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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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Assessment-Based Ethical Referral of Traumatized Individuals to Psychosocial Services

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When conducting assessments for trauma as a psychologist, it is important to have a plan in place on the provision of mental health services and resources for the client or participant. Those participants who screen as having posttraumatic stress disorder (PTSD), complex posttraumatic stress disorder (CPTSD), acute stress disorder (ASD), or who may not qualify for a disorder but still have significant symptoms in amount or severity should be referred for more in-depth assessments or treatment. The International Society for Traumatic Stress Studies (ISTSS) (Forbes et al., 2020) suggests treatments of varying evidence bases for recommendations. This also aligns, and in some cases conflicts, with ethical standards as proposed by the American Psychological Association (APA) (2017) and the International Union of Psychological Science (IUPS) (2008). However, a crucial consideration is the barriers to such treatments, such as cultural factors, socioeconomics, and available resources, which may be difficult to access in some areas of the world.

Trauma assessments could occur in at least two different scenarios, either within the context of a research assessment, or in a clinical environment. In a research context, the APA’s Ethical Principles of Psychologists and Code of Conduct (2017) states in section 8.08 that in order to reduce the risk of harm to participants, debriefing should occur quickly following the conclusion of the research. However, this is conflictual with debriefing as an early intervention in a clinical setting following assessment. The ISTSS (Forbes et al., 2020) reviewed evidence and found that debriefing interventions were largely ineffectual, including psychoeducation, in both individual and group interventions. It must be noted, though, that this was specific to those who had been exposed to trauma within the prior three months, and there appeared to be little research included for its use with survivors and refugees of civil war and genocide. This is relevant because the author of this paper, Emily Lutringer, is working to adapt the International Trauma Questionnaire (ITQ) (Cloitre et al., 2018) into cultural idioms of distress for Syrians, who have significant rates of multiple trauma exposures occurring for potentially over a decade (Hassan et al., 2015). In doing an assessment for research purposes, individuals may have been exposed to trauma longer than three months ago. ISTSS (Forbes et al., 2020) guidelines found strong evidence to recommend the following psychological treatments for adults with PTSD: cognitive processing therapy, cognitive therapy, EMDR, trauma-focused CBT, and prolonged exposure.

In conducting clinical assessments, there may be clients who are recently exposed to trauma, and therefore could partake in prevention and early interventions if they show symptoms of trauma on the assessment. ISTSS (Forbes et al., 2020) found that single sessions of EMDR and Group 512 PM had emerging evidence to prevent or treat symptoms of PTSD. Brief dyadic therapy and self-guided internet-based interventions also showed emerging evidence for multiple-session prevention. Stronger evidence was found in early treatment multi-session interventions of trauma-focused CBT, cognitive therapy, and EMDR. Of pharmacological interventions, only hydrocortisone showed emerging evidence.

In any situation in which an individual screens positively for trauma symptoms or PTSD, there may be barriers to accessing the most effective treatments – or even any interventions at all. Firstly, the interventions proposed by ISTSS (Forbes et al., 2020) are primarily Western models, and may not be culturally appropriate in other contexts (Narvaez, 2019). While ISTSS (Forbes et al., 2020) offers a few treatments which may have limited efficacy which could be culturally accessible, such as acupuncture, it is notably lacking in covering the evidence for interventions from indigenous psychologies which would be highly culturally relevant.

Another serious concern is the lack of access, such as low rates of mental health providers, remote areas, high demand with limited availability, and socioeconomic factors (Patel, 2007). Rojas et al. (2019) found that mental health care could be utilized in such situations through the use of internet-based interventions in a variety of formats, such as virtual counseling, phone apps, and specialized video games. As more people worldwide have access to the use of internet and cellphones, these interventions could reach larger populations and at lower costs. There are two caveats to this, though. Firstly, there are still many areas of the world without such internet or cell phone access. Secondly, internet and phone-based interventions appear to have mixed results in their effectiveness, although ISTSS was able to give a standard recommendation for the use of guided internet-based trauma-focused CBT in adults diagnosed with PTSD (Forbes et al., 2020).

Other barriers include stigma and poor mental health literacy (Wong et al., 2019). For example, Syrians typically hold strong stigmas around mental health and may be afraid to seek help for how others may judge them or their families (Hassan et al., 2015). Wong et al. (2019) had positive results in their pilot study evaluating the reduction of stigma through a mental health course in Hong Kong. Similar strategies for psychoeducation and normalization may be valuable when working with people in high-stigma cultures, as they may otherwise resist any PTSD intervention.

