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Comorbidity of PTSD and CPTSD with Other Mental & Physical Disorders in Syrian Populations

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Comorbidities, both physical and mental, are quite common with PTSD and CPTSD (van der Kolk & McFarlane, 1996). This is especially so among those who have been exposed to significant trauma, including from community violence and war. Hoppen and Morina (2019) conducted a meta-analysis on the comorbidity between PTSD and depression in war survivors worldwide and found that nearly half of those with PTSD also had major depression.

Al-Smadi et al. (2016) found that among Syrian refugees in Jordan, in more than half the participants, chronic diseases were comorbid with PTSD and depression. Chung et al. (2020) found that participants with lower physical health and social health scores had significantly higher rates of posttraumatic stress. Kizilhan (2017) discusses how people from Syria and other collectivistic cultures typically express PTSD through somatic symptoms and chronic pain. Grasser et al. (2020) noted co-morbidities in their sample of Syrian and Iraqi refugees between PTSD, anxiety, and depression. Furthermore, they collected saliva samples from participants and were able to find a correlation between these psychological disorders with higher rates of inflammatory responses, lower immunity, and increased susceptibility to diseases.

Middle Eastern cultures, such as those from Syria, are collectivistic and highly tied to their family groups (Chung et al., 2020; Kizilhan, 2017). As such, an “occurrence of trauma to a family member means trauma to the whole family. In other words, PTSD is a within-and-between-individuals phenomenon for an Arabic family” (Chung et al., 2020 p.6). In most peoples, but especially in those in collectivistic cultures, rely heavily on social networks, which buffer against both physical and mental health problems (Powell et al., 2020). Oppression as experienced by Syrian refugees and internally displaced persons is both individual and collective, and is linked with higher rates of PTSD, CPTSD, poor physical health, higher suicidality, and existential annihilation anxiety (Ibraheem et al., 2017).

References

Al-Smadi, A. M., Halaseh, H. J., Gammoh, O. S., Ashour, A. F., Gharaibeh, B., & Khoury, L. S. (2016). Do chronic diseases and availability of medications predict post-traumatic stress disorder (PTSD) among Syrian refugees in Jordan. Pak J Nutr, 15(10), 936-941.

Chung, M. C., AlQarni, N., AlMazrouei, M., Al Muhairi, S., Shakra, M., Mitchell, B., Al Mazrouei, S., & Al Hashimi, S. (2020). Posttraumatic stress disorder and psychiatric co-morbidity among Syrian refugees: the role of trauma exposure, trauma centrality, self-efficacy and emotional suppression. Journal of mental health (Abingdon, England), 1–9. https://doi.org/10.1080/09638237.2020.1755023

Grasser, L. R., Burghardt, P., Daugherty, A. M., Amirsadri, A., & Javanbakht, A. (2020). Inflammation and Trauma-Related Psychopathology in Syrian and Iraqi Refugees. Behavioral Sciences, 10(4), 75. doi:10.3390/bs10040075

Hoppen, T. H., & Morina, N. (2019). The prevalence of PTSD and major depression in the global population of adult war survivors: a meta-analytically informed estimate in absolute numbers. European journal of psychotraumatology, 10(1), 1578637. https://doi.org/10.1080/20008198.2019.1578637

Al Ibraheem, B., Kira, I. A., Aljakoub, J., & Al Ibraheem, A. (2017). The health effect of the Syrian conflict on IDPs and refugees. Peace and Conflict: Journal of Peace Psychology, 23(2), 140. https://doi.org/10.1037/pac0000247

Kizilhan, J. I. (2018). Trauma and pain in family-orientated societies. International journal of environmental research and public health, 15(1), 44.

Powell, T. M., Shin, O. J., Li, S. J., & Hsiao, Y. (2020). Post-traumatic stress, social, and physical health: A mediation and moderation analysis of Syrian refugees and Jordanians in a border community. PloS one, 15(10), e0241036. https://doi.org/10.1371/journal.pone.0241036

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

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Using the International Trauma Questionnaire (ITQ) in Diverse Global Populations

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The International Trauma Questionnaire (ITQ) was developed based on the criteria for posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) as outlined in the International Classification of Diseases, 11th ed. (ICD-11) (Cloitre et al., 2018). The ICD-11 is a covers physical and mental health illnesses and serves as a diagnostic guide and is widely used worldwide (World Health Organization [WHO], 2019). The ITQ has been translated and utilized within many populations and cultures. This is in contrast to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), the primary diagnostic manual used for mental disorders in the U.S. (American Psychological Association [APA], 2009). The literature on the ITQ’s use within cultures in the Middle East, Africa, and Asia will be examined.

The ITQ is an instrument which measures an individual’s level of PTSD and CPTSD. It is brief, easy to understand, and is designed for individuals to be able to fill it out themselves (Cloitre et al., 2018). It was developed to serve as a diagnostic tool, because the ICD-11 uses a narrative description of symptoms format rather than specific diagnostic criteria. The development of the ITQ focused on inclusion of questions which addressed the core symptoms, rather than every possible symptom. The majority of the questions use a Likert scale of 1-5. An individual taking the assessment can be diagnosed with PTSD or CPTSD, but not both. Early analyses of the ITQ found some questions to have poor reliability, so they were removed or changed. Additionally, the ITQ was found to work well within both community and clinical populations. The ITQ has been translated into at least 28 languages, has a version for children and adolescents, and is freely available in the public domain (The International Trauma Consortium, n.d.). The ITQ has been found to be valid and reliable among many populations internationally, however, additional adaptations to match cultural context and idioms of distress could be useful in capturing the true experience of trauma for many populations.

