Addressing Mental Health and Psychosocial Needs in Displacement: How a Stateless Person from Syria Became a Refugee and Community Helper in Iraq

Hivine Ali; Kawa Ari

doi:10.4103/INTV.INTV_46_20

PERSONAL REFLECTION

Year : 2021 | Volume : 19 | Issue : 1 | Page : 136-140

Addressing Mental Health and Psychosocial Needs in Displacement: How a Stateless Person from Syria Became a Refugee and Community Helper in Iraq

Hivine Ali¹, Kawa Ari²
¹ MHPSS Officer, UNHCR, Kurdistan Region, Iraq
² Mental Health and Psychosocial Support Community Worker, DOH, Kurdistan Region, Iraq

Date of Submission	01-Nov-2020
Date of Decision	06-Dec-2020
Date of Acceptance	08-Jan-2021
Date of Web Publication	31-Mar-2021

Correspondence Address:
Hivine Ali
UNHCR, Erbil
Iraq

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INTV.INTV_46_20

Abstract

This personal reflection contains two stories that got intertwined due to the involvement of both authors with Problem Management Plus (PM+). One of the authors −Kawa Ari − is a stateless young man from Syria who was displaced in 2012 to the Kurdistan region of Iraq. He works as a mental health and psychosocial support community worker in the refugee camp where he lives. He was trained in PM+ and describes how this has helped him and his family and enables him to support others in a more effective way. The second author − Hivine Ali − trained Kawa Ari in PM+. The article is based on an interview with Kawa concerning his personal and professional story. It also includes Hivine’s reflections concerning the key role of forcibly displaced persons in providing support to other community members, drawing on her field experience of PM+ and her close collaboration with MHPSS community workers in Iraq. It describes how interventions like PM+ also have a positive impact on the personal development and resilience of the refugees who are trained as providers. This is an important contribution to their community mental health and psychosocial wellbeing and should be recognised as such. The story of Kawa and many other refugees also prompts reflections on Hivine’s own background, coming from a family that experienced displacement.

Keywords: community-based MHPSS, mental health and psychosocial support, Problem Management Plus (PM+), refugee, resilience, self-development, statelessness, Syria

How to cite this article:
Ali H, Ari K. Addressing Mental Health and Psychosocial Needs in Displacement: How a Stateless Person from Syria Became a Refugee and Community Helper in Iraq. Intervention 2021;19:136-40

How to cite this URL:
Ali H, Ari K. Addressing Mental Health and Psychosocial Needs in Displacement: How a Stateless Person from Syria Became a Refugee and Community Helper in Iraq. Intervention [serial online] 2021 [cited 2023 Jun 7];19:136-40. Available from: http://www.interventionjournal.org//text.asp?2021/19/1/136/312728

Introduction

My name is Hivine (Hêvîn). I am a Lebanese national serving as an expatriate mental health and psychosocial support (MHPSS) officer for UNHCR in Iraq. Like UNHCR’s population of concern, my family’s history is full of displacements due to several conflicts, which led to my parents having to make a “home” in three different countries. In this article, I will be drawing particularly on the experiences of one community worker, Kawa Ari, who in the course of writing this article became a co-author, presenting insights of his experience working in the field of MHPSS.

In Iraq − as in other low- and middle-income countries − the chronic shortage of local mental health professionals to address the population’s needs is a main challenge in delivering sustainable psychological therapies (World Health Organization, 2007). Added to this, there are challenges associated with training on adapted psychological methodologies and supervision (Dawson et al., 2015). Another barrier to a sustainable mental health system is the undue focus on specialised care providers in addressing needs, while overlooking “pretherapeutic” interventions to address the social determinants of health. This requires looking at modifying risk factors on a population level rather than only focusing on the treatment of symptoms of the individual.

Health outcomes are affected by many factors beyond access to medical healthcare. In other words, the availability or absence of quality medical healthcare is insufficient – by itself – to determine the expected health outcomes of a population. To improve the health of a population one needs to go beyond medical treatment and look more towards why people get sick, and how social, economic and political factors lead to health inequities. Social determinants of health include early child development, education, employment and working conditions, minimum income and the sustainability of the shelters/places people are living and working in. Inequalities in health exist across social groups and they are not simply because of lack of access to healthcare. These are due to the conditions in which people are born, grow, live and work. Consequently some of them can be addressed. Our role − not only as public health professionals but also as members of societies looking for social justice and protection of more vulnerable societies − is to work on addressing “avoidable” inequalities to narrow the inequities in health that can produce ill health outcomes (Marmot & Wilkinson, 2005).

