After the Shock: Living with War

By: Matthew McNaught

To many, the word ‘therapy’ carries certain connotations. The butt of a hundred Hollywood jokes, it summons up images of neurotic New Yorkers lying on couches and explaining to their over-paid psychotherapists how their father didn't hug them enough. Yet for many people who have lived through war or other traumatic events, psychotherapy offers a lifeline, helping them rebuild their shattered lives and learn to function once again as confident, active human beings.

 Far away from the plush offices of Manhattan psychotherapists, in shabby concrete flats on the outskirts of Damascus, thousands of Iraqi refugees have far more on their mind than marital strife or teenage angst. Coming to terms with the loss of close family or friends and bitter memories of violence and war, they live off their savings and occasional groceries money from the UNHCR or Red Crescent. But many argue that their psychological needs are being neglected. “By now, the major NGOs have a pretty good system in place for providing things like food parcels and medical services" said Fateh, a young psychologist providing therapy to several traumatized Iraqi families. "But they’re only just starting to address the mental health needs of these people. There's a huge problem of post-traumatic stress among refugees, and it's still not being tackled.” Fateh is one of a number of people in Damascus working voluntarily to provide psychological support to those worst affected by violence. He acknowledges that the UN and aid agencies are beginning to sit up and take notice. A preliminary survey of Iraqi refugees carried out by the UNHCR paints a frightening picture of the scope of the problem. Three out of four respondents had lost close friends or relatives due to violence, while 67% were suffering from Post Traumatic Stress Disorder (PTSD). But until the likes of the UNHCR expand the extremely limited services on offer, it's left to dedicated volunteers like Fateh to do what they can.

“When we first came across him, he wouldn’t communicate at all. He used to shut himself in his room and refuse to talk to anyone, even his family.” Sister Therese describes her first encounter with Qasem, the young boy who became an early beneficiary of the children's psychotherapy program. “His father was murdered in front of him, he saw everything. It had hit him really badly- his mother didn't know what to do”. Sister Therese and her sisters from the Good Shepard convent have been working with Iraqi refugees since the first waves started to arrive around 5 years ago. They initially provided basic goods and moral support but gradually saw there were other needs not being addressed. “A lot of kids we were seeing seemed extremely nervous and withdrawn” said Therese. “Their families complained of a lot of similar problems; their children were losing weight, wetting the bed, suffering from nightmares, often misbehaving.” And when the nuns started to enquire about the children’s histories, they uncovered a litany of horrors that would become sickeningly familiar. “Some of the kids had survived kidnappings and severe beatings,” she said. “Many others had witnessed the killing of family or neighbors”. After researching the topic, they discovered that many of the problems the parents described were recognized symptoms of PTSD.

The sisters enlisted the help of Dr Mahmoud Nuweilati, a psychologist specializing in victims of violence, and started to develop a program to help the children deal with their trauma. Like Fateh, they used play therapy as a way of tackling issues sensitively and indirectly. “Adults have more of an ability to communicate their feelings through speech, but for kids it’s a lot more difficult” said Fateh. “They often lack the vocabulary to describe what they feel or what they’ve experienced. And for the children, it’s natural to use play to deal with things which they can’t fully contemplate or communicate.”

Sister Therese is intensely protective of the children’s privacy, and she initially seems reticent about answering questions about the program. But as she talks of the children, the relationships they’ve built and the progress they’ve made, her warmth and passion for the kids becomes apparent. “A lot of the games we play aim to build trust among the children, and also between the children and the volunteers,” explains Therese. “The first step is to create a safe, supportive environment for them. If a child starts to trust a place, he starts to feel better about himself.” Some games tackle psychological issues but don’t specifically address the traumatic events themselves. “We asked them to draw pictures of their house and their family,” she says. “Some of them were able to do it, but others couldn’t; instead they drew pictures of planes, or corridors, or abstract shapes. Also, we used memory games- some had serious memory problems.” Eventually, after weeks of expressive activities and confidence building, they were able to directly address the traumatic incidents with the children.

We’re not professionals, you know,” said Sister Therese. “We researched the topic, and had help from Dr Mahmoud, but really, we were learning as we went along. But as you get to know the children, you soon start to locate their different needs and their strong and weak points.”

Dr Mahmoud, in his office in central Damascus, stressed the importance of the physical activities. “The activities and the outings were really important in rebuilding confidence and self-esteem in the children. Before, many were reluctant to leave their houses, but this kind of inactivity can be very negative; sitting at home, focusing on the horrors you have seen and the uncertain future. But these activities create a real sense of community among the kids, and give them something positive and constructive to focus on.”

He points out another crucial benefit of the program. “There’s a mixture of religions in the program. A lot of the children are Christian, since it’s a Roman Catholic centre, but the program is open to everyone, and there are also several Muslim children,” he says. “And the volunteers are also a mixture; there are Sunni, Shia, Christian and Druze.” When so many refugees come fleeing sectarian violence, the program has given the opportunity to rebuild trust between children of different denominations, and to help them overcome the fear of ‘The Other’.