In the Middle East, a study of Syrian refugees in Lebanon (Vallieres et al., 2018) tested the use of the ITQ and the ICD-11 in their accuracy in measuring PTSD and CPTSD within this group. They found that CPTSD was more common than PTSD, and there were high amounts of traumatic exposure. The most distressing events as rated by participants were the deaths of loved ones, being separated from family and friends, forced displacement, and bombings. Overall, participants found that the ITQ seemed to accurately reflect their experiences. Limitations of the ITQ were that it lacked any questions related to somatic symptoms such as amnesia and poor concentration (Vallieres et al., 2018), or fainting, dizziness, weakness, and chronic pain, all of which are common cultural idioms of mental and emotional distress for Syrians (Barkil-Oteo et al., 2018). Another issue is that some participants showed hesitancy in answering, exhibiting signs of paranoia and hypervigilance. To address this, trust and rapport may first need to be built with the person administering the ITQ. However, the use of the ITQ helped create a language and normalization for participants and assisted them in opening up in subsequent therapy sessions (Vallieres et al., 2018). Overall, both the ICD-11 and the ITQ were found be culturally viable within this population in this study.

In Africa, Owczarek et al. (2019) tested the ITQ among community members in Kenya, Ghana, and Nigeria. In this study, the ITQ was found to be a valid assessment within these different cultural populations, with a very good internal consistency. There were some differences in the types of traumatic exposures between the countries, as well as levels of PTSD and CPTSD. The limitations described by the authors discuss the lack of generalizability, as the sample demographics were different from the general population, such as having a much higher rate of higher education, which has been shown to be correlated with lower levels of PTSD symptoms. Additionally, the data collection was done online, limiting access. Another study by Barbieri et al. (2019) compared the rates of PTSD and CPTSD between the DSM-V and the ITQ in a clinical sample of African refugees in Italy. 79% of the participants met the criteria for PTSD using the DSM-V. Using the ITQ, 38% met criteria for PTSD and 30% for CPTSD, with a combined total of 68%, showing a statistically significant difference compared to the DSM-V. Understandably, this population of treatment-seeking refugees showed much higher rates of both PTSD and CPTSD than in the study of community members by Owczarek et al. (2019), but it also found the ITQ to be a valid measure for this population (Barbieri et al., 2019).

Examining the ITQ in Asia, Tian et al. (2020) found that the assessment had good validity and reliability among Chinese young adults. They found that the rate of CPTSD was significantly higher at 13.35% as compared to PTSD at 5.85%. One possible explanation is the high rate of childhood maltreatment in China, and early trauma exposure is a major risk factor for CPTSD, in addition to other cultural factors. This study also measured posttraumatic growth (PTG), a heightened state of resilience. PTG was lower among those with CPTSD symptoms than those with PTSD only. Limitations of this study were also a lack of generalizability due to the narrowness of the sample, and that all participants had experienced at least one traumatic event. Another study examined the validity of the ITQ in young adults across multiple Asian cultures – China, Hong Kong, Japan, and Taiwan (Ho et al., 2020). This study also found that PTSD and CPTSD were valid separate diagnoses using the ITQ within these populations, and the association of increased childhood negative experiences (though not necessarily traumatic) correlated with higher rates of CPTSD. This study also found higher rates of CPTSD than PTSD, like Tian et al. (2020).

From these studies, it appears that the ITQ is indeed valid across multiple populations in determining PTSD and CPTSD, and validating the legitimacy of these two related, but different, diagnoses. Despite initial impressions that there should be more specific cultural adaptations more than language translations, these studies show that symptomology of these disorders remains in similar clusters cross-culturally. Still, there is a continued question of if these results would shift if the questions were adapted to use the specific cultural idioms and expressions of emotional distress. As there do not appear to be any studies which modify the ITQ in such a way, there is no current way to compare this.

References

American Psychological Association. (2009, October). ICD vs. DSM. Monitor on Psychology, 40(9). http://www.apa.org/monitor/2009/10/icd-dsm

Barbieri, A., Visco-Comandini, F., Alunni Fegatelli, D., Schepisi, C., Russo, V., Calò, F., Dessì, A., Cannella, G., & Stellacci, A. (2019). Complex trauma, PTSD and complex PTSD in African refugees. European Journal of Psychotraumatology, 10(1), 1700621–1700621.                   https://doi.org/10.1080/20008198.2019.1700621

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: development of a self‐report measure of ICD‐11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12956

Ho, G., Hyland, P., Shevlin, M., Chien, W. T., Inoue, S., Yang, P. J., Chen, F. H., Chan, A., & Karatzias, T. (2020). The validity of ICD-11 PTSD and Complex PTSD in East Asian cultures: findings with young adults from China, Hong Kong, Japan, and Taiwan. European journal of psychotraumatology, 11(1), 1717826. https://doi.org/10.1080/20008198.2020.1717826

Owczarek, M., Ben-Ezra, M., Karatzias, T., Hyland, P., Vallieres, F., & Shevlin, M. (2020). Testing the Factor Structure of the International Trauma Questionnaire (ITQ) in African Community Samples from Kenya, Ghana, and Nigeria. Journal of Loss & Trauma, 25(4), 348–363. https://doi.org/10.1080/15325024.2019.1689718

The International Trauma Consortium. (n.d.). International Trauma Questionnaire. https://www.traumameasuresglobal.com/itq

Tian, Y., Wu, X., Wang, W., Zhang, D., Yu, Q., & Zhao, X. (2020). Complex posttraumatic stress disorder in Chinese young adults using the International Trauma Questionnaire (ITQ): A latent profile analysis. Journal of affective disorders, 267, 137–143. https://doi.org/10.1016/j.jad.2020.02.017

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., Byrne, S., Shevlin, M., Murphy, J., & Hyland, P. (2018). ICD‐11 PTSD and complex PTSD amongst Syrian refugees in Lebanon: the factor structure and the clinical utility of the International Trauma Questionnaire. Acta Psychiatrica Scandinavica, 138(6), 547–557. https://doi-org.tcsedsystem.idm.oclc.org/10.1111/acps.12973

World Health Organization. (2019).  International Statistical Classification of Diseases and Related Health Problems (ICD). https://www.who.int/standards/classifications/classification-of-diseases

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Symptoms of PTSD and Complex PTSD in Western Cultures & Syrian Culture

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Post-traumatic stress disorder (PTSD) is a psychological disorder which is included in both the DSM and the ICD-11, but only the ICD-11 explicitly includes a distinction of Complex PTSD (CPTSD) (Cloitre et al., 2019). The inclusion of CPTSD is important, as it encompasses research on how PTSD manifests within prolonged or repeated trauma exposure, particularly in early childhood, but also include the impacts of cultural and collective trauma (Hirschberger, 2018), such as that which is experienced in mass catastrophic events such as war, genocide, slavery, colonization, racial trauma (Comas-Díaz et al., 2019), etc., and intergenerational trauma (Yehuda & Lehrner, 2018). The civil war in Syria, ongoing since 2011, is one example of such a significant collective trauma, which may have lasting intergenerational trauma effects. However, the Western medical-style model of diagnosis of mental illnesses does not explicitly account for cultural differences in how Syrians experience, understand, and express trauma.

