‘The apocalypse’: A qualitative pilot study of the psychological aftermath of the 2020 Beirut blast

Abstract

Background:

There has been very limited data describing the psychological aftermath of the Beirut blast.

Aims:

This qualitative pilot study aimed to explore the psychological and physical reactions to the trauma experienced by Beirut blast survivors, as well as their coping strategies.

Methods:

From November 2020 to February 2021, in-depth, semi-structured interviews were conducted with eight Lebanese citizens who were within a 4 km radius of the Beirut port at the time of the explosion. A thematic analysis was adopted.

Results:

Three themes were identified: (1) the blast; (2) life after the blast: extended trauma; (3) coping strategies. First, almost all participants vividly remembered the moment of the blast and referred to it as a turning point in their lives. They also remembered being on an emotional rollercoaster, feeling physically numb, worried about another explosion and finding God in the midst of tragedy. Second, all participants reported several negative experiences in their post-blast life, which may have enhanced/prolonged their trauma, including losses of different kinds (of a country, home, loved ones, hope, safety/security, culture and heritage), the cumulative impact of the blast, the impossibility to ever return to ‘normality’, persistent survival guilt and somatisation. Lastly, different coping strategies were adopted to deal with trauma, such as talking it out, establishing a consistent daily routine, helping the community, overworking and detachment.

Conclusions:

This study highlights the many layers of psychological suffering of Beirut blast survivors in the current context of collective distress dominating Lebanon.

Keywords

Lebanon Beirut blast trauma coping experiences

Introduction

One of the most powerful non-nuclear explosions in history took place on August 4, 2020 at 6:08 PM in Beirut, Lebanon (El Hajj, 2021; El Sayed, 2020). On that horrific day, two consecutive explosions, a smaller one that was followed seconds later by a much larger blast, shook the port of the Lebanese capital, resulting in over 200 deaths, 7,500 injured and an estimated 300,000 displaced people (Kerbage & Elbejjani, 2021; Ramzy & Peltier, 2020). The second explosion was so powerful that it generated seismic waves equivalent to a 3.3-magnitude earthquake and was felt in Cyprus, more than 100 miles away from Beirut (El Hajj, 2021; El Sayed, 2020; Ramzy & Peltier, 2020). In the moments before the second massive explosion, many Beirut residents heard, and in some cases, saw low-flying military aircraft, making them fear that it could be an attack from Israel (Flanagan & Jones, 2020; Meuse, 2020). The event was later linked to 2,750 t of ammonium nitrate that had been unsafely stored in the port, adjacent to residential areas, for the previous 6 years and with the full knowledge of several Lebanese government officials (El Hajj, 2021; Kerbage & Elbejjani, 2021). However, up to now, the direct cause of this incident remains under investigation, with theories ranging from a deliberate attack on the storage site to an accidental explosion resulting from the Lebanese government’s negligence (El Sayed, 2020; Ramzy & Peltier, 2020).

The Beirut port explosion has revived previous traumas experienced by generations of Lebanese citizens who suffered from a civil war (1975–1990), the 1982 Israeli invasion of Lebanon, the Israeli occupation of Southern Lebanon (1985–2000), a series of bombings and assassinations from 2005 and the 2006 July war (El Hajj, 2021; Kerbage & Elbejjani, 2021; Rayes, 2021). Arguably, the explosion could not have come at a worse time for the country. Indeed, the recent years have been particularly difficult for Lebanon, starting with a large humanitarian crisis brought on by the influx of over 1.5 million Syrian refugees, followed by mass anti-government demonstrations since October 2019, and a protracted economic crisis that saw the Lebanese pound lose over 80% of its value in under a year (Bizri et al., 2021; El Hajj, 2021; Rayes, 2021). Lebanon’s deterioration has been further aggravated by the COVID-19 outbreak, which reached its worse peak following the August 4 Beirut blast leading to the implementation of strict lockdown measures (El Hayek & Bizri, 2020; Fares et al., 2021).

The repetitive exposure to all of these highly distressing traumatic events and Lebanon’s ongoing multi-layered crisis have created a palpable sense of collective uncertainty, anger and anxiety in the country (Bosqui, 2020). However, in the face of collective trauma that has affected several generations of Lebanese over the past half-century, the construct of psychological resilience, or the ability to ‘bounce back’ after adversity, may inadvertently promote acceptance of the status quo rather than positive recovery (El Hayek & Bizri, 2020). This can lead to different trajectories of trauma progression following the Beirut blast, such as the development of chronic or delayed post-traumatic stress disorder (El Hayek & Bizri, 2020). So far, however, there has been very limited data describing the psychological aftermath of the Beirut blast, mainly coming from news articles and press releases. Hence, to fill this research gap, the aim of the present qualitative pilot study was to explore the psychological and physical reactions to the trauma experienced by Beirut blast survivors, as well as their coping strategies. Findings from this study can inform psychosocial interventions to facilitate recovery from post-traumatic symptoms among people affected by the Beirut blast.

