BEIRUT — M. had not slept for two months when she reached out to Jouhaina Mouslem asking for psychological help. “This woman was devastated, collapsed,” recalled Mouslem, a psychologist originally from Aleppo and currently active in the mental health programs of the ‘Women Now’ NGO in Lebanon.
M. had been detained in a Syrian regime prison. After being released, her husband left her, so she fled to Lebanon, leaving her two children in Syria. M. remarried and had a son, but her second husband also left her. She was in a critical economic situation. “She had depression, acute anxiety; she went through all her Post Traumatic Stress Disorder (PTSD) symptoms living alone,” Mouslem explained.
After nine therapy sessions and receiving financial aid to cover the psychiatrist’s treatment and pay rent, M. started to get back on her feet. “When I saw the difference, I was so moved,” said Mouslem, who herself is a Syrian refugee that has also suffered the loss of “my country, my closest ones, my home; this helps me understand the pain of Syrians.”
This pain might be overlooked amidst the macro figures of ten years of uprising and war in Syria: 227,413 civilian deaths, 99,479 forcibly disappeared, 5.6 million refugees and 6.6 million internally displaced people (IDP). But Syrians are suffering a mental health pandemic.
According to a Syria Relief survey, 99 percent of IDPs and 73 percent of Syrian refugees show symptoms of PTSD, an anxiety disorder that can be developed after being involved in, or witnessing, a traumatic event.
That report shows that among those experiencing a life-threatening event, 52 percent of women had ten or more PTSD symptoms, while among men, that figure drops to 37 percent. Women are more prone to develop PTSD “partly because how women react to stress and trauma; while men have a more action-driven response, women have a more avoidant-type response, which increases the risk of PTSD,” Angela Daaboul, a clinical psychologist at Restart Center for Rehabilitation of Victims of Violence and Torture, explained.
Age is also a factor. “The younger the person is when exposed to a trauma, the higher the risk of developing PTSD,” Daaboul added. Among children, PTSD signs include loss of appetite, bedwetting, nightmares, and increased aggressivity while playing. In Syria, 47 percent of young people have had a close relative or friend killed in the conflict, 54 percent experience sleep disorders and 73 percent deal with anxiety, according to a recent ICRC study.
The most prominent PTSD symptoms among Syrians are “feeling constantly on guard, acting or feeling as if the traumatic event was happening again, irritability or outbursts of anger, problems concentrating and intense physical or emotional distress when exposed to things that remind them of the traumatic event,” Alaa Kaddoura, a psychologist at the Union of Relief and Development Associations (URDA), explained.
While Syrian refugees in Western countries tend to have access to mental health support, in Lebanon, these services are scarce, and in Syria almost nonexistent due to the stigmatization of therapy. Only seven percent of Syrians in Syria and Lebanon receive the psychological support they need.
Ten years of mental health scars in Lebanon
Few of the 1.5 million Syrian refugees who fled to Lebanon in the early years of the Syrian conflict could have imagined they would stay a decade in the neighboring country.
At the beginning of the Syrian crisis, refugees in Lebanon were drowning in “confusion, anxiety, very strong panic attacks and nervous breakdowns,” Kaddoura explained. “At first, it was a matter of adaptation problems. Syrian were living in houses and now in tents, and there were many cases with PTSD; the trauma of witnessing massacres and bombardments was fresh,” Mouslem added.
As the uprising turned to war and then the Assad regime consolidated power, hopelessness set in among refugees. “At the beginning, Syrians had a hope to reach accountability for the crimes of the regime, to see the release of detainees and to return to Syria — not anymore,” Mouslem said. “People now are waiting for the new calamity to happen; the only hope now is to get out of Lebanon.”
As many realized that a safe return to Syria was a distant scenario, they had to deal with the loss of hope. “We let them be aware of how this loss of hope is affecting them, and we try to abandon this idea that if you cannot go back [to Syria] your life is over; let’s find hope somewhere else,” Stephanie Haddad, a psychologist at the Lebanese Center for Human Rights (CLDH), explained.
Therapists have to deal with the fact that Syrian refugees in Lebanon face an uncertain future. “We cannot think what is going to happen in five years, so we focus on the concept of adaptation and on what they are going through now,” Kaddoura said. “They are always on guard and afraid; they don’t know what to expect from the coming day.”
To deal with this uncertainty, refugees have to understand that there are some things that escape their control, according to Maya Zaghloul, a clinical psychologist at Restart Center. “Once they realize that they are not able to control certain things, it allows them to have more control over their feelings of uncertainty and stress.”
In addition to PTSD, many Syrians were diagnosed with depression, anxiety and behavioral disorders throughout the previous years. “You would think that after ten years things would be in place; they are not,” said Kaddoura.
“We observe a lot of behavioral difficulties and conduct disorder among children, and these are caused by the stressors they are living in Lebanon, in addition to the traumatic events they experienced in Syria,” Joelle Wehbe, a clinical psychologist at Restart Center, explained.