Van der Kolk and McFarlane (1997), who provide a deep understanding of the multitude of ways that trauma can manifest beyond what manuals like the DSM provide or ICD-11 provide, write that “experiencing trauma is an essential part of being human; history is written in blood” (p.3). Traumatic experiences can vary in their intensity, and whether they develop into the pathology of PTSD depends on their context, and the coping skills of the individual experiencing the event. Some people can process such traumatic exposures in ways which allow them to return to healthy functioning, while others do not. Those that develop PTSD start to develop unhealthy defense mechanisms and behaviors to avoid even subtle reminders of the trauma, which can affect the entire way that they structure their lives. “The core issue is the inability to integrate the reality of particular experiences, and the resulting repetitive replaying of the trauma in images, behaviors, feelings, physiological states, and interpersonal relationships” (van der Kolk & McFarlane, 1997, p.7). In most cases, PTSD is spurned from a singular event, or tightly clustered events, while CPTSD occurs when there is repeated or prolonged exposure to traumatic situations, such as child abuse at a critical stage of development. Due to the nature of PTSD broadly, trauma victims tend to reenact (usually subconsciously) the trauma in other aspects of their lives, leading to continued traumatic experiences, further deepening the complexity of CPTSD (Foa et al., 2009).

Whole societies and cultures can also be traumatized and can follow “roughly similar patterns of adaptation and disintegration” (van der Kolk & McFarlane, 1997, p. 3) as traumatized individuals. States can react to traumatized populations in various ways – in the U.S. it is typically with some immediate compassion, but a fallback on an attitude of blaming victims as their own responsibility for the trauma, seeking to maintain the status quo, and projecting a message of safety for society (van der Kolk & McFarlane, 1997). When considering the case of Syria, the authoritarian regime has sought to eradicate trauma narratives and instead impose their own version of the story through such tactics as monopolizing higher education to maintain their power and enforce their political agenda. (Al Azmeth et al., 2020). Matos et al. (2021) found that “…war severely disrupted Syrians’ sense of collective self, and that they repeatedly engaged in search for meaning, appraisals of the war, and reappraisals of shattered beliefs, life goals, and sense of purpose, both during wartime and in resettlement” (p.1).

Vallieres et al. (2018) conducted a study of Syrian refugees in Lebanon, using the International Trauma Questionnaire (ITQ) and the ICD-11 in examining both CPTSD and PTSD levels and validity for this population. They found that CPTSD was more prevalent than PTSD, and that the ICD-11 and ITQ were cross-culturally applicable – with some limitations. The levels of traumatic exposure were high, with the events ranked as most distressing by participants being forced displacement, bombings, and losing loved ones both through unexpected deaths and forced separations. Participants shared that they felt that the questionnaire seemed to be understanding of their experience. One noted limitation was that common symptoms were amnesia and lack of concentration, but these weren’t addressed in the ITQ questionnaire. Participants also felt some of the questions were irrelevant to their situation and cultural context. It was also noted that completing the questionnaire was unfamiliar and challenging to many refugees – so it may be that the use of such assessments give poor reliability within this cultural context. Furthermore, the trauma of some participants made them hesitant in answering some of the questions, invoking what would appear to be paranoia and hypervigilance. The authors suggest that the use of such questionnaires or assessments may first require a building of rapport and trust with the person administering them. This challenges the Western model of research, in which the researcher is to remain unbiased and emotionally removed from the participants (Jhangiani & Tarry, 2014).

Syrians express trauma and mental illness differently from Western societies. A study on PTSD and CPTSD using the ICD-11 in the US did not include questions or measures on somatic symptoms (Cloitre et al., 2019). The above study on Syrian refugees by Vallieres et al. (2018) similarly did not include somatic symptoms. However, somatic descriptions were commonly found as expressions of mental illness, distress, and trauma in other studies (Barkil-Oteo, 2018; Borho et al., 2021; Hassan et al., 2015). Barkil-Oteo et al. (2018) state that traditional, even culturally adapted, measures were insufficient in capturing the true range of symptoms experienced by refugees, who, in addition to prior trauma exposures, have “both repeated and ongoing traumatic triggers (fear from the past, current uncertainties, new traumas)” (p.9). They noted high prevalence of fainting, dizziness, weakness, and chronic pain in this population which had been ruled out of medical causes. Patients often first presented with such physical complaints before sharing emotional or mental distress. Borho et al. (2021) found a high correlation between somatic complaints and traumatic exposures, stress, and depression and anxiety symptoms in Syrian refugees in Germany. Syrians “do not separate somatic experience and psychological symptoms, because body and soul are interlinked in explanatory models of illness” (Hassan et al., 2015, p. 22).  One explanation for this emphasis on psychical symptoms is that mental illness is not well understood and is highly stigmatized in Syrian culture. Furthermore, the cultural framework within both Islam and Christianity (the primary religions of Syria) is that suffering is a part of being alive and does not need special interventions unless it is severe. However, with the increased normalization of mental health within host countries and among communities of refugees, knowledge and awareness of mental health and PTSD are growing and losing some of their stigma.