In the context of working with forcibly displaced populations who already have gone through and continue living through health damaging experiences, addressing the systematic inequalities that are judged to be avoidable can build towards making quality of life better and thus reach better health outcomes.

Social determinants of health include many aspects related to MHPSS. For example, children’s development is not only physical but also emotional, behavioural, and cognitive development. We also need to be in good mental health to feel functional and productive in our jobs, etc. Also, challenging experiences and social difficulties can cause mental distress, which if not addressed, can worsen health outcomes.

With all the above in mind, it is core that we look at both the social factors that influence mental health as well as the availability of specialised psychological therapies when addressing mental health and psychosocial needs.

Context in Iraq

As of mid-2020 almost a quarter million Syrian refugees were registered with UNHCR in Iraq. Almost all of them (99%) reside in the Kurdistan region of Iraq (KRI). Most live in urban locations and around 40% live in camps. Given the protracted displacement of most Syrian refugees, UNHCR’s humanitarian assistance in Iraq is gradually transitioning from an emergency response to a longer-term development approach, with the aims to minimise dependency on humanitarian assistance, promote self reliance and include refugees in public services and national systems.

UNHCR supports the provision of MHPSS activities through its partners in the three governorates of KRI. In an unpublished assessment done by REACH Impact in July 2020 in Bardarash refugee camp in Duhok governorate of KRI, 84% of the respondents reported that the financial, social and education related challenges faced resulting from the lockdowns due to the COVID-19 pandemic made them feel stressed and anxious. On a positive note, 72% of the respondents reported that they received MHPSS services, 97% of whom reported that the support they are receiving is helping them and members of their household to cope better¹.

UNHCR’s MHPSS Programme in the Kurdistan Region of Iraq

UNHCR supports refugees’ protection and health needs through a range of interventions, partially related to addressing the social determinants of health. There are continuous efforts to use a MHPSS sensitive approach. This includes, for example, distributing of food and non-food items in a dignified way, using participatory approaches such as including refugees in focus group discussions, training community outreach volunteers and establishing refugee councils in camps which give a sense of governance.

Refugee camps in KRI have MHPSS units through which community-based MHPSS activities as well as one-to-one counselling and specialised care are provided. Structured, group activities for children and adults, community awareness, house to house visits, health promotion sessions and focused psychological counselling are some of the activities covered in these units. The MHPSS team members include community workers, psychologists and psychiatrists. There is close collaboration and coordination among the MHPSS team, protection partners and primary healthcare staff to ensure that the needs are covered and addressed in a multidimensional way.

UNHCR and the Directorate of Health in Duhok governorate in KRI have been collaborating for several years in strengthening the community based level of MHPSS services. Mental health needs are not only addressed through one-to-one counselling but also through community awareness sessions, group activities that bring people from the same community together, children’s structured resilience activities, workshops on mental health and other types of interventions. In addition to all this, capacity building of community members as well as of the government institutions’ workforce has been part of UNHCR’s priorities to ensure sustainability of interventions.

In Duhok governorate, community based MHPSS is being provided by community workers who are mostly refugees themselves. Capacitating the community workers to help their communities is one of the core principles of UNHCR’s work − empowering refugees to help them help themselves and their communities. These community workers have been trained in psychological first aid, identification of cases with mental health needs, leading community workshops, health promotion, I Deal programmes for children and other child-focused programmes. In several focused group discussions with the community workers, they expressed their enthusiasm to learn more techniques to enable them to be more helpful to their community members.

Introducing PM+

Given the enthusiasm and potential of the community workers and the acute need for psychotherapeutic interventions, the implementation of low intensity psychological interventions by trained paraprofessionals was considered very promising. These interventions are receiving more attention on the global mental health research agenda (Collins et al., 2011) and the evidence around their applicability by nonspecialists in low- to middle-income countries is mounting (van’t Hof et al., 2011, Wiley‐Exley, 2007). One of these low intensity interventions is Problem Management Plus (PM+), which is for adults suffering from symptoms of common mental health problems (e.g. depression, anxiety, stress or grief), as well as self‐identified practical problems (e.g. unemployment, interpersonal conflict). It is not suitable for people with severe mental health problems including people in psychotic states or who are suicidal (Dawson, 2015).

PM+ has been adapted for use with Syrian refugees (Akhtar et al., 2020, Uygun et al., 2020) but until now no experience has been documented in using the method among Kurdish Syrian refugees. UNHCR Iraq adapted and translated the PM+ manual into the Badini variant of the Kurdish language, spoken in the Duhok area of KRI and related to the dialect spoken by Syrian Kurds.² It is important that materials such as PM+ are adapted to the language and culture of the people who use it and that the examples of “idioms of distress” fit with their lived experience (Hassan et al., 2015).In January 2020, I participated in training the MHPSS community workers supporting the four main refugee camps in Duhok governorate of KRI on PM+. The training was extremely interactive, with the community workers suggesting adaptations and corrections to the translated version of the manual to make it more contextualized. The community workers continue to use the techniques they learned during this training, supported with continuous supervision despite the pandemic.