 Any mental health resources should include facilities or providers who have experience working with the specific population, to meet the ethical standard of competency (APA, 2017; IUPS, 2008). A researcher would ideally, finding an option that participants could engage in immediately after the study if they chose would allow them to process any trauma that came up without a waitlist. As the assessments are specifically measuring for trauma, a participant may suddenly become aware for the first time that they are suffering from a mental illness and may need immediate support. Furthermore, providing exceptional mental health and other resources is critical to preventing the re-enactment of trauma or intergenerational trauma which could lead to a continued cycle of violence (van der Kolk & McFarlane, 1996). It constitutes the ethical responsibilities of beneficence and nonmaleficence, fidelity and responsibility, justice, and respect for people’s rights and dignity (APA, 2017) not only to individual participants, but in taking a responsibility in the reduction of harm in communities as well.

References

American Psychological Association [APA]. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code

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. DOI: 10.1111/acps.12956

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.

International Union of Psychological Science [IUPS]. (2008). Universal Declaration of Ethical Principles for Psychologists. https://www.iupsys.net/about/governance/universal-declaration-of-ethical-principles-for-psychologists.html

Narvaez, D.F. (October 20, 2019). Indigenous Psychologies Contrast With Western Psychology. Psychology Today. https://www.psychologytoday.com/us/blog/moral-landscapes/201910/indigenous-psychologies-contrast-western-psychology

Patel, V. (2007). Mental health in low-and middle-income countries. British medical bulletin, 81(1), 81-96.

Rojas, G., Martínez, V., Martínez, P., Franco, P., & Jiménez-Molina, Á. (2019). Improving Mental Health Care in Developing Countries Through Digital Technologies: A Mini Narrative Review of the Chilean Case. Frontiers in public health, 7, 391. https://doi.org/10.3389/fpubh.2019.00391

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. 

Wong, P. W. C., Arat, G., Ambrose, M. R., Qiuyuan, K. X., & Borschel, M. (2019). Evaluation of a mental health course for stigma reduction: A pilot study. Cogent Psychology, 6(1), Article 1595877. https://doi.org/10.1080/23311908.2019.1595877

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Trauma, Physical Health, & Psychological Wellbeing in the Context of Adverse Life Events

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Exposure to adverse or traumatic events in life is a common experience (van der Kolk & McFarlane, 1996). These events can vary from minor to severe, can affect individuals or communities, and people react to them in different ways. Many people are resilient, but some develop symptoms of posttraumatic stress disorder (PTSD), have lower physical health, higher rates of mental disorders, and lower psychological well-being. Furthermore, these reactions can vary in how they are expressed between cultural contexts, can be vastly different for everyone, and can both improve or worsen over time. PTSD relates to numerous biological processes, including brain chemistry and hormonal changes. McFarlane (2010) writes, “…PTSD is not simply a psychosocial disorder, but one underpinned by a major neurobiological disruption” (p. 8). In assessing the whole-person impact of PTSD, it is important to consider and treat a variety of factors.

Allostatic load refers to the cumulative stress on the hypothalamic pituitary adrenal axis (HPA) as well as the autonomic nervous system (McFarlane, 2010). Exposure to trauma may not elicit symptoms of PTSD, nor acute stress disorder (ASD), for a significant time (more than 6 months) after the event; this is called delayed-onset PTSD. Furthermore, those who have experienced depression or been diagnosed with ASD may be able to initially manage symptoms to the point of remission – only later to have a resurgence of symptoms. In the case of ASD, this would change the diagnosis to PTSD. Research speculates that this is related to another traumatic event, or even the cumulation of smaller stressors, until the system becomes overloaded. This commonly results in somatic manifestations.

Chronic pain without a medical cause has a strong relationship to PTSD (Andreski et al., 1998), largely thought of to be related to the allostatic load (McFarlane, 2010). In those with chronic pain and PTSD, there are also noticeable changes in the hippocampus, cortisol, amygdala, and gene expressions. These biologic reactions also correspond with fibromyalgia, chronic fatigue, and irritable bowel syndrome. Furthermore, individuals with PTSD are at an increased risk for hypertension and cardiovascular disease, connected with repeated traumatic triggering leading to hyperactivity of the sympathetic nervous system. Significantly higher levels of cholesterol and triglycerides have been found in people with PTSD, even when compared to individuals with depression (Karlovic et al., 2004). Individuals with PTSD are also more likely to be overweight or obese or have coronary heart disease (McFarlane, 2010).

