The Experiences of People From Arab Countries in Coping with Trauma Resulting From War and Conflict in the Middle East: A Systematic Review and Meta-synthesis of Qualitative Studies

Abstract

The Middle East region has been an area of war and political conflict for several decades. There is currently limited research on the experiences of war and conflict among the individuals from Arab countries in the Middle East. The aim of this review was to systematically review and meta-synthesize qualitative literature on the experiences of individuals from Arab countries in the Middle East of going through and coping with war and political conflict. We systematically searched for relevant literature through MEDLINE, PsycINFO, CINAHL, Google Scholar, EThOS, OpenGrey, and The Arab Journal of Psychiatry. Studies selected needed to have a qualitative design reporting on the war and conflict experiences of participants aged 18 years or older from Arab countries in the Middle East. The review protocol was preregistered with PROSPERO (Ref: CRD42022314108). We identified 27 studies to be included in the final review. Four overarching themes were included in the meta-synthesis: War and conflict as life-defining experiences, experiences of hardship, coping with war and conflict, and positives out of a painful experience. Participants in the included studies reported significant distress and losing their sense of self, as well as resilience and positive growth. This review and meta-synthesis revealed the particular culturally informed experiences of individuals from Arab countries in the Middle East in processing their conflict experiences. These experiences highlight the need for culturally sensitive interventions for a population that has been under significant war-related stressors.

Introduction

The Middle East region has been an area of war and political conflict for several decades, many of which remain unresolved. This region includes 13 Arab countries, including Qatar, Saudi Arabia, Jordan, Egypt, Palestine, Bahrain, Oman, Kuwait, United Arab Emirates, Yemen, Iraq, Lebanon, and Syria (Kheir et al., 2008). At the time of writing this article, 4 out of these 13 countries are experiencing war or political conflict, including Syria, Iraq, Palestine, and Yemen. These conflicts have constituted the origin of the world’s largest refugee movement, with Syrians being the largest forcibly displaced population globally by the end of 2019 (United Nations High Commissioner for Refugees (UNHCR), 2020). Other Arab countries in the region, such as Lebanon, have also been experiencing political uprisings and instability. In the past few years, these countries have also witnessed terrorist activities on their lands and inside their cities.

The World Health Organization (WHO) recognizes that violence resulting from war or political conflict is a major threat to public health and that preventing violence should be a public health priority (WHO, 2002). This illustrates the drastic impact that political violence can have on the affected populations. As refugees are escaping their lands to other countries inside and outside the Middle East region following or during the war, the impact of this trauma on their mental health becomes an international concern due to their need for services in the new countries (Skuse, 2021). As for individuals remaining in their lands, the psychological burden of the war or conflict also presents itself in countries with under-resourced mental health systems (El-Khoury et al., 2021).

Psychological Burden of Conflict

A comprehensive review revealed that among Arab populations, Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder were the most common psychological impacts of war and conflict (Al Ghzawi et al., 2014). On standardized assessments, prevalence rates of PTSD in Syrian refugees varied between 30% and 60% (Alpak et al., 2015; Kazour et al., 2016; Mahmood et al., 2019; Tinghög et al., 2017). With regard to Palestinians affected by the long-term exposure to political violence, a recent meta-analysis reported a pooled prevalence of PTSD of 36%, with the prevalence ranging from 6% to 70% (Agbaria et al., 2021). These numbers illustrate the significant distress experienced by these individuals as the result of living through conflict, as the prevalence rates of PTSD reported fall in the higher range when compared to international literature in international populations exposed to conflict (Steel et al., 2009). However, the measures used in most of the studies cited had not been validated within the specific communities that they were used with. Therefore, especially with differences in war experiences and durations and the distinctive ongoing nature of some of the conflicts in the Middle East (Kazour et al., 2016), this presents a limitation in drawing meaningful conclusions from these numbers. A meaningful understanding of their experiences thus remains challenging with current evidence focusing on prevalence rates with less focus on symptom clusters and symptom presentation (Alpak et al., 2015; Kazour et al., 2016; Mahmood et al., 2019; Tinghög et al., 2017).