Stories Intertwined

Most community workers have stories of suffering and adversity during displacement and stories of bouncing back. I can personally relate to this as well. My origins and family experiences built a solid common ground enabling me to stand shoulder to shoulder with UNHCR’s population of concern. Having Levant and Mesopotamian cultures as part of my identity enable me to understand the psychological dynamics and sociocultural variations in this geographical area. Being able to speak the refugees’ languages also means I can understand idioms, metaphors, and expressions to describe different degrees of feelings. For my parents, learning the new languages they got exposed to throughout their years of experiencing displacement was key to access and understand more cultures – which definitely had an impact on shaping and broadening our family’s multicultural identity and capability to learn new languages. This supported my professional involvement in MHPSS for forcibly displaced people who express themselves in the languages I was taught and facilitated my ability to absorb new dialects. This in turn eased communication with them and helped in triggering their creativity, willingness to accomplish more and ability to propose new contextualized interventions.

As I was writing this paper, Kawa Ari − a MHPSS community worker in the camp where he lives in Duhok governorate − showed his eagerness to share his story. Therefore, I am passing the microphone to him to speak about the health damaging experiences he encountered in Syria as a stateless person, his displacement journey and the change in his role from a service receiver to a known member in his community extending help and support to others.

Due to restrictions related to the COVID-19 pandemic, all communication for writing this piece was done over the phone. Kawa shared his story with Hivine who translated it to English. The text of Kawa is in italics.

From Statelessness to Seeking Asylum

I will name myself Kawa Ari as I prefer not to use my real name. I was born in 1985 in Derek in north east Syria. I come from a family that − like many others of Kurdish ethnicity in that area − was stripped of their citizenship in 1962 and became stateless in our own land. This deprived us of many basic rights. Despite the adversities associated with being stateless, I hoped that education would help and I reached the highest level I could in these circumstances. After graduation, my statelessness stopped me from getting a job in governmental teaching institutions. Private sector schools and universities hardly exist in Syria. In order to support my parents and seven siblings I therefore had to do work that does not require a degree.

When the conflicts erupted in Syria in 2012, Derek was relatively safe. Yet, the hardship there started after millions of internally displaced persons moved to north east Syria. Living conditions started deteriorating, unemployment increased and roads and border crossings were blocked. Those who had been internally displaced (IDPs) were not stateless and were given more rights in our area of origin than we did. Stateless people in Syria have difficulties to obtain a document as simple as a birth or death certificate. Afterwards, demonstrations and civil unrest started in my area, with new armed forces taking over, and they began the compulsory recruitment of youth.

It was in September 2012, when I decided to head towards Iraq with my friends, leaving my fiancée and family behind. I walked for a whole day and night to reach the borders with Iraq. The first night at the borders was full of women and children crying either of fear or of hunger and thirst. The Kurdish military forces empathised with us and allowed us to cross the border to safer land.

What is currently our camp in 2020 was back then in 2012 a big desert-like field full of crowds of people walking in different directions, scattered and not knowing what to do or where to go to. When I recall this now what comes back to my mind are the sun burned, desperate faces and the clothes that were full of dust and dirt.

I had expected that we would find tents ready to receive us. But the shocking reality was that thousands of people were waiting for tents. My friends and I found an unfinished mosque. It didn’t have windows or doors, only a ceiling to cover us. We were surrounded by others from all directions which made us fully exposed and not have any privacy. We survived with the minimal food assistance that we were receiving. This was how I lived for around 10 days. The savings I brought with me were nearly spent.

Luckily, I got the chance to be a construction worker in a place that offered me shelter and food. After that I joined one of the international non-governmental organisations (INGO) as an awareness-raising assistant. I used to help new arrivals to fill in their registration forms with UNHCR. After that I moved to another location. I was there when new refugees arrived in the camp. Seeing them reminded me of my first shock when I myself came here. I wanted to save them from the same heavy feelings. I first offered them food and water. Then I wanted to make sure they knew that “I am here to help you”. Then I guided them through the registration process. I still remember that it all seemed overwhelming for me on my arrival and I was trying my best to make it easier for the people I was here to help. I felt fulfilled because I was protecting others from the tough experience and negative feelings I passed through. It was here where I felt that I could do more, and that I could use my capacity in helping my community members to go through their emotional difficulties.