Hasan et al. (2015) provide a comprehensive overview of culturally specific idioms of distress for Syrian peoples. For example, saying one is tired or their psyche is tired “refers to a general state of ill being and may stand for a range of emotional symptoms, but also for relationship difficulties” (Hassan et al., 2015, p. 22). Ruminative thoughts are attributed to the influence of the devil, and severe mental and emotional disorders are sometimes considered to be the work of mischievous or evil spirits such as jinn. Symptoms of mental distress, which can also be comorbid with PTSD and CPTSD include such things as anxiety, depression, cognitive difficulties, helplessness, anger or aggression, and extreme stress, are often described in proverbs or metaphors. Western-trained professionals may misconstrue these as psychotic indicators. An example of a somatic description of fear or anxiety is a literal sensation of one’s heart crumbling or falling. An example of a metaphorical description for helplessness is “the eye sees but the hand is short or cannot reach” (Hassan et al., 2015, p. 23).

There is very little research on Syrians’ mental health, including trauma rates and responses, from before the onset of the war in 2011. Therefore, much of the research today comes from Syrian refugees residing outside of Syria. Furthermore, nearly all the research is focused on trauma exposures and PTSD rather than CPTSD. As noted previously, notions of mental illness and trauma are becoming increasingly normalized in this population, so, the conceptualizations and experiences of trauma may also be shifting to align more with those of the host countries’. Collective trauma is extensive in the case of the Syrian war, and the primary coping method of social connection (Hassan et al., 2015) – of extreme importance in collectivistic cultures – is radically disrupted, damaging possible resilience pathways for many Syrians.

References

Al Azmeh, Z., Dillabough, J., Fimyar, O., McLaughlin, C., Abdullateef, S., Aloklah, W. A., … &      Kadan, B. (2021). Cultural trauma and the politics of access to higher education in    Syria. Discourse: Studies in the Cultural Politics of Education, 42(4), 528-543.

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A    tale of a Syrian refugee. American journal of psychiatry, 175(1), 8-12.

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees          with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21, 896. https://doi.org/10.1186/s12889-021-10731-x

Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M.     (2019). ICD‐11 Posttraumatic Stress Disorder and Complex Posttraumatic Stress   Disorder in the United States: A population‐based study. Journal of Traumatic Stress,   32(6), 833–842.

Comas-Díaz L, Hall, G. N., & Neville, H. A. (2019). Racial trauma: theory, research, and      healing: introduction to the special issue. The American Psychologist, 74(1), 1–5.

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD.        Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.).        New York, NY: The Guilford Press. 

Hassan, G., Kirmayer, L.J., 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.

Hirschberger, G. (2018). Collective trauma and the social construction of meaning. Frontiers of     Psychology, 9, 1441.

Jhangiani, R. & Tarry, H. (2014). Conducting research in social psychology. Principles of social     psychology – 1st international ed.             https://opentextbc.ca/socialpsychology/chapter/conducting-research-in-social-            psychology/

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better   person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective        trauma. Int. J. Environ. Res. Public Health, 18. https://doi.org/10.3390/ijerph18168481

Vallières, F., Ceannt, R., Daccache, F., Abou Daher, R., Sleiman, J., Gilmore, B., … & Hyland, P.       (2018). Are posttraumatic stress disorder (PTSD) and complex-PTSD distinguishable            within a treatment-seeking sample of Syrian refugees living in Lebanon?. Global Mental       Health, 5. DOI: 10.1111/acps.12973

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming            Experience on Mind, Body, and Society. New York, NY: The Guilford Press.  Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role   of epigenetic mechanisms. World Psychiatry, 17(3), 243–257

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Traumatic Stress and Syrian Cultural Conceptualizations

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Defining traumatic stress is a complex task because it incorporates so many different presentations, triggering events, brain developments, resources, and can be individual or collective (van der Kolk, et al., 1996). Non-traumatic stress differs primarily in that it is an almost unavoidable aspect of daily human life, and while it can range from small stressors to significant stressors, and can occur from both positive and negative situations, this stress can range from annoyances to exacerbating or experiencing mental health issues – or propel us forward and give us motivation and positive outcomes (Yeager & Roberts, 2003). Stress also releases certain biological responses and hormones, such as a temporary increase in cortisol production (Richter-Levin & Sandi, 2021). However, in the case of traumatic stress, cortisol takes longer and longer to revert to normal – in some cases that are chronic and severe, this may lead to constantly high levels of cortisol, which can further progress to the point that cortisol is completely depleted and unable to be created, leading to adrenal fatigue.

When one has been exposed to significant non-traumatic stress repeatedly, and does not have adequate coping skills, this can develop into acute stress disorder or post-traumatic stress disorder. However, Richter-Levin and Sandi (2021) write that the most “common reaction to stress is resilience, indicating that resilience is the rule and stress-related pathology the exception” (p.1).

While non-traumatic stress can develop into traumatic stress, traumatic stress itself is usually defined by exposure to a traumatic event with which one is unable to process or cope with (Foa, et al., 2009). Commonly considered forms of traumatic events include such things as war, violence, rape, childhood abuse, natural disasters, and other experiences which dramatically shake one’s sense of safety (van der Kolk, et al., 1996). But what constitutes a sense of safety can vary dramatically, and previous exposure to traumatic stress can make one more susceptible to further traumatic stressors. PTSD is most often viewed as a response to a specific, singular event – however, new research and understandings are evolving on complex trauma, such as in cases of ongoing childhood abuse which dramatically impact the lifelong behaviors, thought patterns, and emotional states within the brain development of those children.

The DSM, used to diagnose psychological disorders, has fairly strict, black and white, guidelines on what symptoms need to be expressed for a diagnosis. However, van der Kolk et al. (1996) point out that these symptoms are manifested in vastly different ways for different people. And culture also frames how we experience these symptoms and behaviors. Western societies, namely the USA, tend to shift towards individualism and place blame often on victims in order to maintain a sense of safety within society, and tends to follow the medical model (such as the use of the DSM) of checklists of symptoms to determine a diagnosis, with emphasis placed on the psychopathologies and mental illnesses in terms of the mind. A century or so ago, individuals used more somatic descriptions in their symptoms of PTSD, which, aside from a few authors pushing research on this topic today such as van der Kolk and the recently developed somatic therapies, is not the mainstream. In many other cultures, mental distress of any sort is often described somatically.

