Mental Health Services for Syrian Refugees in Lebanon: Perceptions and Experiences of Professionals and Refugees

Overview of Mental Health Services for Syrian Refugees in Lebanon

As in the wider health care system in Lebanon, mental health services are divided between a poorly resourced public sector and a highly expensive private sector (Kerbage, 2017). Mental health and psychosocial support services (MHPSS) for Syrian refugees are mostly provided by local and international NGOs to supplement the existing services. These NGOs work in close coordination with the Lebanese Ministry of Public Health (MOPH) and primary health care centers. Accordingly, the MOPH recently developed a MHPSS task force co-chaired by the World Health Organization (WHO) and the United Nations Children’s Fund, which aims to implement evidence-based mental health interventions and to coordinate the work of all MHPSS humanitarian actors involved in responding to the Syrian crisis (Karam et al., 2016).

The MHPSS framework for Syrian refugees in Lebanon is based on the Inter-Agency Standing Committee (IASC, 2007) guidelines on MHPSS in emergency settings, which recommend organizing the mental health response according to a pyramid of interventions. This pyramid constitutes a layered system of complementary support starting with basic services and security at the community level (Level 1), followed by strengthening family and community support (Level 2), individual psychosocial support (Level 3), and specialized clinical services (Level 4). Within this framework, the term “psychosocial” was coined to describe general support of well-being as well as non-specialized interventions for people with mental conditions (IASC, 2007). Hence, the guidelines stress meeting needs at a community level before proceeding to a specialized level (IASC, 2007; Van Ommeren et al., 2005). Humanitarian organizations rely on the IASC pyramid based on an international consensus on the efficiency of this framework for mental health services in crisis settings (Silove, 2011; Van Ommeren et al., 2005). Figure 1 shows the distribution of MHPSS activities in Lebanon by level of the IASC Pyramid of Services according to a service mapping published by the MOPH (Kheir et al., 2015).

OPEN IN VIEWER

Figure 1.

Distribution of MHPSS activities by level of the IASC Pyramid of Services in 2013 and 2014, according to a service mapping by the MOPH.

In this study, we explored the perceptions and experiences of policymakers, practitioners, and Syrians involved in mental health services at the individual focused levels of the IASC pyramid, including Level 3 (non-specialized psychosocial support provided by social workers) and Level 4 (specialized services provided by psychotherapists and psychiatrists). We chose individual focused levels to study the therapeutic relationship in a clinical setting and understand the mental health problems of Syrians deemed severe enough to warrant individual rather than community-based intervention. We inquired about the Syrians’ perceived sources of distress and support, as well as explanations of and attitudes toward their mental health problems. In light of the resource-based model framework, we examined how adaptive processes are impeded, leading to distress warranting mental health services. We simultaneously explored the experiences of professionals, at both the service provision (social workers, psychotherapists, psychiatrists) and the intervention design and implementation levels (policymakers and program coordinators), to have a comprehensive understanding of Syrians’ mental health problems.

Participant Recruitment

Data collection was carried out from April 2016 to March 2017. Participants were recruited following purposive sampling constructed to specifically target Lebanese mental health service professionals providing both individual psychosocial support (Level 3) and clinical services (Level 4), as well as Syrians using those services.

Study Design

We used semi-structured and in-depth interviews to capture subjective experiences and meanings of distress, well-being, and mental health interventions based on the explanatory model approach to illness and health (Kleinman & Benson, 2006). We decided against focus groups, which could have discouraged participants from freely expressing their views in a context where security concerns limit information sharing (Diggle et al., 2017).

Ethics

This study was granted ethical clearance by Saint Joseph University Ethics Board in Beirut, Lebanon. Most Syrian refugees were reluctant to sign the written consent form, despite their desire to share their experiences. They indicated that providing a signature was a source of anxiety by evoking legal implications. After consultation with the ethics committee, it was decided with the Syrian participants that the researchers would sign the consent form in the presence of a witness. Professionals gave written consent to the study. All data were made anonymous and recordings were destroyed following analysis.