Conflict, Culture, and Interventions

As a culturally informed understanding of stress-related disorders remains challenging (El-Khoury et al., 2021), it is important to gain a cultural and contextual understanding of how individuals from Arab countries in the Middle East perceive conflict and how they cope with their conflict experiences. This would be especially informative as some individuals, for example Syrians and Palestinians, have been experiencing distinctively persistent and ongoing conflicts for several years. The culture-specific impact of this trauma must be understood to inform the development or adaptation of culturally informed tools for the assessment of the impact of conflict on this population, considering potential local expressions of trauma and distress. In addition, it is still unclear as to what interventions should be recommended with these populations (Kazour et al., 2016). Therefore, this understanding could also inform the development of culturally sensitive interventions targeted at mitigating this impact, either through prevention or treatment. This could address the challenge of applying Western treatment techniques in refugee settings (Kazour et al., 2016). Understanding how individuals from Arab countries in the Middle East experience this trauma can therefore aid in the development of treatment guidelines in conflict settings in the Middle East, as well as with refugees in new Western or non-Western countries. El Khoury et al. (2021), recommended a review of the evidence and experience of the Arab population with regard to conflict to ensure that their contextual mental health needs are adequately attended to.

Therefore, given the need for a better understanding of these culture-specific experiences, the aim of this study was to systematically review and meta-synthesize qualitative literature on the experiences of individuals from Arab countries in the Middle East in going through and coping with war and political conflict. We sought to contribute to the literature by identifying culturally relevant semantic meanings allocated to war or conflict by the population of interest. As few studies have attempted to gain a culturally informed qualitative understanding of these populations’ war experiences (Al-Natour et al., 2022, Arenliu et al., 2020; Ghnadre-Naser & Somer, 2016), a review of the existing qualitative data could help develop that understanding. Therefore, the following research question guided our study: How do people from Arab countries in the Middle East experience and cope with war and political violence trauma?

Methods

Design

We conducted a systematic review to identify relevant studies related to the experiences of individuals from Arab countries in the Middle East in going through and coping with war or political violence trauma. The review protocol was preregistered with PROSPERO (Ref: CRD42022314108). PRISMA guidelines and the PRISMA checklist (Page et al., 2021) were followed throughout this review to ensure clarity in reporting results (Moher et al., 2009).

This review has exclusively focused on qualitative data to gain an in-depth understanding of the experience of this population in dealing with war or political violence. As research on this topic with this population is still relatively limited, and especially as some of the populations are still going through war or conflict at the time of writing, studying qualitative data is important to gain a thorough understanding of their particular experiences which have not yet been systematically synthesized.

Search Strategy

We systematically searched the databases MEDLINE, PsycINFO, and CINAHL for relevant articles, with the final search being conducted on the 4th of July 2022. We searched the databases Google Scholar, EThOS, and OpenGrey for gray literature as well. We also manually searched The Arab Journal of Psychiatry to identify any other relevant articles that were not picked up through the databases. We also conducted backward and forward citation checking for all included articles to identify further articles that might have been missed by the initial search strategy.

We used predetermined search terms to conduct the search on the three main search topics: War and political conflict trauma, Arab countries in the Middle East, and qualitative research. The search terms followed the PICOS framework (Population, Intervention, Comparison, Outcomes and Study) and were combined with Boolean operators. The detailed search terms were: (trauma* OR war OR conflict OR violence OR political OR PTSD OR post traumatic OR post-traumatic) AND (Arab* OR Middle East OR Gulf OR Qatar OR Saudi Arabia OR Egypt OR Palestine OR Bahrain OR United Arab Emirates OR Kuwait OR Oman OR Yemen OR Iraq OR Lebanon OR Jordan OR Syria) AND (Qualitative OR Thematic Analysis OR Observation OR Focus Group OR mixed method*).

Selection Criteria

Studies were included in this review if they (a) had a qualitative design, or a mixed methods design with a qualitative component from which qualitative data could be extracted, (b) reported on participants from Arab countries in the Middle East, regardless of whether or not they were currently still residing in their country of origin (e.g., refugees, asylum seekers), (c) reported on participants of 18 years or older having experienced trauma from war or political violence, and (d) were published in either English or Arabic.

Studies were excluded from this review if they (a) were unpublished (e.g., non-peer reviewed), (b) had a non-qualitative design, (c) reported on a different population, (d) reported on different types of trauma (e.g., sexual violence), (e) reported on participants who have healthcare-related or military professions (e.g., healthcare professionals, military personnel), and (f) were published in any language other than English or Arabic. Healthcare and military professions were excluded as their experiences are considered distinct in times of conflict (Batley et al., 2008; Litz et al., 2018).

Data Screening and Extraction

The search results were exported to Microsoft Excel for initial screening and deduplication. The first author AH and the second reviewer FE screened the titles and the abstracts independently according to the inclusion and exclusion criteria. We then retrieved the full texts of the remaining articles using Mendeley® (Mendeley, London, United Kingdom) and further screened them for eligibility. We discussed the articles to reach a consensus on eligibility. All the selected articles were included in the qualitative meta-synthesis.