Methods

Study design and participants

This exploratory qualitative study used Colaizzi’s phenomenological method, which focuses on the lived experiences and feelings of participants and finds shared patterns rather than individual characteristics in the study participants (Edward & Welch, 2011). Participants for this study had to be Lebanese adult citizens who were within a 4 km radius of the Beirut port at the time of the explosion. The exclusion criteria were being non-Lebanese and having a previous diagnosis of any severe psychopathologies (psychosis, personality disorders, etc.).

Purposive sampling was employed to recruit study participants because it allows careful selection of cases which are information-rich (Palinkas et al., 2015). Overall, 11 potential participants were invited to take part in this study, but 3 of them declined, leaving 8 meeting the eligibility criteria in the study sample. The study was reviewed and approved by a local research ethics committee.

Data collection

In-depth, semi-structured, one-on-one interviews were chosen as the data collection tool, since they are particularly useful for investigating complex behaviours and emotions and for collecting information on a diverse range of experiences (Longhurst, 2009). Due to the continuing COVID-19 restrictions, the interviews were conducted via Zoom from November 2020 to February 2021. All interviews were performed in Lebanese Arabic, and were recorded, anonymised, transcribed verbatim and then translated into English. The interviews ranged in duration from 20 to 74 minutes, with a mean duration of 45 minutes. All interview recordings and transcripts have been stored on a secure, password-protected and encrypted server.

Prior to conduct of the interviews, an informed consent was obtained from each respondent. A detailed explanation of the study purpose was also provided to the participants. During the interviews, participants were given ample opportunity to ask questions, were reminded that the study was completely voluntary and that they could withdraw at any stage without prejudice. The interview structure was largely flexible. However, a topic guide of seven open-ended questions with probes was used during the interviews to investigate the impact of the August 4 Beirut blast on the participants’ lives. The topic guide included the following questions: (1) Can you tell me about your experience of the blast? (2) What has changed in your life after the blast? (3) Can you describe a recent episode where you had an unpleasant memory of the blast? (4) What happens when you are reminded of the blast? (5) What coping strategies do you use to deal with your trauma? (6) Are there things you do not do anymore? (7) How has your way of thinking or mind pattern changed when compared with before the blast?

Data analysis

Thematic analysis was adopted based on Colaizzi’s seven-step phenomenological method (Edward & Welch, 2011). In brief, after reviewing the interview texts several times, significant statements were extracted and meanings were formulated from the significant statements. These formulated meanings were then organised into themes and subthemes (Edward & Welch, 2011).

After producing the final themes and subthemes, all interview transcripts were reviewed again to make sure that the final results reflected the overall feel of the original data. Participants were de-identified throughout the analysis, and codes were used (the first interviewee was P1 for Participant 1).

Results

Characteristics of the study participants, who were between the ages of 24 and 40 with a mean age of 27, are presented in Table 1. All the participants, three of whom were men and five were women, were employed full-time at the time of the Beirut blast, and they all had completed university education. P6 was married with children, while the rest of the participants were unmarried without children. All, but one participant (P4), were severely injured following the Beirut blast, with four participants (P1, P5, P6 and P8) needing more than 40 stitches. Three participants emigrated from Lebanon after the blast, and the rest had been planning or thinking of leaving the country. Three overarching themes summarising the survivors’ reflections of the Beirut blast and its psychological aftermath were identified: (I) the blast; (II) life after the blast: extended trauma; (III) coping strategies. Exemplar quotes for each theme are displayed in Tables 2 to 4.

Table 1.

Participant characteristics.

ID	Gender	Age	Residence status	Injury sites	Location at the time of the blast
1	Male	28	Still in Lebanon	Head, fingers, hands, knees, nose, lips and lower eyelid	Home
2	Female	24	Still in Lebanon	Legs and shoulders	Office
3	Male	25	Still in Lebanon	Elbows and hands	Office
4	Female	24	Left Lebanon after the blast	No physical injuries	Office
5	Male	26	Still in Lebanon	Upper eyelid, elbows and head	Office
6	Female	40	Still in Lebanon	Back, head and legs	Office
7	Female	25	Left Lebanon after the blast	Feet, buttock and back	Restaurant
8	Female	24	Left Lebanon after the blast	Head, hands, shoulders, legs and back	Restaurant

Table 2.

Theme I – The blast.