Since interviews with refugees took place at their homes, it was challenging at times to ensure privacy in overcrowded housing. This obstacle was overcome as some participants indicated preferred times for interviews or by going for walks around the neighborhood. Other participants insisted on talking in the presence of family or community members, involving them as witnesses to confirm information. We adapted as needed for the participants’ comfort and let them establish the interview setting while trying to combine acting ethically with responding culturally to different conceptions of privacy. Previous research has shown in this regard that in some indigenous contexts, Euro-American ethical codes for informed consent and confidentiality may not always make sense for community-centered social groups (Zaman & Nahar, 2011).

There was no financial compensation for participation in the study. All participants were given the contact information of the research team in case they had questions after the interviews. When participants showed signs of severe emotional distress, the researchers, with the participants’ consent, contacted the social worker assigned to their case at the NGO to arrange a follow-up. This happened with only one participant, as we excluded Syrian refugees who were suffering from severe mood episodes. The study’s findings were presented in the presence of UNHCR and MOPH representatives at a symposium organized by one of the NGOs that allowed us access to Syrian refugees.

Data Analysis

Interviews were transcribed verbatim and translated by a researcher. Native Arabic speakers on the research team verified the translations. Preliminary data analysis and data collection were conducted concurrently, allowing us to cease recruitment upon achieving coding saturation (Saunders et al., 2018). After several interviews, there were diminishing returns from further data collection and we were confident of having closely approached coding saturation. Thematic analysis methods were used to allow for themes and patterns to emerge from the triangulated data (Morse, 2012). Data were compiled, disassembled, and reassembled, following a multistage recursive coding process (Braun & Clarke, 2006). Following repeated data immersion to gain analytic insight into the data, transcripts were inductively coded by two researchers. Coding was redone as a group to reach consensus on coding discrepancies and refine the codes. No software was used. The framework for this study was developed using a bottom-up approach based on key themes emerging from the data (Braun & Clarke, 2006). The emergent themes were checked by asking two Syrian participants and three Lebanese practitioners for feedback. Relevant suggestions were incorporated into the results.

Sample Characteristics

All professionals interviewed were Lebanese nationals. All service providers had more than 2 years of experience at the NGO and their ages ranged between 24 and 39 years. Supplementary Table 1 shows the gender distribution among the types of practitioners interviewed.

The Syrian participants’ ages ranged between 24 and 46 years, and they originated from different regions of Syria. The age range and higher proportion of women among participants represent the population of refugees most likely to use MHPSS services, according to the two NGOs’ records. All participants were married with children. Refugees from Beirut (10 participants) lived in rented apartments shared with other Syrian families; the ones from Bekaa (15 participants) lived in informal refugee settlements (tents or shacks). Supplementary Table 2 shows the Syrian participants’ educational attainment by gender.

At the time of the study, all 25 Syrian participants received individual psychosocial support from a social worker (Level 3 of the IASC pyramid) consisting of informal counseling once a week, awareness sessions, and regular home visits. Among them, 16 were also receiving supportive psychotherapy centered on providing emotional support and developing coping skills, based on the psychotherapists’ description. Ten participants were also seen by a psychiatrist once a month and took antidepressant medications for depression, anxiety disorder, and/or PTSD; they were considered to be in remission at the time of the study. The psychiatric care consisted of regular sessions with a psychiatrist to detect and monitor symptoms of psychiatric conditions based on international classifications.

In the following section, we present the most recurrent themes and sub-themes that emerged from our inductive analysis of the perceptions of professionals and refugees.

Professionals’ Perceptions

Professionals in our study are divided into two categories: 47 service providers (social workers, psychotherapists, psychiatrists) working in the field with refugees, and 13 policymakers/program coordinators working on mental health programs at the national (three policymakers) or NGO level (10 program coordinators). The three themes below were common to both categories; however, one theme that emerged exclusively from the policymakers/program coordinators’ interviews is highlighted in a separate section (Theme 4).

