Keywords
Resilience - Human Devastation Syndrome (HDS) - PTSD - Syrian refugees
Since March 2011, the Syrian conflict has led to the most significant refugee crisis
since World War II. This protracted crisis has resulted in over 5.5 million registered
Syrian refugees worldwide, with estimates from the host governments suggesting this
number exceeds 7 million total refugees.[1] In addition, there are over 6.4 million internally displaced persons (IDPs) in Syria—a
number that is expected to grow given recent escalations in regional conflicts.[2] Together, these data suggest there are over 13.5 million Syrians in dire need of
comprehensive humanitarian assistance.[1]
As indicated by their refugee or IDP status, each of these 13.5 million individuals
has been exposed to trauma and is subsequently at greater risk of developing severe
psychiatric disorders.[3],[4],[5],[6] Recent estimates suggest more than 50% of Syrian refugees and IDPs have some form
of mental illness.[7] Moreover, the chronic psychological stress experienced by displaced individuals,
from protracted financial and security concerns to a pervasive sense of helplessness
and hopelessness,[8],[9],[10] has compounding impacts on long-term emotional and physical well-being.[11],[12] Indeed, as the Syrian conflict continues into its eighth year, the extent of trauma
experienced by Syrian refugees has manifested beyond contemporary knowledge of post-traumatic
stress disorder and other trauma-related disorders. The amount of repeated trauma
in this population has resulted in a “devastation of the human experience”, a condition
coined Human Devastation Syndrome by Dr. M.K. Hamza to provide a comprehensive description
of Syrian refugees’ unique psychological conditions.[10],[13],[14] Consequentially, the mental health and psychosocial needs of displaced Syrians should
be placed as an utmost priority to host communities and nongovernmental aid organizations
(NGOs).
Numerous barriers prevent the provision of such humanitarian aid; however, in 2018,
the UN Regional Refugee and Resilience Plan received only 62% of funds required to
meet the humanitarian needs of Syrian refugees in neighboring countries.[1] In Lebanon, this number was a stark 48%. Mental health and psychosocial support,
in particular, are often overlooked in attempts to accommodate more basic needs (i.e.,
food, water, and shelter) and primary health concerns.[15],[16],[17] Although these basic needs are essential for immediate stabilization and crisis
management, extant evidence suggests the incorporation of mental health care in a
holistic humanitarian response improves functional outcomes and long-term rehabilitation.[18],[19] Yet, specialized mental health resources are scarce in primary host countries such
as Lebanon and Jordan. Refugees and host communities alike feel these effects, highlighting
the universal need for improved access to mental health care.
To this end, the Syrian American Medical Society (SAMS) launched its inaugural mental
health mission trip to Lebanon and Jordan, from June to July 2019, to advance the
state of mental health care for refugees. In his keynote address for the mental health
mission trip, Dr. M. K. Hamza, a medical and forensic neuropsychologist, professor
of clinical mental health at Lamar University, and chairman of the Mental Health Committee
at SAMS, called for an overhaul of the entire mental health system as we know it:
a move from the traditional crisis-response system into a holistic, progressive, and
future-oriented system. He emphasized the importance of addressing the long-term effects
of the human devastation refugees have suffered by transitioning from traditional
medical models to community-based models for psychosocial interventions, resulting
in a shift in conceptualizations of mental health diagnosis and treatment. As Dr.
M. K. Hamza noted, these shifts will require progressive mind-sets focused on the
building of resilience by bridging the gap between humanitarian aid and professional
mental health and creating clear, concrete, and coherent guides for improved mental
health.
With this in mind, the SAMS mental health mission trip consisted of mental health
and psychosocial support trainings for local mental health and psychosocial support
(MHPSS) staff from various government and NGOs. Provided by eight international experts
in psychiatry, trauma psychology, and social work, these trainings covered a broad
range of mental health topics, including the neurobiological response to psychological
trauma, management of traumatic brain injuries, advancements in the assessment of
suicide risk, dialectical behavior therapy, and mental health in primary care settings.
Additional trainings such as reflective supervision and group therapy were provided
to focus on advancing the practice of mental health care in humanitarian settings.
These trainings were conducted to improve the accessibility and sustainability of
high-quality mental health care for refugees and provide the initial foundation for
the unity between humanitarian aid and professional mental health.
The mission then culminated with a two-day scientific symposium attended by government
officials, international experts, and NGO representatives that addressed the regional
to global transition of refugee mental health toward resilience. The symposium focused
on advancing MHPSS services available to the Syrian refugee community with an emphasis
on sustainable community-based resilience. This meeting of humanitarian actors, government
officials, academics, and mental health professionals bridged humanitarian aid and
mental health to create an international coalition devoted to the promotion and advancement
of refugee mental health care.