Subthemes	Quotes
(1) A turning point	‘The explosion was a big turning point in my life. For me, there is life before August 4 and life after August 4. There is no going back to life before August 4’. (P1) ‘I do refer to my life now as “pre-explosion” and “post-explosion”, which is bad, but the explosion was a resetting point in my life, and there is the “me before” and the “me after”, and nothing could ever be the same again’. (P8)
(2) Emotional rollercoaster	‘I saw so many horrifying scenes. . .so horrifying to the point where you don’t feel frustration or sadness anymore but so much anger and at the same time utter disgust from the political system in Lebanon’. (P3) ‘It was an apocalypse. I saw dead bodies everywhere, people severely injured, people running, people crying. And a lot of these people were people that I knew. I also saw destroyed houses, and shocked people in these houses. I tried as much as I can not to look at the ground because I didn’t want to see dead people that I knew. It was survival mode for me. But I felt hopeless. It was the epitome of hopelessness. We were just all hopeless’. (P7) ‘Despite all the chaos, what was unforgettable is the silence. After we left the building, you see the people in complete shock. We didn’t hear loud screams or anything like that. But it was dominating silence; everyone was in shock and just didn’t understand what was going on’. (P5) ‘After the big blast, I found myself lying on the floor, and I remember that it was all very foggy. It was like a movie scene. I felt like it wasn’t me living in that moment. It was like an out-of-body experience, and I’m living this experience as if I’m watching a movie’. (P8) ‘There was this third person experience or out-of-body experience that was dominating. I just felt like I was outside of my physical body, and I was looking at myself and at others’. (P5)
(3) The body is numb	‘I was very injured after the blast. I was bleeding a lot from my left shoulder, my hands, my legs, my back, my head and I was losing so much hair at the time. But I wasn’t feeling any pain. At the hospital, the doctors just stitched me up without giving me any anesthesia, because all the hospitals in Beirut and its surroundings were just completely overcrowded. And still, even while getting stitched up without anesthesia, I did not feel anything. There was no pain. My body was completely numb’. (P8) ‘I wasn’t feeling any pain, although my back was heavily bleeding at the time. All I could think about was my daughter and how she’s too young to lose her mommy’. (P6) ‘I opened my eyes while I was crawling beneath the desk. I wasn’t able to see from my left eye. I thought to myself that I lost my eye, but that I’m still alive. My eye was bleeding but I wasn’t feeling pain at all at that time’. (P5)
(4) Another bomb	‘After the second blast, my priority in my head was that we should go down to the underground parking, because maybe a third blast was going to happen’. (P2) ‘I knew that I was going to die, because at that time, it didn’t make sense not to die. I thought at that time that it was Israel that was bombing us, and that they were going to probably bomb and kill everyone’. (P7) ‘After the big blast, I remember that the first thing I did was scream to everyone: “Get down! Get down!”, because I thought that this was Israel that was bombing us, and it was specifically targeting this area’. (P5)
(5) God in the midst of tragedy	‘I felt that God was there during the explosion. He wasn’t there to save me from the explosion, but he was there to reassure me that whether I survive the blast or I die, I will be safe, not physically, but spiritually. And that was something that I had never experienced before’. (P1) ‘When the explosion was happening, I was praying so much, and I had this personal and interior confidence that I will stay alive, even though we were literally in the middle of an apocalypse’. (P3) ‘I am Christian, but I don’t really practice. But for more than a month after the explosion, I wouldn’t leave my rosary necklace and I would have it with me at all times. I really feel that my family, friends and I all had a near-death experience, and it’s a miracle that we survived. I felt like God was there’ (P8)
(6) Reliving the blast	‘I just have all of these repetitive, never-ending thoughts about the blast. I just live in constant worry of another blast and my mind is never at ease. After I go to bed, I spend so much time running different scenarios in my head about what would happen to me if another explosion would happen now’. (P1) ‘Every night, before I sleep, I replay the scene of the blast. It’s like my brain entered a loop, and keep replaying the same memories of the blast. At first, I used to think that it’s normal, but now 4 or 5 months after the blast, it’s not normal anymore’. (P2) ‘Even though I did trauma therapy after the blast which allowed me somehow to heal, I still have constant nightmares about the blast. I also always think about the worse things. For example, when I’m driving a car, I think to myself that it’s so easy to get hit by another car and die. Three months after the blast, I was once in a metro station, and I imagined the metro crashing and me dying’. (P7) ‘Every time I close my eyes and try to fall asleep, I would see the abat-jour of the window falling on me again’. (P8)

Table 3.

Theme II – Life after the blast: Extended trauma.