Syrian Refugees’ Perceptions

Refugees View Their Distress as a Normal Collective Reaction to Adversity, While Professionals Perceive It as Symptomatic of Mental Health Disorders

In line with a large body of evidence, both within the Syrian refugee setting (Panter-Brick et al., 2018; Sim et al., 2018, 2019; Wells et al., 2018; Wells, Steel, et al., 2016; Wells, Wells, et al., 2016) and other refugee contexts (Eggerman & Panter-Brick, 2010; Jayawickreme et al., 2017; Li et al., 2016; Miller & Rasmussen, 2010; Ryan et al., 2008), our findings highlight that Syrians perceive economic, institutional, and psychosocial stressors related to ongoing displacement as the main sources of emotional distress. The interaction of these stressors creates a build-up of “pressure” (ضغط), resulting in mental health difficulties. The attribution of distress to external events—rather than internal dysfunction or disease—along with a shared sense of suffering may explain the normalization of mental health problems among Syrians in our study. Research focusing on a sample of Syrian informants in Jordan reached similar conclusions (Wells, Wells, et al., 2016), thus challenging the common notions that Arabic-speaking cultures view mental health problems as indications of “craziness” or personal weakness (Hassan et al., 2015; Nasir & Al-Qutob, 2005) and that stigma is a barrier among refugees to seeking mental health services (Morris et al., 2009; Saechao et al., 2012). Alternatively, this finding may be due to the Syrian refugees’ belief that emotional suffering is an inherent aspect of life; it is only an explicit psychological or psychiatric label that makes it shameful (Hassan et al., 2015).

Professionals in our study tended to attribute the Syrians’ emotional distress to individual vulnerability and used medical language to describe the refugees’ mental health problems. The psychiatric knowledge is validated through medical legitimization (“it is a disease like any other”) and a universalizing process (“depression is one of the most frequent illnesses in the world”) with the aim of “educating” refugees on the nature of their problems and “convincing” them of the need of services. This translation of distress into medical terms seems justified within specialized services focused on diagnosing and treating mental health disorders (Level 4). However, diagnostic categories were also used by social workers at the non-specialized level of individual support (Level 3), where the mhGAP is widely used to screen for mental health conditions and refer individuals to clinical services accordingly. We recognize that the use of diagnostic categories ensures continuity of care in case of referral, enables concise communication between practitioners, and facilitates reporting to investors. Yet, our findings suggest the value of practitioners avoiding psychiatric labels when communicating with Syrian refugees suffering from mental health conditions and acknowledging the role of the crisis and displacement stressors in generating emotional distress. This recognition might be more beneficial and conducive to trust and could replace efforts to convince refugees to seek mental health services. The presence of a psychiatric disorder and the need for clinical treatment should not invalidate refugees’ own perceptions regarding the social nature of their emotional difficulties. The clinical process of diagnosing mental health conditions is clearly important, but an exclusive emphasis on symptom checklists for disorders might lead to ignoring the political and social context shaping them and leave refugees feeling misunderstood by practitioners (Shannon et al., 2015).

Culture as a Source of Misunderstanding

Professionals view Syrian culture as an obstacle to discovering the underlying psychiatric disorder, whose universality is hidden by culture. Syrian culture is equated with behavioral ineptitude, defined by illiteracy and a lack of education. The labeling of behaviors deemed inexplicable by practitioners as “cultural”—such as high birth rates—prevents them from understanding these behaviors from the refugees’ perspectives or identifying with the displacement experience (Sahab et al., 2018). This need to distance themselves from the Syrians—emphasized by the fact that they did not use the word “culture” in Arabic, the language they share with Syrians—may be a way to manage feelings of countertransference. Indeed, the term “refugee” in Lebanon may be negatively associated with the 15-year Lebanese civil war and the Syrian occupation of the country until 2005 and may awaken mixed feelings and attitudes among Lebanese professionals (Geisser, 2013).

This finding has practical implications for program coordinators. Training sessions to develop awareness of the concept of culture as a dynamic system of meaning and practices (Kirmayer, 2006) might help avoid cultural stereotyping. The explanatory model approach of mental health and illness seems appropriate for a clinical setting, as it explores the patients’ viewpoints concerning their own symptoms to reach an understanding of how the social world affects and is affected by illness alongside expert knowledge (Kleinman & Benson, 2006). This model can be framed as an interview technique with six steps detailed in Supplementary Figure 4 that has been used efficiently to explore explanatory models of illness in other settings (Kleinman, 2007).