Syrian refugees, like many war-exposed refugees, have been exposed to major levels of traumatic stress – within Syria, during migration, and post-migration all carry their own different circumstances which constitute extreme levels of stress, much of which is traumatic (Mahmood et al., 2019). Syria is a collectivistic society, so cultural trauma is felt very deeply within the interconnected web of individuals, damaging the sense of self dramatically (Matos et al., 2021) and is worsened by the separation of family members and communities as refugees find asylum in different countries or from internal displacements (Kakaje et al, 2021). Furthermore, mental illness has been stigmatized within Syria even prior to the onset of the war, with very limited clinicians and resources available, relying mainly on medical staff without mental health training for supports (Kakaje et al., 2021). This worsened even further as medical facilities have been explicitly targeted to be bombed in the war. Syrians tend to express mental illness, including PTSD, in terms of somatic complaints such as insomnia, headaches, and stomach or chest pain (Borho et al., 2021). Because Syrians express trauma in ways that are different from the Western model, some authors have questioned the efficacy of other studies, even when they use “adapted” Western-made diagnosis instruments (Barkil-Oteo et al., 2018).

References

Barkil-Oteo, A., Abdallah, W., Mourra, S., & Jefee-Bahloul, H. (2018). Trauma and resiliency: A tale of a Syrian refugee. American Journal of Psychiatry, 175(1).

Borho, A., Morawa, E., Schmitt, G.M. et al. (2021). Somatic distress among Syrian refugees with residence permission in Germany: analysis of a cross-sectional register-based study. BMC Public Health 21, 896. https://doi.org/10.1186/s12889-021-10731-x

Foa, E.B., Keane, T.M., Friedman, M.J., & Cohen, J.A. (2009). Effective Treatments for PTSD. Practice Guidelines from the International Society for Traumatic Stress Studies (2nd ed.). New York, NY: The Guilford Press. 

Kakaje, A., Al Zohbi, R., Hosam Aldeen, O., Makki, L., Alyousbashi, A., & Alhaffar, M. (2021). Mental disorder and PTSD in Syria during wartime: A nationwide crisis. BMC psychiatry, 21(1), 2. https://doi.org/10.1186/s12888-020-03002-3

Mahmood, H.N., Ibrahim, H., Goessmann, K. et al. (2019). Post-traumatic stress disorder and depression among Syrian refugees residing in the Kurdistan region of Iraq. Confl Health 13(51). https://doi.org/10.1186/s13031-019-0238-5

Matos, L., Costa, P.A., Park, C.L., Indart, M.J., & Leal, I. (2021). ‘The war made me a better person’: Syrian refugees’ meaning-making – Trajectories in the aftermath of collective trauma. Int. J. Environ. Res. Public Health, 18. https://doi.org/10.3390/ijerph18168481

Richter-Levin, G. & Sandi, C. (2021). Labels Matter: Is it stress or is it Trauma?. Transl Psychiatry 11, 385. https://doi.org/10.1038/s41398-021-01514-4

Van der Kolk, B.A. & McFarlane, A.C. (1996). Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, NY: The Guilford Press. 

Yeager, K. & Roberts, A. (2003). Differentiating Among Stress, Acute Stress Disorder, Crisis Episodes, Trauma, and PTSD: Paradigm and Treatment Goals. Brief Treatment and Crisis Intervention, 3. 10.1093/brief-treatment/mhg002.

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Sway Presentation: Traumatic Stress & Syrian Cultural Conceptualizations

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The role of bystanders in group conflict

Staub (1999) investigates how bystanders can both normalize and perpetuate violence in group conflict but can also provide interventions which can end such violence. Bystanders can be internal, as in within the country or group, or external, such as in humanitarian aid organizations or other nations. In either case, my understanding is that bystanders are ones who bear witness to the conflict, but may not be directly involved in it, at least for a time. Passive bystanders are explicitly described by Staub (1999), but active bystanders are not named, although there are descriptions of active bystander interventions.

The involvement of other external bystander states are most often passive, unless they see an opportunity for self-gain in their involvement, such as in relation to “power, wealth, or influence. They have not seen themselves as moral agents with responsibility for the welfare of people outside their borders” (Staub, 1999, p.316). Furthermore, it is not uncommon for some countries to “actively support perpetrators” (Staub, 1999, p.308).

Internal bystanders also tend to remain passive (Staub, 1999), and while this might apply to much of the bystander population, I can think of many examples where internal bystanders have become active and attempted to intervene through various methods, such as both peaceful and violent protests. However, passive bystanders further create divide between groups, by the repeated messages by one group or government reinforcing the scapegoating of another group. Over time, these become ingrained beliefs in the civilian population – “it distances them from and leads them to increasing devalue victims. It diminishes their capacity to empathize with those in distress and their sense of guilt about their inaction. In the end, they go along with and frequently even support persecution and violence…” (Staub, 1999, p.308).

A current conflict showing many examples of the role of bystanders is the Syrian Civil War. The war has endured since 2011, and its length may have been significantly affected due to bystanders. It is a complicated war with many different sides triangulated against one another. The Assad governmental regime, the rebel groups opposing it, ISIS, the Kurds, Shia Muslim militias, and Hezbollah are the primary internal groups in conflict (BBC, 2017).  President al-Assad is himself from a minority group in Syria, the Alawites, and since coming to power he has systemically and actively encouraged discrimination towards many of Syria’s other ethnicities and religions. Thus, divisions were created between groups, as Staub (1999) identifies as part of the initial stages towards group conflict. When some protested this discrimination in Syria, the government took violent action, and conflict escalated quickly. Furthermore, Staub (1999) points out several cultural risk-factors contributing towards capacity for group conflict, and according to Hofstede Insights (n.d.), Syria has a number of these factors, including high power distance – which is tolerant of authoritarian systems, and high uncertainty avoidance. Another factor which perpetuates conflict is trauma, which can be imparted on multiple generations, and may make traumatized individuals more likely to have feelings of insecurity and react to real or perceived persecution with “defensive aggression” (Staub, 1999, p.310). Syrians have experienced high rates of individual and collective trauma, both in the internally and externally displaced, from not just the conflict, but also forced labor, human trafficking, and discrimination and violence by host communities where refugees seek asylum (Gerson, 2018).