Subthemes	Quotes
(1) Losses	‘For me, Lebanon, as we know now, is over. “Over” is a big word, but this is the truth. The blast ended the Lebanon that we knew and that we loved’. (P1) ‘After the blast, there was no home to go back to, because my childhood house was completely destroyed’. (P8) ‘I don’t want myself, or my children, or my parents to live here because I lost hope in change. I can never trust again in a government that turned a paradise on earth into a living hell’. (P2) ‘Before the blast, I had hopes for Lebanon. And now, I truly don’t, which makes me so angry and sad because of the huge potential of Lebanon. But for my own sake and sanity, I need to give up on this idea of Lebanon becoming a better country for all the Lebanese people to go back to’. (P8) ‘We lost so many amazing people. . .the crème de la crème of this country. They died in a split of a second. And there was nothing we could do to rescue them’. (P3) ‘We lost so many great people. . .the future of this country. And now I am just constantly worried about my family. I would just die if something happens to them. I wouldn’t even bear the thought of it’. (P1) ‘You see all the memories that you had in the streets of Beirut, in the pubs, nightclubs, restaurants of Beirut all being taken away by this blast. All the traditional Lebanese houses that we love so much, our heritage, all destroyed. There’s nothing left now there. It’s a real shame’. (P5) ‘Unfortunately, Beirut lost its spirit, its vibe. This is something that makes me really sad. It’s a part of me, part of my memories, part of my life. I wanted to share it later on with my children. Now, I can’t anymore’. (P5)
(2) Cumulative and intergenerational trauma	‘Everyone in my family is already so traumatised because of the repetitive explosions, assassinations, the occupation and the wars that we’ve been through in this country. Trauma after trauma after trauma. Everything gets destroyed over and over again and we have to build everything each time. We can’t take it anymore’. (P1) ‘The cumulative impact of the blast, the deep political and economic crises, the COVID-19 pandemic and the strict lockdown measures make it impossible to go back to a normal life to try to forget what happened to you. You’re just stuck in your misery and your trauma’. (P2) ‘Some days, I wake up very tired. But I feel that it’s not just because of the explosion but also because of the daily stress of every single Lebanese nowadays. We are facing very huge challenges, and so many sources of stress. When I am alone, with all of my sources of stress, I get consumed by my ideas’. (P3) ‘One of my grandparents is an Armenian genocide survivor whose whole family got killed by the Ottomans, and another grandparent almost died in the Lebanese Civil War. So, you inherit this huge trauma, and the anxiety in everything. And the blast just reminded me of my inherited trauma, and it made me realise that I cannot return to Lebanon, and I cannot pass down the trauma and the anxiety, that myself, my parents and my grandparents have lived, to my children’. (P7) ‘After the blast and the economic crisis, I felt as if I am a 50-year-old woman living in the body of a 25-year-old. Instead of worrying about going to parties, I am worrying about the daily exchange rate from USD to Lebanese pound or about road closures or about my future in a dead-end country or whether I will die tomorrow or not’. (P7)
(3) Impact on daily life	‘I used to love sitting on my balcony. Now, I can never do that again. I’m just too scared to even be close to any balcony now. There were also a lot of places that I used to love to work in, but they all have glass windows, so I stopped working in all of these places because of the glass windows’. (P1) ‘I have anxiety attacks all the time, especially when I know that I am somewhere all alone. I’m especially afraid to be alone in the office. I always try to invent any excuse to work from home. I think this is also related to the fact that two employees in the office that I work in fell into a 1-month coma because of the blast, and they’re still doing pretty bad. So, I’m always anxious of losing people that I love. I’m also in a constant state of fear. If I hear thunder, I get scared’. (P2) ‘I am just much more alert now, and I always expect the worse now in every situation. For example, hearing the low-flying Israeli jets that constantly fly over Lebanon makes me very alert. It didn’t have that impact on me before the blast’. (P4) ‘Before the explosion, I used to feel fearless, but now after the explosion, I have so much fear in me. I have become more careful in everything’. (P3)
(4) Survivor guilt	‘So many people died, but I didn’t. So, I always tell myself that I don’t have the right to nag or to complain about anything. People have lost their lives. People lost parents and children, and entire families were killed. I have no right to complain about my physical injuries or about my trauma’. (P2) ‘Everyone’s life is equally important and sacred. Why did I live? Why me and not others? A girl who was literally sitting in the table facing our table died. It doesn’t make sense that I survived this blast with only minor injuries’. (P7)
(5) Somatisation	‘On the days where my anxiety is really bad, I can’t eat. My appetite is completely gone, and I have severe stomachaches. I also feel like my chest is congested and my throat feels tight’. (P2) ‘I have so much acne on my face. I didn’t have acne before the explosion. I know that it’s due to stress. The blast is a major cause of my daily stress. . .of my stress in general’. (P3) ‘After the blast, I also got my head scanned, because I was just having very strong headaches all the time. I still have them up to now. I also had tinnitus that lasted for quite a while after the blast. But the doctor told me that everything was normal. But the buzzing in my ears would not go away’. (P6)

Table 4.

Theme III – Coping strategies.