In a study of pregnant Peruvian women, there was shown to be a high correlation between those that had both migraines and PTSD (Friedman et al., 2017). Interestingly, the authors explain that there are numerous overlaps in brain chemistry and hormones between both migraines and PTSD, including lower levels of cortisol, plasma, norepinephrine, higher levels of pro-inflammatory cytokines, and reduced or unstable levels of serotonin. A study of Syrian and Iraqi refugees similarly found increased pro-inflammatory cytokines among those who had PTSD, depression, or anxiety (Grasser et al. 2020).

All of these medical issues are frequently comorbid with individuals with PTSD. Interestingly, many of them also correspond with common cultural idioms of distress in collectivistic cultures, such as in Syria, who often describe trauma and mental distress symptoms as having headaches, racing or pressure on the heart, insomnia, unexplained pain, and stomach pain (Hassan et al., 2015). Systemic, social, cultural, and community factors should also be addressed – especially if one is from a collectivistic society, or the traumatic event impacted a group – a family, a community, or a whole culture or country, such as in the case of war and genocide.

Furthermore, general psychological well-being is also often dramatically reduced in conjunction with traumatic stress. Roberts et al. (2020) write that more than “80% of individuals with PTSD will experience at least one additional lifetime mental health disorder, and around 50% will experience three or more comorbidities” (p.417) in the general population. Common psychological comorbidities are depression, anxiety and panic disorder, substance use disorders, severe mental illnesses, and personality disorders, especially borderline personality disorder. ADHD is also a common comorbidity (van der Kolk & McFarlane, 1996). Furthermore, people impacted by PTSD tend to organize their whole lives around the trauma, such as recreating the pattern in their relationships, and avoiding any hint of a traumatic trigger, causing profound changes in their thoughts, feelings, and behaviors (van der Kolk & McFarlane, 1996). Adults with a large number of adverse childhood experiences have significantly increased risk of a poor mental well-being (Hughes et al., 2016). Such individuals also have shown to have significantly lower social well-being (Mosley-Johnson et al., 2019).

Clinical implications are that treatment and assessment needs to expand to consider all of these factors. Traditionally, the use of anti-depressants and cognitive behavioral therapy have been the norm in treating PTSD (McFarlane, 2010), and medical doctors treat physical problems as separate issues. The ideal treatment would occur shortly after the traumatic event, even if an individual has not yet expressed symptoms, to train one’s psychophysiology to regulate itself early on. A study of Tutsi genocide survivors showed high rates of PTSD and CPTSD, and their children also suffered secondary symptoms of trauma (Shrira et al., 2019). Both parents and offspring had lower rates of resilience when parents suffered from CPTSD. Had trauma focused interventions occurred shortly after the genocide, it is possible that intergenerational trauma may have been avoided. Additionally, co-morbid symptoms both psychological and physical should be addressed in holistic approaches. One promising recent therapeutic modality that seeks to do this is Somatic Experiencing, which has been found to reduce symptom severity of PTSD and depression (Brom et al., 2017) and in PTSD-related chronic pain and disability (Andersen et al., 2017).

Clearly, the implications of the havoc of PTSD are severe. “There is the potential for a pervasive disruption of an individual’s neurobiology and psychophysiology following exposure [of traumatic stress], and PTSD is only one end point…exposure to traumatic stress leads to a general disruption of an individual’s underlying homeostasis” (McFarlane, 2010, p.7). Trauma-exposed individuals should be treated immediately even without symptoms and should be educated to self-assess over their lifespan. Holistic models which treat both physical and mental disruptions and comorbidities are paramount. Culture and environmental factors also should be carefully considered in assessment and treatment. Trauma changes us to our very core and in our entire well-being; increasing awareness and treating it as such is critical for both sufferers, and medical and mental health providers.

References

Andersen, T. E., Lahav, Y., Ellegaard, H., & Manniche, C. (2017). A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid post-traumatic stress disorder symptoms. European Journal of Psychotraumatology, 8(1). https://doi-org.tcsedsystem.idm.oclc.org/10.1080/20008198.2017.1331108

Andreski P, Chilcoat H, & Breslau N. (1998). Post-traumatic stress disorder and somatization symptoms: a prospective study. Psychiatry Res, 79, 131-8.

