. The largest obstacles commonly reported to receiving mental health care were financial and socio-cultural. Gaps in the research were pronounced in the interventions used and the burden of mental illness primarily for those living within Syria.  Access to care and barriers were also in need of further research, as well as evaluation of psychosocial programs and interventions. Furthermore, a common problem found amongst the studies reviewed was that MHPSS interventions had not been validated with the Syrian population and had not been adapted to cultural symptoms or expressions of distress. Barriers to services were found to be “cost, language, cultural understanding, limited availability and quality of services, poor quality of services, low knowledge of mental disorder symptoms, lack of awareness of MHPSS services, and stigma and discrimination” (Hendrickx, Woodward, Fuhr, et al., 2019, p.9).

The 2018 Semi-Annual report from the Syrian Arab Red Crescent Society (SARC) shows little detail on the provisions or specifications of psychosocial support or mental health services. However, they do mention that a significant number of trainings were given on the topic of psychosocial support, numbering 15, tied for the third most numerous training category with disaster management, following first aid and community health trainings. The document also reports that psychosocial support was an included service within the thirteen community centers established in conjunction with the UNHCR in the humanitarian support project. It notes there were 22,803 beneficiaries of these psychosocial services, which also included services for children with special needs, direct support, and awareness sessions and recreational activities. In addition, SARC serves 334 shelters across Syria, which provide services to 12,000 families, and include psychosocial support activities.

The International Medical Corps is also providing psychosocial services in Syria as part of their humanitarian aid in the region. They are working on multiple projects and call for additional support in several areas. First, they seek to scale up sustainable and comprehensive MHPSS services within Syria and surrounding countries who have Syrian refugee populations. They also are training doctors and nurses in mental health and improving the training of mental health professionals within Syria to address the needs currently but also in the future. Additionally, they are “[i]nvolving affected Syrians in community outreach and in learning basic psychosocial support skills, which can strengthen community support and help establish links to formal mental health care services” (International Medical Corps, 2015). They also apply the IASC guidelines to coordinate MHPSS groups, which communicate and collaborate programs and services, advocate to donors, share resources and tools, and map current humanitarian MHPSS efforts (Hijazi & Weissbecker, 2017).

Much of the lack of support for psychological services in Syria is likely to be related to the stigma around mental illness found in many Middle Eastern societies.  While there is very little research on mental health in Syria prior to the war, we can draw assumptions from what we know of the responses of refugees towards mental health and in cultural assumptions from surrounding countries with similar cultural makeups. Syrians consist of a diversity of backgrounds and identities and are considered Arabs – though “this is a term based on the spoken language, not ethnicity” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p.10). There has been an increasing emphasis placed on tribal affiliation since the beginning of the war, which helps establish identity, community, and a structure of leadership within groups in a fragmented country. Multiple ethnic groups have been marginalized and oppressed, the largest of these being the Kurdish, which has seen a resurgence and reclaiming of cultural identity in recent years. Prior to the conflict, there were also significant amounts of refugees residing within Syria, mostly from Iraq and Palestine.

For mental health professionals working with Syrians, there should be caution when diagnosing mental illnesses, as high rates of daily stressors may cause them to show increased symptoms for a period of time, although this is not necessarily indicative of a mental disorder (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Similar to other populations affected by war-related trauma, Syrian refugees have most commonly shown to have emotional category disorders, such as post traumatic stress, anxiety disorders, depression, and prolonged grief. Interventions which focus on non-clinical aspects such as safety, living conditions, identity, community, social roles, and building hope may have significant results in addressing mental health concerns as well (Hassan, Kirmayer, Mekki-Berrada, et al., 2015).