Subthemes	Quotes
(1) Forgetting and detachment	‘I don’t remember most of the blast. The whole blast was just a blackout for me’. (P6) ‘I’m doing everything that I can to forget about the blast. I always delete every video of the blast that people send me. Honestly, up to now, I still don’t have the guts to even watch videos of the blast. I am also trying something called thought suppression, which is a psychological behaviour in which people protect themselves by blocking the recall of anxiety-arousing memories. I’m really trying to make that work, because I just want to forget about this phase of my life. I just want to have a complete blackout of the blast’. (P1) ‘I decided to detach myself from the entire situation in Lebanon. So, I will build my own future and my own life with a complete detachment from the situation in the country. That detachment has brought me so much comfort’. (P5) ‘I have to admit that I have distanced myself from the people who I saw the day the blast happened. I know that this is not healthy, but I feel like I associate them too much with what happened that day. And in order to forget, I have to stay away from them’. (P8)
(2) Overworking	‘I’m trying to work as much as I can to run away from my thoughts. I also usually sleep just 2 hours every night. I prefer to just keep working instead of going to bed where I think constantly about the blast’. (P1) ‘I was using work to cope with my physiological pain. I used to work as much as I can to deal with the trauma and to get over the blast’. (P6)
(3) A second chance at life	‘I put things in perspective much more than I used to do before the blast. I was given a second chance at life, and the blast made me see how precious life is’. (P2) ‘I was talking with my psychiatrist about the blast, and he told me something very important. He told me that: “Your role in this life has not ended yet for you to reach the other life. You still have something to offer in this life.” It’s a very harsh thing to say, especially since very young children died in this blast, but this sentence gave me a lot of strength and reminded me that I still have something to fulfil in this life before I die’. (P7) ‘Right now, I put things in perspective much more than I used to do before the blast. We are all going to die one day. Death is part of life. We just have to see the positive things in life and focus on them. It’s a question of perception’. (P5) ‘I say to myself that I was lucky that I came out alive from the blast. So maybe my mission in life is not over yet’. (P1) ‘I was very lucky to survive this tragic event. So, I should not stop my life’. (P6)
(4) Talking it out	‘I feel like when I talk about the blast, I don’t let it have control over me and I also heal from it at the same time. So, I like to talk about the explosion, and I encourage people to talk about it, because I feel that this will allow more healing’. (P7) ‘After the blast, I really needed to talk about it, and I used to talk about it all the time. For a month after the blast, I couldn’t talk about anything else. I talked because I needed to understand what actually happened with me. I needed to talk it out, and that really helped me in my recovery process’. (P5)
(5) Establishing a consistent daily routine	‘A couple of days after the blast, I said to myself that I will not let this tragedy control my life. So, I made a conscious effort to stick to my daily routine’. (P4) ‘It’s what helped me recover: to work, to exercise, to see my friends and to try to live as much as possible a normal life’. (P2)
(6) Helping the community	‘After the blast, I volunteered to clean and fix damaged houses of Beirut. So, that kept me really busy, and it was very therapeutic’. (P4) ‘Two days after the blast, I started helping needed families. And that was very helpful for me. Although I was really injured and tired, I helped the families by cleaning and fixing as much as I can their houses. I also distributed meals and water to the volunteers who were reconstructing damaged houses. That was my capacity to help, but it was very therapeutic for me’. (P5)

Theme I: The blast (Table 2)

All participants, with the exception of P6, vividly remembered the moment of the blast and referred to it as a turning point in their lives. They also remembered being on an emotional rollercoaster at the time of the blast, and feeling scared, sad, frustrated, angry and disgusted with the Lebanese political class, hopeless, shocked, confused, guilty, anxious and grateful. In addition, two participants (P5 and P8) reported having an out-of-body experience, in which they felt that their consciousness was separate from their body and it was as if they were outside themselves. Participants also commonly reported not feeling any physical pain or being physically numb, despite having sustained serious physical injuries. Following the second massive explosion, half of the participants remembered feeling worried that a third explosion might occur, as they thought at the time that the two consecutive explosions were due to bombardment by Israel. Moreover, half of the participants reported feeling God’s presence in the midst of tragedy, and attributed their survival to God or the Universe.

In the weeks and months following the Beirut explosion, participants often experienced, or still experienced, very distressing nightmares and flashbacks. According to the participants, the flashbacks could be triggered by thunderstorms, the sound of low-flying planes, by being alone in a quiet place (i.e. during night-time) or by seeing footage of the blast on social media or on television.

Theme II: Life after the blast: Extended trauma (Table 3)

Throughout all interviews, participants reported several negative experiences in their post-blast life, which may have enhanced/prolonged their trauma and hindered their psychological recovery. Following the Beirut blast, all participants were grappling with losses of different kinds, namely the loss of a country/homeland, of a home, of hope/faith, of loved ones, of safety/security and of culture and heritage. Moreover, all participants referred to the cumulative impact of the Beirut blast, as Lebanese communities were already overburdened with spiralling economic and political crises in addition to the COVID-19 pandemic. According to the participants, this blast exacerbated the collective suffering of the Lebanese people and added new wounds to the old psychological scars left by the continuous conflict that Lebanon has been under for more than four decades.

Participants also mentioned the impact of the Beirut blast on their daily life, and reported being much more fearful and alert as a result of the blast. They thought that it was impossible to ever return to ‘normality’ and to the routine activities of daily life, as activities like sitting on a balcony, being in the office alone or driving can be very distressing for some participants. Additionally, half of the participants expressed persistent survivor guilt, as they viewed their survival of the Beirut blast as ‘unfair’ because others had died. There was also salient evidence of somatisation (i.e. nausea, severe stomachaches, chest congestion, acne, headaches, tachycardia, tinnitus, dyspnoea and fatigue) identified in most participants.

Theme III: Coping strategies (Table 4)

Different coping strategies and defence mechanisms were adopted by the participants to deal with the trauma of the Beirut blast. Some of these strategies were however rather unhealthy. For instance, forgetting and detachment were commonly used among the participants to cope with their trauma. In P6, this forgetting was unconscious, as it was caused by a brain injury as a result of the blast that led to temporary memory loss and a ‘blackout’ of most of what had happened that day. By contrast, P1 described his conscious attempts to forget about the Beirut blast, through thought suppression. Detachment was also mentioned by most participants, and it was either an emotional detachment from the situation in Lebanon or a physical detachment through the immigration to another country within the 3 months following the blast. Overworking was another unhealthy coping strategy reported by two participants (P1 and P6).