Brom, D., Stokar, Y., Lawi, C., Nuriel, P. V., Ziv, Y., Lerner, K., Ross, G., & Nuriel-Porat, V. (2017). Somatic Experiencing for Posttraumatic Stress Disorder: A Randomized Controlled Outcome Study. Journal of Traumatic Stress, 30(3), 304–312. https://doi-org.tcsedsystem.idm.oclc.org/10.1002/jts.22189

Friedman, L. E., Aponte, C., Perez Hernandez, R., Velez, J. C., Gelaye, B., Sánchez, S. E., Williams, M. A., & Peterlin, B. L. (2017). Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women. The journal of headache and pain, 18(1), 67. https://doi.org/10.1186/s10194-017-0775-5

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

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.

Hughes, K., Lowey, H., Quigg, Z. et al. (2016). Relationships between adverse childhood experiences and adult mental well-being: results from an English national household survey. BMC Public Health, 16,222. https://doi.org/10.1186/s12889-016-2906-3

Karlovic D, Buljan D, Martinac M et al. (2004). Serum lipid concentrations in Croatian veterans with post-traumatic stress disorder, post-traumatic stress disorder comorbid with major depressive disorder, or major depressive disorder. J Korean Med Sci, 19, 431-6.

McFarlane A. C. (2010). The long-term costs of traumatic stress: intertwined physical and psychological consequences. World psychiatry : official journal of the World Psychiatric Association (WPA), 9(1), 3–10. https://doi.org/10.1002/j.2051-5545.2010.tb00254.x

Mosley-Johnson, E., Garacci, E., Wagner, N., Mendez, C., Williams, J. S., & Egede, L. E. (2019). Assessing the relationship between adverse childhood experiences and life satisfaction, psychological well-being, and social well-being: United States Longitudinal Cohort 1995-2014. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 28(4), 907–914. https://doi.org/10.1007/s11136-018-2054-6

Roberts, S.E., Mueser, K.T., & Murray, L.K. (2020). Treatment considerations for PTSD comorbidities. In Effective Treatments for PTSD, 3rd ed. Forbes, D., Bisson, J.I., Monson, C.M., & Berliner, L., eds. The Guilford Press.

Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry research, 271, 121–123.   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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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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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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Papers, Docs, and Essays

Traumatic Stress and Syrian Cultural Conceptualizations

faceless person demonstrating unofficial syrian flag while standing in crowd
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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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Presentations and Videos

Sway Presentation: Traumatic Stress & Syrian Cultural Conceptualizations

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Categories
Humanitarianism

Aspects of international humanitarian law, refugee law, & human rights law relevant to mental health delivery in diverse settings

The Sphere project is a manual assembled and updated by multiple international groups and humanitarian aid organizations, with “concrete measurable benchmarks” (The Sphere Project, 2011) to outline quality, accountability, and values for humanitarian agencies, developed after mistakes from humanitarian groups during the Rwandan genocide. The Sphere has been updated to include four primary essential rights for all, and to guide the actions of humanitarians.  These are:

  1. Enhance the safety, dignity and rights of people, and avoid exposing them to harm.
  2. Ensure people’s access to assistance according to need and without discrimination.
  3. Assist people to recover from the physical and psychological effects of threatened or actual violence, coercion or deliberate deprivation.
  4. Help people claim their rights (Sphere Handbook, 2018, p.33)

In a TEDGlobal talk with António Guterres (2015), the impacts on Syrian refugees and on the communities they are fleeing to are discussed through the lens of how global policies affect human rights and suffering. The needs of Syrian refugees are exacerbated when surrounding countries taking them in, like Lebanon and Jordan, do not have the resources and also do not qualify for additional funding from sources such as the World Bank, as they are middle-income countries. These countries are then unable to provide enough support for the refugees.

As a global community, we should be supporting these countries as the front lines of defense and in supporting our collective international humanitarian commitment to refugees. Additionally, we should not be limiting how many refugees we can take in each country, as it is our duty to adjust our own society to meet the need.  Fear over security causes leaders to make harmful statements, such as Trump stating he would not allow any Muslim refugees in the US. However, statements like these actually provide fodder and support for terrorists, particularly Muslims who already reside in the US who are then ostracized and see themselves as needing to assert themselves and fight back against such statements, and so join terrorist groups. Refugees endure severe suffering, or else they would not be refugees in the first place – but then continue to be exposed to the worst conditions, unable to work, dependent on social support but often ineligible for it, health conditions and lack of medical care, and tensions with locals. 