Syria’s rise of internal active bystanders are comprised of several capacities, from armed militia rebel groups resisting and fighting back against the human rights violations of the government on civilians, and also groups like the White Helmets who avoid any active conflict, but take dangerous risks in order to rescue and provide medical care to those injured in attacks from both sides. Passive bystanders might include those civilians who have aligned themselves to the Assad regime, such as other Alawites, Christians, and the wealthy, and those in fear that the fall of the government would allow terrorist groups such as ISIS to take over (Christian Science Monitor, 2011). Both violent active and passive bystanders could be perpetuating the conflict through an overall increase in retaliatory violence on both sides, and in upholding discriminatory, divisive beliefs and institutions about the “other.”

External active bystanders have been many, and likely are the largest contributors to the ongoing conflict. Supporters of the Syrian government include Russia and Iran (BBC, 2017). Russia has carried out air strikes and provided political backing on behalf of the Assad regime at the UN (BBC, 2017), and this seems to be highly motivated by their own self-interest in being a major source of power in the Middle East and is concerned that regime changes could create even further instability – and a loss of Russian power, in addition to the benefits of their naval base and $5 billion in weapon sales to Syria (Calamur, 2013).

External bystanders on the side of the rebels include Turkey, the Gulf Arab states, and the U.S. (BBC, 2017). Under the Obama administration, the U.S. intervened by suppling some arms and troops to the rebels, but these were comparatively minimal (Gerson, 2018). While the U.S. claimed it was becoming an active bystander based on the human rights abuses by the Syrian government, it limited its aid because of hopes to make a nuclear deal with Iran, who supports the Syrian government. Under President Trump, the U.S. troops with withdrawn from Syria and ended all support to the rebels. It has been speculated that this decision was largely motivated by Trump’s intention to be on Russia’s ‘good’ side, with Russia backing the Syrian government.

There are many more examples and instances of how the war in Syria has been accelerated and worsened through complicated international bystanders, and also from within through internal bystanders. All of these examples are much too complex to lay out in full within this assignment, but I do hope this gives an overview of how Staub’s (1999) roles of bystanders in group conflicts has had a significant impact on the Syrian civil war.

References

BBC. (April 7, 2017). Syria war: A brief guide to who’s fighting whom. BBC News. https://www.bbc.com/news/world-middle-east-39528673

Calamur, K. (August 28, 2013). Who are Syria’s friends and why are they supporting Assad? NPR. https://www.npr.org/sections/parallels/2013/08/28/216385513/who-are-syrias-friends-and-why-are-they-supporting-assad

Christian Science Monitor. (September 14, 2011). Why many Syrians still support Assad. https://www.csmonitor.com/World/Middle-East/2011/0914/Why-many-Syrians-still-support-Assad

Hofstede Insights. (n.d.). Country comparison: Syria. https://www.hofstede-insights.com/country-comparison/syria/

Gerson, M. (April 2, 2018). Would you trust America? The Washington Post.  https://www.washingtonpost.com/opinions/would-you-trust-america/2018/04/02/5fc5b854-369e-11e8-8fd2-49fe3c675a89_story.html

Staub, E. (1999). The origins and prevention of genocide, mass killing, and other collective violence.  Peace and Conflict: Journal of Peace Psychology, 5, 303-336.

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Papers, Docs, and Essays

Cultural Demographics of Syria

Syria is a middle-income developing country which has been ravished over the last 9 years by civil war. Because of the war and the mass number of civilian refugees and internally displaced persons, it is nearly impossible to calculate the current demographics within the country.  Most of the information I have been able to gather is based on pre-2011 data. 

Religious beliefs are often closely connected to individuals’ ethnic identities in Syria.  About 75% of the population is Sunni Muslim (BBC, 2011). The remaining 25% is split between Christians, Alawites, Druze and Ismailis.  There are also groups of Gypsy peoples, such as the Bedouin and Roma. Additionally, prior to the war, refugees from Iraq and Palestine and migrants from Lebanon, Armenia, and Israel, resided in Syria, though most have now left (Minority Rights Group International, 2011).

The Kurds comprise the largest ethnic minority with 10-15% of the population (BBC, 2011), and are concentrated around Northern and Northeastern Syria. Many Kurds were marginalized in Turkey and Iraq and so had moved into Syria prior to the civil war. However, with the civil war, many Kurds accused the Syrian government of discrimination and refusing them basic social, political, and cultural rights.  Kurdish protestors can expect to be jailed, and their political party is banned.

Alawites are Shia Muslim, and are the largest religious minority in Syria, accounting for 8-15% of the population (BBC, 2011). Despite being a minority, they control the most power.  President Bashar ad-Assad is Alawite, and most of his top government officials are also. Despite this, the Alawite community as a whole has been taken advantage of because of this, being coerced into being “thugs” which are used to intimidate, beat, and kill protestors of the regime.

Syrian Christians observe the Greek Catholic and Greek Orthodox denominations and have most of their populations focused in the major cities (BBC, 2011). Christians in Syria, despite being a significant minority, have a high amount of religious tolerance, worshiping freely and holding some high positions in government. Christians in Syria have mostly not been active in the protests, out of fear that the Islamic government would deny them religious freedom. They have been more visible in support of the regime. 

Ismailis are made up of about 200,000 people in Syria and are a branch of Shia Muslim with about 15 million followers worldwide (BBC, 2011). They are most concentrated around the city of Salamia. They reportedly fall on both sides of the civil war – some pro-regime, and others against it. 

The Druze reside mostly in Southern Syria, and number between 500,000 – 700,000 (BBC, 2011). They follow a religion based on Ismailism. The Druze have a history of being revolutionaries, and a major Lebanese Druze leader scolded the community for not being more active in the protests in Syria.  This was countered by the government regime actively seeking their support. 