Healthy coping mechanisms or strategies included ‘putting things into perspective’ and feeling ‘very lucky’ to be ‘given a second chance at life’. Processing the trauma, by talking about what happened with friends and family, was also considered helpful by several participants. Likewise, establishing a consistent daily routine and helping the community, by clearing debris, covering broken windows and doors and offering water and food to those affected by the Beirut blast, were described as ‘therapeutic’ coping strategies.

Discussion

The present study offers insight into the many layers of the psychological suffering of Beirut blast survivors and how they cope while living in a social context of collective trauma. Capturing the psychological aftermath of a nuclear-like explosion is very difficult, particularly in a complex setting like Lebanon, which has a populace that has faced and is still facing numerous traumatic events. However, and perhaps unsurprisingly, the findings of this study are in line with other studies investigating the traumatic experiences of survivors of mass trauma events including the atomic bombings of Hiroshima and Nagasaki occurring on August 6 and August 9, 1945, respectively (Ohta et al., 2000; Sawada et al., 2004), the September 11, 2001 (9/11) terrorist attacks (North et al., 2015) and the Norway terror attacks of July 22, 2011 (Aakvaag et al., 2014; Bugge et al., 2019; Jensen et al., 2015; Thoresen et al., 2012).

Similarly to the current study, the survivors of these aforementioned attacks all had vivid and long-lasting memories of the attack they have lived through and of the immediate disaster timeframe, with their rumination on their personal experience being a reflection of the severity of the horror and terror they experienced during the attacks (Bugge et al., 2019; North et al., 2015; Sawada et al., 2004). They also reported a significant impact of these attacks on life afterwards, with a wide array of psychological concerns such as survivor guilt, difficulty of daily life, worries about the future, altered perceptions of safety and chronic stress (Aakvaag et al., 2014; Bugge et al., 2019; North et al., 2015; Ohta et al., 2000; Sawada et al., 2004; Thoresen et al., 2012). Likewise, news articles published after the August 4 Beirut port explosion reported findings consistent with the current study, in which interviewed survivors of the Beirut blast described an impossibility to ever return to ‘normality’, a constant fear of losing loved ones, and a heightened sense of alertness, with thunderstorms and the sound of the Israeli warplanes that regularly violate and fly low through Lebanon’s airspace being particularly alarming (Associated Press, 2021).

In this study, somatisation (i.e. nausea, severe stomachaches, chest congestion, acne, headaches, tachycardia, tinnitus, dyspnoea and fatigue) has been found to be a prominent part of the reaction to the Beirut blast trauma. This finding is not surprising, given that in the Lebanese culture, expressing post-traumatic stress symptoms through somatic complaints is considered socially acceptable, since it is uncommon to express psychological distress for fear of stigmatisation (Farhood et al., 2014). Somatisation has also been frequently reported in survivors of the 9/11 attacks (Alper et al., 2020), of the Hiroshima and Nagasaki bombings (Yamada & Izumi, 2002) and of the 2011 Norway attacks (Stensland et al., 2020). The presence of somatic symptoms is particularly concerning, as it might hinder recovery from post-traumatic stress, since it can (a) lead to excessive functional impairment, (b) function as a potent reminder of persistent threat, (c) reflect more extensive underlying neurobiological adaptive or maladaptive responses to trauma exposure or (d) impact access to or efficiency of early interventions (Stensland et al., 2020).

Given the painful history of Lebanon, the Lebanese people live in constant anticipation of violence and war (Moghnieh, 2015). This was reflected in the present study, as half of the participants were worried that a third explosion might occur following the second massive Beirut port explosion. In addition, all study participants reported that the Beirut blast had a cumulative impact, exacerbating the collective suffering of the Lebanese people. Collective trauma can shape a society’s identity. According to König and Reimann (2018), there are three interconnected ‘collective identity markers’, which are all highly present in the Lebanese society and which were somewhat reflected in the present study. These are: (1) collective narratives of loss and despair, of victimhood and of guilt and shame; (2) collective emotions dominated by mistrust, insecurity, exaggerated fear and anger; (3) collective mental models or belief systems that are characterised by rigid thinking, scapegoating and prejudices. Hence, in this context of collective trauma, it is important that mental health professionals in Lebanon go beyond the individualistic clinical models used to currently treat mental disorders, and integrate community interventions that can target social distress and that can acknowledge the structural drivers of the collective suffering of the Lebanese people (Bosqui, 2020; Kerbage & Elbejjani, 2021).