              In the Nobel Prize acceptance speech by Medicins Sans Frontiers (MSF), also known as Doctors without Borders (Orbinski, 2000), they state “[h]umanitarian action is more than simple generosity, simple charity. It aims to build spaces of normalcy in the midst of what is profoundly abnormal. More than offering material assistance, we aim to enable individuals to regain their rights and dignity as human beings…Our action and our voice is an act of indignation, a refusal to accept an active or passive assault on the other.”

They also state “[h]umanitarianism occurs where the political has failed or is in crisis. We act not to assume political responsibility, but firstly to relieve the inhuman suffering of that failure. The act must be free of political influence, and the political must recognize its responsibility to ensure that the humanitarian can exist” (Orbinski, 2000). The responsibility for addressing the suffering of humans lies, ultimately, with political systems and countries. The needs for humanitarian organizations exist because these systems either fail to provide adequate interventions and support or are the instigators of human suffering in the first place. “Humanitarianism is not a tool to end war or to create peace. It is a citizens’ response to political failure. It is an immediate, short term act that cannot erase the long-term necessity of political responsibility” (Orbinski, 2000)

Additionally, ”[h]umanitarian action requires a framework in which to act. In conflict, this framework is international humanitarian law. It establishes rights for victims and humanitarian organizations. It fixes the responsibility of states to ensure respect of these rights, and to sanction their violations as war crimes. Today this framework is clearly dysfunctional. Access to victims of conflict is often refused. Humanitarian assistance is even used as a tool of war by belligerents. And more seriously, we are seeing the militarization of humanitarian action by the international community” (Orbinski, 2000).

The speech (Orbinski, 2000) also addresses how language shapes our view. Aside from natural disasters, humanitarian aid is not existing without the responsibility of another for a crime – and usually a crime on a massive scale, which causes significant human suffering. We tend to downplay the roles and responsibilities that actors have when we discuss the situation as a humanitarian emergency, removing it from it’s context.  At the same time, those providing humanitarian aid should refrain from politicizing or allow their preference of who to help rely on which side of a conflict one is on. The speech by MSF acknowledges that their humanitarian work exists within societal, cultural and political contexts, while at the same time working to clarify its purpose and goals outside of such, in terms of human rights and other essential rights, such as environmental ones, and to resist the urge to polarize peoples, systems, and governments as good or bad. As part of maintaining this, MSF remains an independent organization, and resists funding or oversight by any militarized group, which it views as being impossible to remain impartial.

I personally see the standards of MSF (Orbinski, 2000) as being important and applicable to using mental health care in humanitarian aid across diverse settings and peoples. Acknowledging that biases exist, and to choose to work on them in our own personal spaces with peers, mentors, and our own therapists, while aiming to approach each individual that we work with as a human being with an inherent right to dignity, worth, value, and deserving of empathy and care, regardless of their behaviors or actions. This aligns with the principles of Sphere (2018), and can be guides for how to approach care with refugees.

References

Orbinski, J. (2000). There is no such thing as military humanitarianism. Peace Magazine; Winter 2000. Retrieved from http://www.peacemagazine.org/archive/v16n1p08.htm

TEDGlobal (2015). António Guterres: Refugees have the right to be protected. Retrieved from https://www.ted.com/talks/antonio_guterres_refugees_have_the_right_to_be_protected

The Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response. (2018). Retrieved from https://www.developmentbookshelf.com/doi/book/10.3362/9781908176707. DOI: 10.3362/9781908176707

The Sphere Project (2011). Introducing the Sphere Handbook 2011 . Retrieved from http://www.youtube.com/watch?v=zpXxVg-Cv8A&feature=related.

Categories
Humanitarianism

STRENGTHS PM+ for Syrian Refugees

A FAQ and introduction to a culturally-sensitive mental health program to address problems of daily living, stress, anxiety, depression and PTSD by trained peer mentors.

Categories
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

Aikins, M. (2014). Whoever saves a life. Medium. Retrieved from https://medium.com/matter/whoever-saves-a-life-1aaea20b782#.kelvvhn3f

Al Asaad, S. (2018). The White Helmet myth: A soft war propaganda. Op-Ed. MEHR News Agency. Retrieved from https://en.mehrnews.com/news/132739/The-White-Helmet-myth-A-soft-war-propaganda

Amnesty International. (n.d.). Syria. Retrieved from https://www.amnestyusa.org/countries/syria/