Together, these two components of the 2019 SAMS mental health mission trip provided
a preliminary assessment of the current status of mental health services available
to Syrian refugees and generated a vision for future improvements in refugee mental
health care in host communities worldwide. Here, we outline key outcomes from this
inaugural SAMS mental health mission trip, including key recommendations from the
scientific symposium. We hope these findings will justify the continued use of such
missions and generate a model for future advancements in the international humanitarian
response to refugee crises.
COMMUNITY-BASED MENTAL HEALTH: BENEFITS AND NEEDS
COMMUNITY-BASED MENTAL HEALTH: BENEFITS AND NEEDS
A core theme spanning the two domains of the mission trip was the emphasis on community-based
mental health care. Established in 1996 to meet the overwhelming mental health needs
following extensive community trauma, the base principles of community-based mental
health focus on improving access to care through nonspecialized MHPSS services.[20],[21] This is particularly relevant for low- to middle-income areas. The primary host
communities for Syrian refugees, Jordan and Lebanon, have limited mental health resources.
In Jordan, there are fewer than two psychiatrists and less than one psychologist or
social worker per 100,000 citizens.[22],[23],[24] In Lebanon, there are approximately two psychiatrists and fewer than three psychologists
or social workers per 100,000 citizens.[24]
To remediate the imbalance generated by needs that outweigh available resources, community-based
mental health seeks to generate population-based services that are sustainable and
scalable to size.[25],[26] This is accomplished by expanding mental health care from specialized settings to
primary care settings, perhaps most notably promoted through the World Health Organization
Mental Health Gap Action Program.[27] Moreover, nonspecialized psychosocial support (in contrast to specialized individual
psychotherapy) circumvents the needs for mental health specialists and offers accessible
programs that support general mental health and psychological well-being. Indeed,
current provisions of mental health care for Syrian refugees by international actors,
such as the International Medical Corps and Arabian Medical Relief, follow this model
given the shortage of mental health specialists available in host communities. Yet,
these models are unable to overcome the lack of awareness of MHPSS programs and mental
health in general, with upward of 80% of Syrian refugees reporting no knowledge of
psychosocial support programs in their community.[23],[28] This is particularly relevant in the host country Turkey, where despite hosting
more refugees than any other country, only 9.7% of refugees receive mental health
care due primarily to a lack of knowledge about existing services.[29]
To address this gap in awareness and accessibility, the SAMS mental health mission
advocated for the expansion or modification of this community-based model beyond primary
care settings into community-based providers, termed “peer leaders.” These peer leaders
are embedded within their communities to provide nonspecialized MHPSS care that is
highly visible and accessible by all.[21],[30] This model follows recent advancements in the operationalization of community-based
mental health, which call for community services that are cognizant of the systemic
influences on mental health, including socioeconomic contexts and cultural influences.[31],[32] This can be accomplished by utilizing multiple levels of community (i.e., family,
social networks, and surrounding organizations) and placing providers with firsthand
experience of the reported hardships directly in the primary setting.[30],[32]
Specifically, the use of peer leaders creates MHPSS providers that are not only more
readily accessible and suitable for scaling services up to size, but also have an
intimate understanding of the underlying context from which mental illness emerges
in a refugee population. This knowledge is essential to progressing the system of
mental health from the current medical model to a more holistic and progressive system
that accounts for the pervasive, long-term effects of repeated, sustained trauma experienced
by refugees and IDPs.[13] The extent of trauma experienced by Syrians reflects a human devastation that extends
beyond our current understanding of trauma-related psychopathology.[10],[14] This misconceptualization may account in part for the relatively low prevalence
of trauma-related disorders in Syrian refugees,[10] as the clinical manifestation of the human devastation experienced by Syrians may
not fit with existing categorical diagnoses.[33],[34] To this end, additional research is needed to generate diagnostic criteria for Human
Devastation Syndrome to more accurately index their trauma symptomatology and generate
novel interventions tailored to their unique experiences.[13],[14]
The complexities of these cases are further reflected by the reported need from community
MHPSS providers for greater supervision and case consultation. Although community-based
mental health services provide increased access to care for beneficiaries, the MHPSS
providers are often left with suboptimal specialized support to manage more difficult
cases. Approximately 72% of MHPSS providers, both specialized and nonspecialized,
who attended the SAMS mental health trainings reported a need for more continuing
education opportunities and resources for case consultation and supervision. This
report was echoed by providers in refugee camps, where there is very limited access
to mental health specialists. These findings highlight a gap in extant models of nonspecialized
community-based mental health, which needs to be filled through continued training
opportunities such as those provided by the SAMS mission trip, greater collaboration
across the spectrum of providers as shown at the SAMS scientific symposium, and extensions
of existing telepsychiatry models to include case consultations and specialized supervision.