With collective trauma comes collective action. In the present study, the participants reported using different coping strategies, and this ability to flexibly use many coping strategies has been argued to be helpful in adjusting to trauma (Bonanno & Diminich, 2013). Among the mentioned coping strategies was offering help to others affected by the Beirut blast. Engaging in collective actions has always been common in Lebanon, and can be seen as an example of the Lebanese resilience. In the aftermath of the Beirut port explosions, community-oriented behaviours have been widely observed, with hundreds of volunteers from all over the country doing the Lebanese government’s work by rebuilding Beirut and providing help to affected people (Bosqui, 2020). In addition, the collective processing of events, through the sharing of stories, perspectives and thoughts, has also been intensely observed in the days, weeks and months following the explosion (Bosqui, 2020). This collective trauma processing was also highlighted in the present study, as several participants reported that it was helpful to talk about what happened with friends and family. These collective coping strategies of helping others and of sharing one’s experience with others are consistent with a recent qualitative study from Gaza Strip, in which collective action was found to create community solidarity, to facilitate Palestinian coping with stress and traumatic experiences and to provide protection against fear and helplessness (Afana et al., 2020).

Avoidance coping, through distraction by overworking or through active efforts to avoid unwanted emotions, thoughts and memories in the aftermath of the Beirut blast, has been commonly described in the present study. The choice of coping strategies is thought to be influenced by the degree of perceived control, and a situation viewed as outside of one’s control is more likely to induce avoidance coping strategies (Jensen et al., 2015). Since the Beirut blast was a situation in which the victims had little control, the use of avoidance coping strategies is expected. However, this finding is worrying, since avoidance coping has been linked to more severe post-traumatic stress symptoms and slower recovery patterns (Steil & Ehlers, 2000).

Although this study is one of the very first studies focussing on the traumatic experiences of Beirut blast survivors and their coping mechanisms, several limitations should be acknowledged including the use of a small and purposive sample which limits the transferability of the results, as well as social desirability and recall biases. We tried to reduce social desirability bias by asking neutral questions. Recall bias on the other hand was mitigated by completing the in-depth interviews within 6 months of the Beirut blast. It is nevertheless important to have more solid, longitudinal research data in large populations in order to better understand the course, prognosis and severity of post-traumatic stress disorder in the Lebanese population.

In conclusion, this qualitative explorative study highlights the broad spectrum of post-traumatic behaviours and symptoms experienced by survivors of the 2020 Beirut blast. In the current context of collective loss and distress dominating Lebanon, both person-focussed and community-focussed multicomponent psychosocial interventions are needed to heal individual and collective trauma layers. In addition, by strengthening adaptive responses that are already present in the Lebanese people, positive psychosocial outcomes may be fostered. Findings from this qualitative pilot study also underscore the urgent need for further large-scale studies in the greater population of Lebanon.

Footnotes

Acknowledgements

A big thanks goes to the individuals who participated in this study for their cooperation.

Conflict of interest

MEH is a Partner 4 Health employee.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study was reviewed by a local research ethics committee, and informed consent was obtained from all participants.

ORCID iD

Magalie El Hajj

References

Aakvaag

H. F.

Thoresen

Wentzel-Larsen

Røysamb

Dyb

(2014). Shame and guilt in the aftermath of terror: The Utøya Island study. Journal of Traumatic Stress, 27(5), 618–621.

Afana

A. J.

Tremblay

Ghannam

Ronsbo

Veronese

(2020). Coping with trauma and adversity among Palestinians in the Gaza Strip: A qualitative, culture-informed analysis. Journal of Health Psychology, 25(12), 2031–2048.

Alper

H. E.

Gargano

L. M.

Cone

J. E.

Brackbill

R. M.

(2020). Injury severity and psychological distress sustained in the aftermath of the attacks of 11 September 2001 predict somatic symptoms in World Trade Center Health Registry enrollees sixteen years later. International Journal of Environmental Research and Public Health, 17(12), 4232.

Associated Press. (2021). Beirut explosion survivors endure psychological scars. Retrieved July 24, 2021, from https://www.pbs.org/newshour/world/beirut-explosion-survivors-endure-psychological-scars.

Bizri

El Hayek

Beaini

Kobeissy

Talih

(2021). National trauma and substance use disorders: A slippery slope in Lebanon. Substance Abuse, 42(3), 264–265.

Bonanno

G. A.

Diminich

E. D.

(2013). Annual research review: Positive adjustment to adversity – Trajectories of minimal-impact resilience and emergent resilience. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 54(4), 378–401.

Bosqui

(2020). The need to shift to a contextualized and collective mental health paradigm: Learning from crisis-hit Lebanon. Global Mental Health, 7, e26.

Bugge

Jensen

T. K.

Nilsen

L. G.

Ekeberg

Ø.

Dyb

Diseth

T. H.

(2019). Psychosocial care for hospitalized young survivors after the terror attack on Utøya Island: A qualitative study of the survivors’ experiences. Injury, 50(1), 197–204.

Edward

K. L.

Welch

(2011). The extension of Colaizzi’s method of phenomenological enquiry. Contemporary Nurse, 39(2), 163–171.

10.

El Hajj

. (2021). Writing (from) the rubble: Reflections on the August 4, 2020 explosion in Beirut, Lebanon. Life Writing, 18(1), 7–23.

11.