Asif, S.M. & Asif, S. (2018). Doctors with borders: The White Helmets and radical political medicine. In: Weber AS, Verjee MA, editors. Proceedings of the 1st International Conference on Medical Humanities in the Middle East [Internet]; 2018 Nov 17-18: Doha, Qatar: Innovations in Global Health Professions Education; 2019 March. p. 27-29. https://dx.doi.org/10.20421/ighpe2019.01.09

Atlantic Council. (2017). Breaking Aleppo. Retrieved from http://www.publications.atlanticcouncil.org/breakingaleppo/

BBC. (June 12, 2012). Syria in civil war, says UN official Herve Ladsous. BBC News. Retrieved from https://www.bbc.com/news/world-middle-east-18417952

BBC. (July 22, 2018). Syria conflict: White Helmets evacuated by Israel. BBC News. Retrieved from https://www.bbc.com/news/world-middle-east-44915099

Daley, B. (October 7, 2016). Who are Syria’s White Helmets, and why are they so controversial?. The Conversation. Retrieved from https://theconversation.com/who-are-syrias-white-helmets-and-why-are-they-so-controversial-66580

Haddad, B. (2016). The debate over Syria has reached a dead end. The Nation. Retrieved from https://www.thenation.com/article/archive/the-debate-over-syria-has-reached-a-dead-end/

Harsin, J.  (2018). Post-Truth and Critical Communication Studies. Oxford Research Encyclopedia of Communication. Oxford University Press.

James, L. (2014). The most dangerous job in the world. New Internationalist. Retrieved from https://newint.org/features/web-exclusive/2014/10/10/syria-civil-defense-volunteers/

Kakade, S. (2016). White Helmets: Heroes or propaganda?. Ruggles Media. Retrieved from https://camd.northeastern.edu/rugglesmedia/2016/09/26/white-helmets-heroes-or-propaganda/

Lester, N. (2018) Introducing a Trauma-Informed Practice Framework to Provide Support in Conflict-Affected Countries. The RUSI Journal, 163(6), 28-41. DOI:10.1080/03071847.2018.1562016

Lynch, M., Freelon, D., and Aday, S. (2014). Syria’s socially mediated civil war. United States Institute of Peace. Retrieved from https://www.usip.org/publications/2014/01/syrias-socially-mediated-civil-war

Malsin, J. (n.d.). The White Helmets of Syria. Time. Retrieved from https://time.com/syria-white-helmets/

Moore, T. (2019). The White Helmets: Unneutral in the Syrian conflict. Kent State University Undergraduate Symposium on Research, Scholarship and Creative Activity. Retrieved from https://oaks.kent.edu/ugresearch/2019/white-helmets-unneutral-syrian-conflict

Palma, B. (December 15, 2016). Are the Syrian ‘White Helmets’ Rescue Organization Terrorists?. Snopes Fact Check. Retrieved from https://www.snopes.com/fact-check/syrian-rescue-organization-the-white-helmets-are-terrorists/

Solon, O. (December 18, 2017). How Syria’s White Helmets became victims of an online propaganda machine. The Guardian.  Retrieved from https://www.theguardian.com/world/2017/dec/18/syria-white-helmets-conspiracy-theories

South China Morning Post [username]. Syrian conflict: who are the White Helmets? . YouTube. Retrieved from https://www.youtube.com/watch?v=mnhkH6lYJxM&t=13s

Specia, M. and Samaan, M. (June 6, 2017). Syrian boy who became image of civil war reappears. The New York Times. Retrieved from https://www.nytimes.com/2017/06/06/world/middleeast/omran-daqneesh-syria-aleppo.html

Syria Civil Defense. (n.d.). ”Who we are” and “What we do.” Retrieved from https://www.syriacivildefence.org/en/

The Syria Campaign. (2017). Killing the truth: How Russia is fuelling a disinformation campaign to cover up war crimes in Syria. Retrieved from https://thesyriacampaign.org/wp-content/uploads/2017/12/KillingtheTruth.pdf

The White Helmets. (n.d.). Retrieved from https://www.whitehelmets.org/en/

Wright, R. (July 23, 2018). The White Helmets – Syria’s noble rescuers – have to be rescued by Israel. The New Yorker. Retrieved from https://www.newyorker.com/news/news-desk/the-white-helmets-syrias-noble-rescuers-have-to-be-rescued-by-israel

Yee, V. (November 11, 2019). James Le Mesurier, backer of Syrian White Helmets, is found dead in Turkey. The New York Times. Retrieved from https://www.nytimes.com/2019/11/11/world/middleeast/james-le-mesurier-white-helmets-dead.html