Syrian Gypsies are much harder to calculate their population, as some are nomadic, but are estimated to number around 250,000 – 300,000 (Williams, 2001).  They consist of Bedouin peoples, who traditionally are nomadic herders, whose religious beliefs are a mix of pre-Islamic indigenous beliefs and modern Islam. Roma, Nawari, and Dom are other Syrian Gypsy groups.  

The primary languages spoken in Syria include Arabic (the official language), Kurdish (Kimanji dialect, Armenian, Aramaic, Circassian, and Turkish (Minority Rights Group International, 2011). The CIA World Factbook lists the following estimated population spread of Syria as of 2017: 

0-14 years: 31.62% (male 2,923,814/female 2,777,073)

15-24 years: 19.54% (male 1,790,360/female 1,732,694)

25-54 years: 39.22% (male 3,522,653/female 3,547,540)

55-64 years: 5.41% (male 482,576/female 493,085)

65 years and over: 4.21% (male 342,407/female 416,347

The economy has declined by about 70% since the onset of the war in 2011 (CIA World Factbook, 2017). More than half the population live in poverty, and a quarter live in extreme poverty, and an unemployment rate of nearly 50%, as of 2013 (Syrian Centre for Policy Research, 2013). Services have become extremely limited, with schools and healthcare facilities being targets of bombing by the government.

Human rights violations are a constant concern in Syria.  Working as an international psychologist, the challenges to help Syria are many and complex. The priority would be finding a way to have the government end the civil war and the attacks on civilians.  Following this, infrastructure within the country will need to be rebuilt.  Addressing the mental health concerns, including war trauma, for residents as well as refugees is also of a high priority. 

References

BBC. (December 9, 2011). Guide: Syria’s diverse minorities. BBC News. Retrieved from http://www.bbc.com/news/world-middle-east-16108755

CIA World Factbook. (2017). Syria. Retrieved from https://www.cia.gov/library/publications/the-world-factbook/geos/sy.html

Minority Rights Group International. (October, 2011). World directory of minorities and indigenous peoples – Syria. UNHCR.  Retrieved from http://www.refworld.org/docid/4954ce5ac.html

Syrian Centre for Policy Research. (October, 2013). Syria: War on development: socioeconomic monitoring report of Syria, second quarterly report (April – June 2013). United Nations Development Program. Retrieved from http://www.undp.org/content/undp/en/home/librarypage/crisis-prevention-and-recovery/syria-war-on-development–socioeconomic-monitoring-report-of-syr.html

Williams, A. (2001).  The Gypsies of Syria. Dom Research Center, 1(4). Retrieved from http://www.domresearchcenter.com/journal/14/syria4.html

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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

The Syrian White Helmets

The Syrian Civil Defense, more widely known as the Syrian White Helmets, are an organization of volunteers within Syria and in parts of Turkey. The group is made of up of “[f]ormer bakers, tailors, engineers, pharmacists, painters, carpenters, students and many more professions besides” (White Helmets, n.d., par.5). They primarily operate in opposition-held areas of Syria It was formed in 2014, but began with grassroots movements of volunteer rescue teams in 2012 (Aikins, 2014) with the escalation of the Syrian Civil War after a failed ceasefire which had been implemented by the UN (BBC, 2012). It was the beginnings of The White Helmets which drew the world’s hearts towards the conflict in Syria – the image of Omran, the five year old covered in blood and dust sitting alone in the ambulance; the video of an infant being desperately pulled from the rubble of a bombed building (Malsin, n.d.).

The group’s humanitarian framework comes from international humanitarian law from the Geneva Convention, and guided by philosophy from the Quran (The White Helmets, n.d.). Their motto, from the Quran, is “to save a life is to save all of humanity” (The White Helmets, n.d., par. 7), and they ascribe to the international humanitarian laws principles of Humanity, Solidarity, and Impartiality. They have been nominated three times for the Nobel Peace Prize and have had a Netflix documentary made about them. Their organizational structure is run by a democratically elected council and led by Raed al Saleh.

They have nearly 3000 volunteers and have rescued more than 115,000 individuals from the rubble after air raid attacks (Syria Civil Defense, n.d.). They have 221 female volunteers and openly state that they seek to include women in their work alongside male volunteers, and also in services specific to women such as maternal health clinics (The White Helmets, n.d.), as is culturally acceptable. 252 volunteers have been killed, and more than 500 injured (The White Helmets, n.d.). More than half of those killed have been in “double tap” attacks, where there is an initial attack, then a second attack after rescuers arrive to help, to specifically target them. Additionally, in 2018, about 100 White Helmet volunteers along with their families were emergency evacuated by a rescue group from Israel after becoming trapped by the Syrian military (BBC, 2018).  800 volunteers and their families had been planned for, but nearly half did not make it for the one-time rescue operation.

One of the founders of the organization, from Britain, James Le Mesurier, had created another nonprofit, called Mayday Rescue, in order to fundraise, provide equipment, and train the White Helmets in urban search and rescue (Yee, 2019).  He was found dead in Turkey in 2019 under suspicious circumstances following multiple disinformation campaigns against him by the Russian Foreign Ministry, claiming that both he and the White Helmets were actually a terrorist organization linked with al-Qaeda (Yee, 2019). Others, likely fueled by this propaganda, speculate that the White Helmets are propaganda themselves for the interests of the US and NATO (Kakade, 2016). However, the claims that the White Helmets are linked with terrorist organizations and have staged mass casualty events have been thoroughly discredited as a clear ploy by the Russian and Syrian governments (Palma, 2016, Solon, 2017).