El Hayek

Bizri

. (2020). Beirut blast and mental health in Lebanon: Finding ways out. Asian Journal of Psychiatry, 54, 102458.

12.

El Sayed

M. J.

(2020). Beirut ammonium nitrate explosion: A man-made disaster in times of the COVID-19 pandemic. Disaster Medicine and Public Health Preparedness. Advance online publication. https://doi.org/10.1017/dmp.2020.451

13.

Fares

M. Y.

Musharrafieh

Bizri

A. R.

(2021). The impact of the Beirut blast on the COVID-19 situation in Lebanon. Zeitschrift fur Gesundheitswissenschaften. Advance online publication. https://doi.org/10.1007/s10389-021-01562-6

14.

Farhood

L. F.

Richa

Massalkhi

(2014). Group mental health interventions in civilian populations in war-conflict areas: A Lebanese pilot study. Journal of Transcultural Nursing, 25(2), 176–182.

15.

Flanagan

Jones

A.M.

(2020). ‘A humanitarian catastrophe’: Eyewitness accounts from Beirut. CTV News. Retrieved July 24, 2021, from https://www.ctvnews.ca/world/a-humanitarian-catastrophe-eyewitness-accounts-from-beirut-1.5050894

16.

Jensen

T. K.

Thoresen

Dyb

(2015). Coping responses in the midst of terror: The July 22 terror attack at Utøya Island in Norway. Scandinavian Journal of Psychology, 56(1), 45–52.

17.

Kerbage

Elbejjani

(2021). Mental health in the aftermath of the Beirut blast: Community healing and the quest for justice. Psychiatric Services, 72(2), 234–235.

18.

König

Reimann

(2018). Closing a gap in conflict transformation: Understanding collective and transgenerational trauma. Retrieved July 24, 2021, from https://www.ximpulse.ch/wp-content/uploads/1806CollectiveTrauma.pdf.

19.

Longhurst

(2009). Interviews: In-depth, semi-structured. In Kitchin

Thrift

(Eds.), International encyclopedia of human geography (pp. 580–584). Elsevier.

20.

Meuse

A.T.

(2020). Planes heard, seen in skies of Beirut before blast. Asia Times. Retrieved July 24, 2021, from https://asiatimes.com/2020/08/planes-heard-seen-in-skies-of-beirut-before-blast/.

21.

Moghnieh

(2015). Humanitarian therapeutics of war and the politics of trauma and violence in Lebanon. Civil Society Knowledge Centre. Lebanon Support. Retrieved July 24, 2021, from https://civilsociety-centre.org/paper/humanitarian-therapeutics-war-and-politics-trauma-and-violence-lebanon.

22.

North

C. S.

Barney

C. J.

Pollio

D. E.

(2015). A focus group study of the impact of trauma exposure in the 9/11 terrorist attacks. Social Psychiatry and Psychiatric Epidemiology, 50(4), 569–578.

23.

Ohta

Mine

Wakasugi

Yoshimine

Himuro

Yoneda

Yamaguchi

Mikita

Morikawa

(2000). Psychological effect of the Nagasaki atomic bombing on survivors after half a century. Psychiatry and Clinical Neurosciences, 54(1), 97–103.

24.

Palinkas

L. A.

Horwitz

S. M.

Green

C. A.

Wisdom

J. P.

Duan

Hoagwood

(2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health, 42(5), 533–544.

25.

Ramzy

Peltier

(2020). What we know and don’t know about the Beirut explosions. The New York Times. Retrieved July 24, 2021, from https://www.nytimes.com/2020/08/05/world/middleeast/beirut-explosion-what-happened.html. [accessed 24 July 2021].

26.

Rayes

(2021). The Beirut explosion’s impact on mental health. The Tahrir Institute for Middle East Policy. Retrieved July 24, 2021, from https://timep.org/commentary/analysis/the-beirut-explosions-impact-on-mental-health/.

27.

Sawada

Chaitin

Bar-On

(2004). Surviving Hiroshima and Nagasaki–experiences and psychosocial meanings. Psychiatry, 67(1), 43–62.

28.

Steil

Ehlers

(2000). Dysfunctional meaning of posttraumatic intrusions in chronic PTSD. Behaviour Research and Therapy, 38(6), 537–558.

29.

Stensland

S. Ø.

Thoresen

Jensen

Wentzel-Larsen

Dyb

(2020). Early pain and other somatic symptoms predict posttraumatic stress reactions in survivors of terrorist attacks: The longitudinal Utøya cohort study. Journal of Traumatic Stress, 33(6), 1060–1070.

30.

Thoresen

Aakvaag

H. F.

Wentzel-Larsen

Dyb

Hjemdal

O. K.

(2012). The day Norway cried: Proximity and distress in Norwegian citizens following the 22nd July 2011 terrorist attacks in Oslo and on Utøya Island. European Journal of Psychotraumatology, 3, 19709.

31.

Yamada

Izumi

(2002). Psychiatric sequelae in atomic bomb survivors in Hiroshima and Nagasaki two decades after the explosions. Social Psychiatry and Psychiatric Epidemiology, 37(9), 409–415.