Refugees Emphasize Resettlement as the Definite Solution to Their Problems While Policymakers Prioritize Clinical Short-Term Interventions

Syrians in our study perceive UNHCR refugee resettlement as the only definitive solution to their social and mental health problems, suggesting pessimism toward other durable solutions to the refugee crisis, such as repatriation or full integration into Lebanese society. This finding can be interpreted in light of the political climate in Lebanon, where Lebanese authorities exert continuous pressure on refugees to return to Syria and threaten to demolish refugee shelters (Geha & Talhouk, 2018). Furthermore, the lack of a legal and administrative framework for Syrian refugees in Lebanon excludes any possibility of long-term integration into the host society (Geha & Talhouk, 2018; Nassar & Stel, 2019).

In this context, the resource-based model of migrant adaptation (Ryan et al., 2008) and the conservation of resources theory (Hobfoll, 2012; Hobfoll et al., 2015) are useful for interpreting refugees’ emphasis on resettlement. According to Ryan et al. (2008), migrant adaptation to the host environment presents the individual with a series of potentially stressful demands. The capacity to manage these demands depends on access to a range of resources—personal (mental and physical health), material (paid employment), social (social support), and cultural. Our study reveals that refugees attending mental health services perceive a total lack of availability of material (financial strain), social (social isolation), and cultural (perceived discrimination) resources. This forces reliance on their straitened personal resources, leading to mental health problems. According to the conservation of resources theory, individuals will not be motivated to pursue new resources if they feel that doing so will jeopardize their already tenuous ones (Hobfoll, 2012; Hobfoll et al., 2015). Therefore, their adaptive efforts will focus on leaving this poorly resourced environment and conserving their personal resources instead of unsuccessfully trying to adapt. In this context, a clinical diagnosis of adjustment disorder or the incapacity to adapt may be understood as the result of an adverse environment that seems structurally constituted to rebuff all adaptation.

However, some participants expressed the need for community interventions centered on skill building and social engagement. In an environment marked by uncertainty, these interventions may help them access resources and withstand losses, preventing the build-up of pressure leading to specialized services. Policymakers, however, emphasized the importance of short-term clinical interventions as a response to refugees’ distress. This finding is in line with official recommendations published by the UNHCR (El Chammay et al., 2013) and the MOPH (Kheir et al., 2015) regarding MHPSS services for refugees that include training non-specialized staff on the mhGAP to detect mental health conditions and training specialized staff on IPT, EMDR, and/or Trauma-Focused Therapy (Karam et al., 2016; Kheir et al., 2015), which are short-term specialized forms of therapy. Policymakers and program coordinators justified this focus on clinical services through the lack of evidence on psychosocial interventions in refugee settings, whereas brief specialized therapies have been studied in conflict-affected settings (Bolton et al., 2003; Rahman et al., 2016). Without denying the importance of clinical interventions, we note that the international consensus holds that mental health interventions in a humanitarian setting should primarily aim to strengthen communities and individuals by re-establishing a sense of safety and organizing social networks (IASC, 2007; Quosh, 2013; Silove, 2011; Wells et al., 2018). Moreover, emerging evidence validates the necessity of psychosocial interventions that respond to refugees’ needs through structured group-based activities promoting social support and skill building (Panter-Brick et al., 2018; Sim et al., 2019). Undoubtedly, interventions that target social suffering cannot replace clinical interventions for individuals with mental illnesses; measures to address refugees’ distress must rely on both types of interventions, capturing suffering as both shared and unique, rather than an individual or isolated experience. The official recognition and implementation by the Lebanese MOPH of sustainable community and psychosocial programs would help bridge this gap.

In addition, policymakers justified the choice of short-term interventions by defining the Syrian situation as an “acute emergency crisis.” However, the Syrian crisis has continued for over 9 years and should be considered a protracted crisis. This position may reflect the Lebanese Government’s policy of “institutional ambiguity” (Nassar & Stel, 2019) in response to the Syrian refugee crisis. In the context of limited resources and the country’s dysfunctional political system, the maintenance of a temporary, emergency status allows the government to abstain from establishing long-term strategies for refugees.