Mouslem has also noticed “social anxiety” given that some refugees feel that “this society is not accepting us; they suffer from racism, they stay home, and this anxiety develops into depression.”
Lebanon, no place for healing
The recent turbulent chapters lived in Lebanon — the Lebanese uprising in 2019, the economic collapse, the COVID-19 pandemic and the Beirut explosion — have affected Syrian refugees’ mental state.
The Lebanese uprising was triggering for many Syrians because it was felt “as a reminder of how the war started in Syria and this led to a lot of fear,” according to Zaghloul.
The financial crisis has also pushed 80 percent of Syrian refugees under the poverty line. Suicidal ideations are on the rise. “Now there is a higher incidence of suicidal thoughts and suicidal attempts. It used to be the exception, now it is the rule,” Daaboul said. Mouslem is currently dealing with two women who suffer from deep depression and attempted suicide. “Even among the young people, there are thoughts about death,” she said.
The August 2020 Beirut port explosion that shattered the Lebanese capital was a trigger for many Syrians who “had flashbacks, recurrent dreams and the same emotions they had when they went through other kinds of explosions back in Syria,” explained Haddad, who tries to show them how their reaction is tied to their previous traumas in Syria.
The Beirut blast was the breaking point for one of Haddad’s patients. A man survived torture in a Syrian regime prison and fled to Beirut, where he works as a plumber. He reached out to CLDH seeking therapy. “He used to have a lot of flashbacks. He was in a state of depression, wouldn’t get up to go to work, and had back problems because of the torture,” Haddad said.
A few months into therapy and physiotherapy, he showed progress. Paradoxically, the COVID-19 lockdown helped him: “Seeing Lebanese living the same thing helped him build some kind of resilience.” He found comfort through this shared pain. “We are fine because everyone is not ok,” he told Haddad.
But in the Beirut blast, his pregnant wife lost her baby due to the shock. He fell apart. Two months later, he went back to therapy and started showing progress. But as he was getting better, his wife was getting worse. “As long as he was not okay, she was okay because she had to be ok; when he started to get better, it switched on her,” Haddad explained. His wife refused to go to therapy, so he “decided to stop getting better so that she would feel better again.”
The taboo about mental health among the Syrian community in Lebanon has decreased in the last decade. In the beginning, when they were offered mental health services, “we would face a lot of people saying ‘we are not crazy,’” Kaddoura recalled. The therapists interviewed for this story agree that now therapy is not seen as controversial.
The healing toolbox
“Psychologists do not do magic.” Kaddoura had to repeat this idea to patients that saw therapy as a way of getting rid of painful feelings. “Therapy is not magic erasing memories; it is about adapting and thinking about the future.”
At ‘Women Now,’ Mouslem organized support groups of Syrian women to build a safe space and try to heal together. “We talk about depression, the loss of their family and their economic difficulties; when they talk about shared pains, they realize they are not alone. This is part of the treatment,” Mouslem said. They also learn how to manage stress, anger and how to “take care of themselves and occupy themselves with activities they like, so they don’t go through this on their own.”
To deal with PTSD, Cognitive Behavioral Therapy (CBT) is commonly used. The goal is to “change negative thought patterns into positive thought patterns,” Lana Kalawoun, therapist from the Lebanese Center for Human Rights, explained. A change in thoughts would later translate into a change in emotions and then behaviors.
“The most important thing is trying to find the feeling behind that intellectual thinking. Usually, the intellect is blocking the emotions that didn’t get out when the trauma happened,” Haddad added. Once these feelings can get out, pain is appeased.
To fight intrusive memories or flashbacks of traumatic events, psychologists teach patients grounding techniques, like relaxation, breathing exercises and mindfulness, so they can calm down, be present in the moment and understand that what they are feeling is something that happened in the past. Kaddoura recalled one of her patients suffered episodes of intrusive memories. This woman was kidnapped, raped and, as a result, got pregnant. Later, her husband left her, so she came with her children to Lebanon. She still goes to therapy, and although she still suffers flashback episodes, “she is standing on her feet.” She has learned to sew, and now she “feels productive again because she is able to provide for her children.”
Another technique to process trauma is Narrative Exposure Therapy (NET), where the patient narrates the traumatic experience. “This allows him to place the event in the timeline, it grounds it in the past and it also helps fill those gaps in which there is a fragmentation of memories,” Kalawoun explained.
Accepting a loss is an uphill battle. Daaboul recently had a case of a Syrian woman who struggled to deal with the death of her brother. “She was hopeless, depressed and had nightmares about her brother’s death,” Daaboul explained. In 15 sessions, “she was able to deal with this grief and talk about it without being overwhelmed.” In the end, she told Daaboul she dreamt she was with her brother in a garden, and he told her, “Don’t worry, I am safe.”
“This dream reflected that she had come to terms with the loss,” Daaboul explained. In a decade where Syrian dreams turned to nightmares, therapy is helping some find healing.
This article was produced in cooperation with Friedrich Ebert Stiftung.