Syrians traditionally have used their family and friends for high levels of support and for coping with difficult situations (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). As many of these social circles have been drastically disrupted from the war, helping Syrians establish a sense of community support would be highly important. Other coping mechanisms for Syrian individuals have been reported to including praying, listening to music, watching TV, drawing, withdrawal, and smoking. Negative coping mechanisms should be watched for and sought to be decreased, while increasing positive coping mechanisms. Men may struggle to admit any “weakness” as is the cultural norm and may benefit from the use of collective activities. Women’s roles, routines, and social networks are also impacted, and they may need ways to engage in active coping and develop new routines and social networks. Many adolescents restrict themselves from sharing their emotional difficulties with their parents, because they do not want to cause them more stress or suffering in addition to the war.  Some parents report “increasingly resorting to maladaptive coping strategies, such as beating their children or being overprotective” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 17). As a result of losing caregivers or family members, family structure and the roles for individuals and between genders may have changed and cause tension within the family, and conflict with traditional norms and gender roles. Sexual violence can be exceptionally troubling to individuals, as it can result in further consequences such as being ostracized.

Domestic violence has increased since the conflict, with stress for men being the reported cause (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Use of evidence based treatment for men to reduce aggressions such as anger management and parenting classes can be used by counselors, although it should be noted these have not been adapted to the Syrian context. In providing services to victims of abuse, counselors should be mindful of the risks for stigmatization and further abuse which may occur at victims seeking counseling or being encouraged to leave their partners. Helping victims identify supportive and safe individuals in their social network can be helpful as part of treatment.

Another consideration is the increase in early marriage for girls as a result of the conflict (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). This is used as a coping mechanism which is seen as a way to provide protection and secure the future of girls at a time when many families are facing poverty, insecurity, uncertainty and the loss or absence of male family members. Early marriage can stall or end girls’ education, increase the risk of health problems and domestic violence, and cause feelings of stress and abandonment by parents for girls.

Counselors working with Syrian survivors of torture have reported that clients typically have multiple emotional and psychological symptoms, in addition to financial and legal issues (Hassan, Kirmayer, Mekki-Berrada, et al., 2015).  LGBTQI+ individuals in Syria face severe discrimination, and same-sex acts are illegal. Since the conflict, LGBTQI+ individuals are  especially vulnerable to being abused or exploited, in addition to high levels of stress and stigma. Elder Syrians are also at increased risk for psychological problems, especially those with health conditions or who have limited support networks; many have lost family members and friends due to death or displacement because of the conflict. Individuals with disabilities or chronic health conditions also show above-average levels of psychological distress. It is common for older adults and those with disabilities to be concerned about being a burden on their caretakers, feel powerless, and have fear about being separated from their families and losing access to health and social supports as a result of the conflict.

Children constitute more than 50% of displaced Syrians, and more than 75% of these are under age 12 (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). It is not uncommon for children to become separated from their families, witness acts of destruction and death, be at risk for sexual exploitation, human trafficking, physical abuse, recruited as child soldiers, and be unable to access basic services. Children have exhibited abnormally high levels of behavioral and emotional problems, with clinical levels of anxiety at around 50%. “Problems include: fears, difficulties sleeping, sadness, grieving and depression (including withdrawal from friends and family), aggression or temper tantrums (shouting, crying and throwing or breaking things), nervousness, hyperactivity and tension, speech problems or mutism, and somatic symptoms. Violent and war-related play, regression and behavioral problems are also reported among children” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 20). Most children have been forced to stop schooling as a result of the conflict. Roles for children may have also shifted, taking on adult responsibilities and concerns due to loss or injury to caregivers. Evidence from Syrian refugees shows that with positive support from families, communities, and service providers, over time emotional and behavioral problems are reduced. Interestingly, the International Medical Corps has shown high rates for children using mental health services within Syria (69%), likely due to the otherwise lack of outlets for socializing and activities (Hijazi & Weissbecker, 2017).

For international humanitarian mental health providers, it is important to understand the Syrian cultural contexts and models of illness and distress to provide improved communication and appropriate interventions with clients. It is recommended to avoid labeling and diagnostics when possible as this “can be especially alienating and stigmatizing for survivors of violence and injustince” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 22). Models of counseling should emphasize building rapport and a therapeutic alliance, and be open to exploring multiple avenues of support such as “both formal and informal medical systems, religious or community resources and strategies” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p.22).