The primary goals of the group exist within the physical and cultural space of Syria, comprised of Syrians. Their ultimate aim is to provide emergency humanitarian relief in the Syrian Civil War to anyone who is suffering, and they are known for their dangerous attempts at saving lives at any cost (James, 2014). Their actions are to act as first responders following airstrikes in Syria, providing “emergency evacuation, urban search and rescue, firefighting, community engagement, and medical response” (Asif & Asif, 2018, p. 27). Additionally, they have developed an emergency plan to prevent the spreading of COVID-19 in Syria and go door-to-door to raise awareness, while also disinfecting public areas including camps and buildings, coordinating with medical professionals in setting up quarantine facilities, and training specialized teams on how to safely evacuate COVID-infected individuals to hospitals (The White Helmets, n.d.).

An important cultural consideration of humanitarian work is the effect that outside international aid has towards the local community. The White Helmets have been much more successful than Doctors Without Borders AKA MSF, most likely due to this discrepancy of trust (Asif & Asif, 2018). An outsider can create a feeling of shame, as if one is being pitied by the international community and is hopeless to help themselves, while a culturally native individual represents strength, solidarity, trust, and resiliency. “Thus, the clinical encounter between the native population and the foreign doctor becomes a microcosm of colonial rule, one that is characterized by confrontation and distrust” (Asif & Asif, 2018, p.27). The White Helmets are also committed to the long-term rebuilding of Syria as they are Syrians themselves, and want to ensure the peace, safety, and welfare of Syrian communities in infrastructure, and social, physical, and emotional health. It is because of these culturally-relevant investments and actions that it has been recommended to increase trauma-informed psychological care training for the volunteers, as they are in a unique position to deliver such services in the immediate and long term within Syria (Lester, 2018).

While the group was founded by international backers, its approximately 3000 volunteer members are Syrians themselves (Daley, 2016). As such, they have not ever been involved in another conflict, so can only be judged on their capacity within the one context they are serving. Additionally, they appear to be culturally sensitive in that they operate within the Syrian context.  However, this does not always mean that all Syrian cultures are equally respected, although the group strives for impartiality. There have been some criticisms of their ability to do so, stating that they are opposed to the government regime, and actually are encouraging the Syrian Civil War to continue through taking sides in the conflict and continuing to accept funding from Western backers (Moore, 2019). However, evidence and support of this opinion is scarce. That being said, it is understandable that the group would be largely opposed to the governmental regime, who has been criticized heavily for their attacks on their own civilians and human rights abuses (Amnesty International, n.d.). Despite this, The White Helmets claim that they have saved lives on all sides of the conflict, including government soldiers (The White Helmets, n.d.).

Below is the information directly from the Syria Civil Defense web page on “What We Do” (n.d.)

We are a humanitarian organisation dedicated to helping communities to prepare for, respond to and rebuild after attacks in our beloved Syria.

We are best known for our search and rescue services following bombings but we provide a range of services inline with the internationally recognised activities of civil defense.

We work according to the guidelines for civil defence organisations across the world, as well as in accordance with International Humanitarian Law. As defined in Protocol I (Article 61) of the Geneva Conventions of 1949, we pledge to provide the services listed at paragraph 5:

  1. Warning the civilian population of attacks and dangers
  2. Urban Search and Rescue
  3. Evacuation of the civilian population from areas into which fighting is encroaching
  4. The provision of medical services – including first aid – at the point of injury
  5. Fire-fighting
  6. Management of emergency shelters
  7. Detection and marking of danger areas (such as areas with unexploded ordnance)
  8. Provision of emergency accommodation and supplies
  9. Emergency repair of indispensable public utilities
  10. Decontamination and similar protective measures
  11. Assistance in the preservation of objects essential for survival
  12. Emergency assistance in the restoration and maintenance of order in distressed areas
  13. Emergency disposal of the dead
  14. Management of blackout measures
  15. Complementary activities needed to carry out any of the tasks mentioned above.

As outlined in the Protocol I (Article 61) of the Geneva Conventions of 1949 we provide these services for the following purposes:

  • To protect the civilian population against the dangers arising from hostilities or other disasters
  • To speed recovery from the immediate effects of such events To provide the conditions necessary for survival of the civilian population.

While civil defence organizations are protected under the international humanitarian law applicable to all civilians and civilian objects in general, the Additional Protocol I to the Geneva Conventions, adopted in 1977, makes protection specific for civil defence.

Additionally, the White Helmets web page (n.d.) makes it clear that the organization is committed to helping rebuild physically and mentally in rebuilding communities following the end of the Civil War. One point that I found somewhat confusing is the utilization of two different web pages for the organization. It appears the White Helmets web page (n.d.) is aimed more towards generating support and fundraising, while the Syria Civil Defense website (n.d.) has more information about the organization itself and press releases.

Remember Omran, that bloodied and dusty five-year-old in the ambulance whose image wrecked our hearts all over the world? In 2017, the Syrian government media released new photos and videos of him, along with statements by the boy’s father that the family was pro-regime and that the child had been used by the rebel forces as fake propaganda (Specia & Samaan, 2017). This is just another example of how the truth around the White Helmets, and the war in Syria as a whole, is constantly being twisted and changed, making it difficult to know the truth (Haddad, 2016). Social media exacerbates this, with clearly differing messages posted to different sites, aimed at different followers, and between Arabic and English (Lynch, Freelon, & Aday, 2014). This is a common modern tactic in civil wars and human-causes acts of humanitarian crises, the post-truth age (Harsin, 2018).

Overall, it appears the White Helmets are a legitimate organization working diligently within a high-risk area to serve the Syrian community.  They provide an invaluable service that international organizations have struggled to do. Despite the conflict being ongoing, the organization has been successful in its mission, and seems to have the ability to continue doing so, despite the direct attacks on their lives and through the media to discredit them and attempt to eliminate their funding. That being said, Asif and Asif (2018) recommend that the White Helmets increase their indigenous independence by eliminating Western funding. While I understand this position, I think that there is always a struggle for organizations to have enough funding, so to get it from any source possible may be necessary in order to complete their mission.

I find the Syrian White Helmets to be incredibly inspiring personally and would like to see other models for indigenous humanitarian organizations given research and support around the world. I would like to see the larger international aid organizations focus their resources and funding towards supporting local, grassroots movements such as the White Helmets.  I think this is done in some capacity already, but I think there is much room for improvement.

References

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