And for Dr Mahmoud, a Muslim, there is one gesture of kindness that will always stay with him. “At first, some of the Christian kids had an intense fear and distrust of Muslims, because of the violence they had suffered from extremist groups,” he said. “But throughout the course of the program, we were able to breach these sensitive topics, and talk about different religions and denominations”. And eventually, when the end of Ramadan came, Dr Mahmoud received a poignant surprise. “They all came in with flowers and sweets, as Eid gifts for me and my family”.

“I think by the end of the program, we had built up a lot of trust within the group, and the improvements in the kids were really evident” reflects Dr Mahmoud. “Towards the end, we were taking them on day trips, doing activities in the countryside, which would have been impossible earlier on.” Sister Therese agrees, enthusing about the end-of-term party at the social centre where the program is based. “The kids all prepare something to share; they sing songs, or perform plays,” she says, smiling. “It’s wonderful to see the difference in the children at the end. They’re so much more confident and outgoing- and so different from the quiet and withdrawn kids we saw at the beginning”.

“Of course, the main aim of the program is to help the kids be more active and confident, and cope with their trauma” said Dr Mahmoud. “But in order to do this, you have to work with the family as well.” The children need to have support and understanding of their condition when once they go home, and once the program is over. “We work very closely with the families, and try and build awareness of the issues of PTSD, and what can be done about it. Their cooperation is vital, because they can monitor the children’s progress far more effectively than we can.”

Unfortunately, cooperating with the family is not always so straightforward. The desperate situation of one family that Fateh is working with highlights many of the potential complications. A group of seven siblings, ranging from a four month-old baby to a 14 year old, who came to Syria having lost both their parents. Fateh recounts their story. “It was the afternoon, and three of the children were playing outside. The other four were inside with their parents. A group of gunmen entered the house and told the parents they had 12 hours to change their religion. They then kidnapped the father, and when the mother resisted, they shot her dead. Four of the children were witness to the killing.” The children were taken to Syria by a relative, and they are now living in a one room apartment in Damascus, being looked after by their grandmother. Fateh is now meeting them regularly for therapy sessions, but this is made difficult since Fateh has little background information about the family. “If you want to know how a trauma has affected a family, it’s vital to know how the family functioned before the event; their personalities, how they related to each other” he says. “But in this case, they’ve lost both their parents, and are now being looked after by their grandmother, who has been an asylum seeker in Germany for the last 15 years.” There is also a language barrier; as part of Iraq’s Assyrian minority the children only speak basic Arabic, in a thick Iraqi accent.

“It’s clear that these kids are suffering. They seem unhappy; they don’t smile a lot, they don’t play together” explains Fateh. But despite this general state of unhappiness, they’re not showing any clear symptoms of PTSD. “I’m pretty sure that more symptoms will appear in the future, but sometimes these things can take months, even years to surface,” said Fateh. The children are currently seeking asylum in Germany, and Fateh believes the severity of their case gives them a good chance of acceptance. “There’s only so much I can do for them at the moment,” he says, “but if they go to Europe they’ll definitely have access to psychological support. I see my job as familiarizing them with this kind of therapy, so it’s not so alien when they eventually receive more extensive treatment.”

For all the progress made in his children’s play therapy program, Dr Mahmoud acknowledges that, with a capacity for just 15 children, it’s only a drop in the ocean. For this reason he’s passionate about building awareness and changing attitudes about mental health conditions and psychological therapy in the Middle East. “The idea of psychotherapy is still relatively unknown in this part of the world, and some people are still suspicious of it.” Yet this is a region which has had more than its fair share of trauma. “We worked a lot with Lebanese refugees fleeing the war in 2006,” he said. “And if there’s one small positive thing to come out of the violence in Lebanon and Iraq, it’s that slowly, attitudes towards mental health are changing, and the idea of psychological therapy is becoming more accepted.” But while attitudes may be changing, the Syrian bureaucracy and major aid agencies are taking a little longer to catch up.

Dr Mahmoud tells of another innovative project that has the potential to provide support on a far larger scale, using internet-based therapy. The Berlin Centre for Trauma therapy has recently launched an Arabic-language website, www.ilajnafsy.org, which adapts traditional behavioral therapy to be used over the internet. Currently in an experimental phase, it’s aimed at Arabic-speaking victims of war and violence that don’t have access to mental health professionals. Dr Mahmoud is one of a team of ten Arabic-speaking specialists, based in various European and Arab countries, which will provide email-based therapy. “There’s a form that anyone can fill in, where you describe your symptoms, your circumstances, and your history,” he says. “It’s analyzed, and they decide if you would benefit from the program. If you’re an appropriate candidate, you undergo a six-week course of internet therapy free of charge”.

For people such as Fateh, this work can sometimes appear an uphill struggle. “The problem,” said Fateh “is that for these people, the war isn’t over yet.” As refugees, their future is uncertain, and the threat of violence isn’t confined to the past. And even when the danger has passed, the experiences will be with them for a lifetime. But he remains optimistic. “You have to understand, the purpose of this therapy isn’t to help people ‘get over’ the traumatic events, or to bury the painful memories they have. It’s about stopping these experiences from dominating their lives, and helping them to be in control of these memories, instead of being controlled by them.”

Some names have been changed to protect the identities of those involved.