Mental health is not discussed or understood broadly in Syrian culture, and any ideas of psychological states carry negative connotations (Hassan, Kirmayer, Mekki-Berrada, et al., 2015). Suffering is seen as just a part of life does not require psychological care unless it is debilitating. Usually, clients will report physical complaints rather than psychological ones. “Most Arabic and Syrian idioms of distress do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan, Kirmayer, Mekki-Berrada, et al., 2015, p. 22). The use of images or metaphors may be seen by international counselors as a lack of awareness, communication, or even as psychosis. However, by working with the client to understand the meaning of their expressions it can be determined what their psychological symptoms are within their cultural framework.

With the above cultural considerations of mental health in mind for Syrians, humanitarian organizations can plan interventions and aid to address both short- and long-term assistance in a multi-layered approach. The IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007) identify how MHPSS services can be coordinated and integrated throughout multiple aspects of a humanitarian operation. This includes recruiting staff and volunteers who understand the local culture, so in implementing any MHPSS service, the above information should be utilized so that all members of the team understand how to properly work with and interpret meaning from Syrian clients. This is also useful in developing a train-the-trainer model for teaching Syrian lay counselors, and while they may innately understand the local culture, it will be important for their supervisors and teams of international origin to accurately relay and understand information.

Areas of concern which present significant difficulty within Syria include the protection and human rights standards (IASC, 2007). International humanitarian organizations attempting to provide services in Syria should prepare in advance for a strategy to how they can best protect clients from human rights abuses, which are rampant in Syria currently. There may be active opposition to their aid and protections by the Syrian government, and so humanitarian actors should be well versed in International Humanitarian Law and International Human Rights Law (International Committee of the Red Cross Factsheet, 2003) and what extend their funds and resources will allow them to actively protect clients. The rebuilding of an internal network of mental health support, targeting stigma, building awareness, and strengthening the infrastructure to improve the accessibility, quality, and availability of mental health services within Syria should constitute part of long-term goal planning for humanitarian organizations (Hijazi & Weissbecker, 2017).

References

Hassan, G, Kirmayer, LJ, Mekki-Berrada A., Quosh, C., el Chammay, R., Deville-Stoetzel, J.B., Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A.,Coutts, A., Song, S. & Ventevogel, P. (2015). Culture, context and the mental health and psychosocial wellbeing of Syrians:

A review for mental health and psychosocial support staff working with Syrians affected by armed conflict. Geneva: UNHCR.

Hendrickx, M., Woodward, A., Fuhr, D.C., Sondorp, E., & Roberts, B. (2019). The burden of mental disorders and access to mental health and psychosocial support services in Syria and among Syrian refugees in neighboring countries: a systematic review. Journal of Public Health (Oxford, England). Advance online publication. https://doi.org/10.1093/pubmed/fdz097

Hijazi, Z, and Weissbecker, I. (2017). Syria crisis: Addressing regional mental health needs and gaps in the context of the Syria crisis.  International Medical Corps. Retrieved from https://internationalmedicalcorps.org/wp-content/uploads/2017/07/Syria-Crisis-Addressing-Mental-Health.pdf

Inter-Agency Standing Committee (IASC). (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC. Retrieved from http://www.humanitarianinfo.org/iasc/content/products

International Committee of the Red Cross. (2003). Factsheet: International humanitarian law and international human rights law: Similarities and differences. 

International Medical Corps. (March 16, 2015). Ongoing war creates invisible mental health crisis for Syrian people. Retrieved from https://internationalmedicalcorps.org/press-release/ongoing-war-creates-invisible-mental-health-crisis-for-syrian-people/

Syrian Arab Red Crescent Society (SARC). (2018). Semi Annual Report 2018. Retrieved from http://sarc.sy/semi-annual-2018-report/

Weissbrodt, D. & De La Vega, C. (2007). Overview and history of international human rights. In         International Human Rights Law: An Introduction (p.14-26). Philadelphia, PA:        University of Pennsylvania Press.

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Humanitarianism Presentations and Videos

Culturally Sensitive Mental Health in International Humanitarian Crises

A presentation designed to be a potential workshop for mental health professionals who already have significant training in their field, and some awareness of working in humanitarian contexts. Maybe they have worked as a volunteer in the U.S. and are looking at volunteering abroad. This is an outline to considerations of working with both clients and staff in diverse communities in culturally sensitive ways.