Overall, there is a need for an interdisciplinary approach to provide adequate specialized
support for community-based providers and improve case conceptualizations and diagnostics
of mental illness within a Syrian refugee population. This can be accomplished by
bridging the gaps between humanitarian aid, professional mental health, and academia
through improved data sharing and the expansion of education opportunities for community
MHPSS providers through academic institutions.[35],[36] To this end, the SAMS scientific symposium called for the formation of a joint committee
consisting of Ministries of Development, Health, and Planning, affiliated academic
institutions, and NGOs. These branches will provide the necessary specialized support
and resources to promote the development and implementation of evidence-based community
mental health practices. This provides a blueprint for future collaborative initiatives
promoting community-based models of mental health care in international humanitarian
settings.
MOVING FORWARD: RESILIENCE AND GROWTH
MOVING FORWARD: RESILIENCE AND GROWTH
An additional theme spanning the mental health trainings and scientific symposium
was the promotion of resilience and a transition away from a pure crisis management
model of mental health. As the Syrian crisis extends into its eighth year, the mental
health needs of the refugee community are proving to be long-standing, requiring a
sustainable response that promotes growth and rehabilitation. The concept of building
resilience has been positioned as a critical means to address such long-standing psychological
stressors and burdens of mental illness.[37],[38] However, to date, the construct of resilience has yet to be operationalized, preventing
the development of adequate methodologies to foster resilience in an individual and
their community.
The concept of resilience operates on the idea of one’s ability to defy challenges
placed on them by their predispositional traits, circumstances, or environments.[39] Individuals subjected to severe trauma are often confronted with profound and lasting
psychological and physical sequelae.[6] Moreover, as seen in the refugee experience, these traumas can be prolonged and
repeated over time, exposing an individual to protracted states of psychological trauma
that has lasting effects.[40] An individual’s response to these subsequent stressors is explained, in part, by
their prior reactions or adjustment attempts to trauma.[41] Resilient individuals are able to apply effective coping strategies to overcome
their adversity and move forward in life effectively and productively.
Although psychological resilience is often discussed as a fixed, trait-like quality,
there is accruing evidence to suggest psychological resilience is malleable and can
be developed over time.[39] This includes building, among other qualities, (1) self-efficacy and hardiness,
(2) the ability to tolerate and overcome emotional distress, (3) a positive acceptance
of change (i.e., progressive, growth mind-set), (4) a perception of control and agency,
(5) spirituality, and (6) positive coping skills. This can be accomplished by empowering
individuals with skills that are necessary to feel capable of overcoming adversity,
including both distress tolerance and emotion regulation skills as well as practical
occupational and life skills.[42],[43] Under the principles of self-determination theory,[44] building resilience improves therapeutic outcomes and generates sustained growth
post-intervention by increasing self-efficacy, self-agency, and the ability to cope
with and overcome emotional distress, positioning it as an essential component to
facilitate long-term success in adaptation and later reintegration or repatriation
efforts.
Indeed, the topic of resilience and related principles of positive psychology were
popular among community MHPSS providers. Approximately 66% of responding trainees
reported a desire for more training opportunities on resilience and psychotherapeutic
interventions promoting positive psychology. More nonspecialized, positive psychology
therapy groups were among the most reported needs from MHPSS providers in surveyed
refugee camps. However, to date, there are limited evidence-based interventions to
build resilience, specifically in the context of refugee mental health and humanitarian
response. As the extent of trauma, which these individuals have experienced, extends
far beyond current models of trauma-related disorders, novel conceptualizations and
advancements in the understanding of their psychological trauma are needed to generate
adequate and sensitive interventions to build resilience.
Toward this end, the scientific symposium further proposed an interdisciplinary approach
to define resilience in the context of refugee mental health, with the direct goal
of generating a clear and coherent guide for methodologies to build resilience. Attendees
noted the importance of generating holistic and community-based interventions for
resilience that account for the biopsychosocial influences underpinning the human
devastation experienced by so many Syrians. This includes expanding services beyond
standard clinical models of mental health care to include occupational skills training
and provision of basic needs that empower and embolden the individual. This method
can be seen in practice through the peer leaders program enacted by SAMS, which gives
individuals the skills necessary to not only overcome their own adversities but teach
others how to do so as well. This provides a model for psychosocial support programs
that meet both the basic and psychological needs of individuals to prepare them for
the future living of a satisfactory and functional life. Under these principles, resilience
can provide the bridge between humanitarian aid and professional mental health, improving
both psychological and functional outcomes. Eight years after the Syrian crisis, the
time is now ripe to incorporate the concepts of a resilience model into current psychosocial
interventions to move toward a progressive, growth mind-set and promote success in
future reintegration and repatriation efforts.