After several months of work, I took the role of MHPSS community worker in the camp where I still live. I received training in psychological first aid, child resilience techniques, psychosocial support for children, child protection and PM+. I face numerous challenges when working in the field of mental health. To start with, mental health is stigmatised in our community and therefore people’s readiness to listen to awareness messages on mental health was previously extremely limited. Back home in Syria, people used to go to “shaawaza” places to get treated from psychiatric disorders and to religious leaders when they were feeling stressed. People avoided visiting mental health professionals so they would not be stigmatised for a lifetime, and if they did go, it used to be thought of as a big secret. Prior to my displacement, even medical professionals weren’t taught courses related to mental health. Everybody’s knowledge in this field was limited. People are happy to be counselled and psychologically supported but when I call it a psychological counselling session, they refuse! But when I say; “We will have a chat over tea”, all goes well! It’s funny and sad at the same time.

I used to counsel people before, but not in a structured way. Now I know where to start and what to focus on. Shortly after our training in PM+, the camp was put in lockdown due to COVID-19. My mother and wife were showing signs of anxiety and I started working with them on PM+. They were my first success stories with PM+! Problem listing really helped us and the programme made the whole family feel better. This gave me more confidence and I felt that if I’m doing it right here, then I can do it right for others too.

Some of the activities I was holding before the COVID- 19 pandemic were community awareness workshops, activities for children and adolescents, house visits to disseminate tips and advice on mental health and others. These helped us and helped the people themselves in identifying their own needs and to know when to seek support. During the lockdown we are not able to receive people in our MHPSS units, so I am helping over the phone using brief, focused sessions. The support and advice my colleagues and I are receiving from our supervisor is very important especially about telecounselling. Before learning about PM+, the biggest challenge was that I identified many cases in need for help but all I could do was to refer them to the psychologists. But now, I can help more and based on the criteria I either refer or not.

Hivine’s Reflections about PM+ Training and the Challenges Raised

Training the community workers in PM+ was received with their usual drive and excitement to learn more. The practice sessions throughout the training showed how PM+ makes it possible for non-specialists to learn less intense versions of cognitive behavioural therapy and interpersonal therapy as long as they are trained and supervised well. One of the trainees also said, “We learned life skills we can use in our daily encounters and not bound to the work setting”.

As a result of the training, the community workers are now more competent in the counselling they offer. PM+ is structured and yet flexible, so it has been used through telecounselling in response to the demands of the COVID-19 pandemic. There is of course always room for further adapting interventions to address the needs of the local context. I consider it vital as an MHPSS Officer to visit and hold group discussions with the MHPSS team to continue working on localizing and contextualizing PM+. This is still ongoing amid the COVID-19 pandemic but in a different modality.

One of the challenges that I used to face was the expectations of the community from the MHPSS team and the helplessness that we feel when we are being asked for a lot and what they can offer is little. This can easily lead to compassion fatigue and that is why it is important to talk about the stress the helpers face themselves. Capacity building on various topics including self care helped in gaining knowledge on how to help more.

In my view, implementing PM+ through refugee community workers is more than just “bridging the treatment gap”. As the story of Kawa shows, the effects of PM+ training are also felt in his personal life and in his family. It helps people cope with social stressors. It really empowers them. It reduces the pressure of the walls that displacement forced on their hearts and minds. As such, it helps in identifying and addressing the social determinants of mental health. Of course, it is important that the MHPSS team is closely supported by a clinical psychologist who offers continuous supervision to address the psychological challenges the team might be encountering.

Kawa, one of millions of stateless people in the world, is now a productive member of his community and is extending help and support to others to have a better life. Seeing people like Kawa having the inner power and resilience not only to get back to themselves but also to extend help to others gives hope for a better future. In my view, having MHPSS interventions and activities integrated within the various types of assistance that international humanitarian organisations support is very important for forcibly displaced populations. Social and mental wellbeing are associated with better health outcomes and give people a sense of connectedness and control over their lives. This is what this population has desperately lost and wants to acquire again.

Acknowledgements

The first author wants to thank Peter Ventevogel and Benedicte Duchesne for their comments on earlier drafts of this paper, and Monica Noro for leading by example.

Financial support and sponsorship

Nil.

Conflict of interest

Both authors are, or have been, involved in the humanitarian response for Syrian refugees in Iraq. The views expressed in this article are those of the authors and not necessarily those of the institutions that they serve.

¹Datasets can be presented if requested.

²See: https://apps.who.int/iris/bitstream/handle/10665/206417/WHO-MSD-MER-16.2-kur.pdf?ua=1

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