Practitioners Consider Refugees’ Lies as Manipulative, While Refugees Resort to Lying as an Adaptive Mechanism

The significance of the relationship between refugees and the humanitarian system as well as the phenomenon of lying emerged inductively from the datasets, as the data underlying our analysis were not initially gathered to highlight these issues. Lying presented itself as a defining feature of the Syrians’ daily life. To survive adversity and perceived discrimination, Syrian participants feel forced to adopt behaviors and narratives in line with the agencies’ perceived expectations, even if they do not conform to their usual self. Changing narratives allows refugees to legitimate their requests to the authorities, yet institutions expect them to express a truthful and credible narration of self. MHPSS services are affected by this issue since Syrians perceive them as an agency that can advocate on their behalf to the UNHCR, while MHPSS practitioners feel manipulated when refugees lie to them. This dynamic threatens the therapeutic alliance by generating doubt and mistrust.

Beneduce (2015) suggested the concept of the “moral economy of lying” in an exploration of the narrative strategies used by migrants to face the bureaucratic violence of the asylum procedure. Even though it does not necessarily apply to all refugee settings, this concept helps explain the attitude Syrians adopt toward institutions: lying discloses a field of power relations, the humanitarian space, in which the refugee is embedded, and appears to result from the extreme dependence of the refugees on aid. In unstable environments where resources are unpredictable, developing a set of behavioral and conversational norms with agencies allows refugees to deal with the perceived arbitrary procedures of the UNHCR and/or the constant fear of random arrest by the Lebanese Government. Lying may have an adaptive function in response to the humanitarian and governmental system, where refugees are rational actors who adjust their behaviors and narratives based on assessments of environmental risks and benefits in line with the resource-based model and the conservation of resources theory (Hobfoll, 2012; Ryan et al., 2008; Sim et al., 2018). In our study, strategies employed by Syrians to adapt to their resource-constrained environment involved changing behaviors and stories to meet eligibility for aid and resettlement or avoid arrest. These strategies allowed the participants to survive but generated distress, as they feared being discovered.

Finally, the phenomenon of lying in this study matches Gambetta’s theory of trust (Gambetta, 1998) and more specifically the issue of trust or mistrust in relation to the refugee’s experience (Hynes, 2003). If trust is understood as being able to have confidence in a person or a system, lying reveals that refugees have a fundamental lack of trust in the capacities of the humanitarian system and/or the Lebanese Government to help them. This can be the result of the structural violence they are exposed to and the institutional ambiguity they are embedded in (Nassar & Stel, 2019; Parkinson & Behrouzan, 2015). The refugee mistrusts and is mistrusted (Hynes, 2003), as the aid agencies continuously attempt to define their eligibility for aid or resettlement based on target or vulnerable group definitions. At the level of the practitioner–refugee relationship, this has significant repercussions, as reciprocal trust is fundamental to building a therapeutic alliance (Lambert, 2013) and establishes a moral dimension to healing that is related to but distinct from the medical aspects of treating a mental health condition. Understanding the refugee lying phenomenon and potential countertransference attitudes through reflexive trainings and peer-to-peer supervision might help strengthen the therapeutic alliance in this context.

Limitations

Our sample of Syrian refugees did not include respondents from all regions of Lebanon and was smaller than the sample of professionals due to the lack of access to refugees granted by NGOs. Nonetheless, the regions we sampled, Bekaa and Beirut, host the largest number of Syrian refugees in the country (UNHCR, 2019). We did not include individuals suffering from severe and chronic mental health conditions, and the majority of our participants were women. Our sample of professionals did not afford us a comprehensive view of all MHPSS services available to refugees, as it only focused on NGOs providing individual-based interventions at Level 3 (individual psychosocial support) and Level 4 (clinical services) of the IASC pyramid. Finally, our findings emphasize the need for further qualitative and participant-centered research that samples a larger population of refugees as well as mental health services at all levels of the IASC pyramid to allow for an in-depth understanding of the refugees’ struggle for survival.