Quality Appraisal

For the quality appraisal of the selected studies, we used the Critical Appraisal Skills Programme (CASP) qualitative studies checklist (CASP UK, 2018). The CASP checklist contains criteria relating to the validity, relevance, and transferability of the results. This appraisal tool was chosen as it is the most widely used instrument for the assessment of qualitative studies (Hannes & Macaitis, 2012). Criteria presented by Lachal et al. (2017) was used as guidance in assessing the quality of the articles. Quality appraisal was carried out independently by AH and FE. Any disagreement arising was resolved through discussion with the research team.

Meta-synthesis

The method described by Lachal et al. (2017) was followed for the thematic analysis and synthesis of qualitative data. All the selected articles were imported into NVivo® version 12 (NVivo, QSR International, Burlington, Massachusetts, United States) for synthesis.

In line with Lachal et al. (2017)’s process, the analysis first involved actively reading and rereading the articles and getting familiar with the data. This step involved identifying, organizing, comparing, and mapping the data. This was followed by coding the data to then group them and categorize them into a hierarchical structure. This involved comparing themes across studies and coming up with a list of descriptive themes of the data. The final step involved generating analytical themes based on the data and the research team’s interpretations. This led to the development of a set of original overarching themes and subthemes, which we report in the synthesis. The report includes verbatim accounts of participants from the included studies to illustrate the themes derived.

The first author carried out the theme coding independently. The analysis and theme coding were frequently discussed with the research team to increase validity. Excerpts from the articles are included to increase transparency of our analyses and a statement of reflexivity is provided below to illustrate the trustworthiness of our approach.

Reflexivity

Reflexivity is a measure recommended in standards for the reporting of qualitative data (O’Brien et al., 2014). It can help ensure clarity with regard to the researchers’ perspectives and potential influence while interpreting qualitative data. It can allow readers to understand how the researchers’ cultural backgrounds, preconceptions, and personal experiences may have affected the lens through which they understood and interpreted the data. This review involved a diverse team, with Arab Middle Eastern and White British researchers. The team provided a balanced interpretation of the literature between lenses of lived and professional experiences. AH is a Lebanese woman who has a lived experience of the 2006 war and the 2020 explosion in Lebanon. She was motivated by her desire to shed light on the war and conflict experiences of people from Arab countries in the Middle East. FE is an Egyptian woman with research interests focusing on Middle Eastern mental health. AA is a Qatari who is a qualified healthcare professional and researcher with particular expertise in severe mental illness who has lived experience of the Lebanon war in 2006. JB is a White British consultant clinical psychologist and an associate clinical professor in the United Kingdom, who has worked extensively with victims of war and conflict.

Results

A total of 2,502 studies were identified from the initial search. Three further studies were identified through the backward and forward citation checking process. Three PhD theses were removed as a result of finding published articles based on the theses. The study selection process, shown in the PRISMA flowchart in Figure 1, resulted in 27 studies being selected for the systematic review and meta-synthesis.

Figure 1.

PRISMA flowchart of the selection process.

Characteristics of the Studies

The 27 studies selected for this review were conducted with a diverse population, including individuals from Iraq, Kuwait, Lebanon, Palestine, and Syria. The studies were published between 1998 and 2022, with the majority of studies being peer reviewed and published between 2012 and 2022. All the studies selected aimed to explore the war or political violence experiences of individuals from Arab countries in the Middle East. The study characteristics can be found in Table 1.

Table 1.

Characteristics of Selected Studies.

Study Number	Author(s) (Year)	Study Country	Sample Size/Population Studied	Aim(s)	Method	Analysis
1	Abdulah et al. (2022)	Iraq, Syria	N = 13 (Yazidi capture survivors; 100% females)	To explore the lived experience of Yazidi women who experienced attacks by ISIS (Islamic State in Iraq and Syria)	Individual interviews, paintings	Content analysis
2	Afana et al. (2020)	Palestine	N = 34 (Palestinian civilians; 53% males, 47% females)	To explore the structural features of coping with trauma among Palestinians	Semi-structured focus groups	Phenomenological analysis
3	Al-Natour et al. (2022)	Jordan	N = 16 (Syrian refugees; 100% females)	To explore the experiences of Syrian refugee families who have fled the country due to war	Semi-structured individual interviews	Content analysis
4	Arenliu et al. (2020)	Turkey	N = 67 (Syrian refugees; mixed, gender characteristics not specified)	To explore the displacement and war experiences and the coping strategies of Syrian refugee families living in Istanbul	Minimally structured family interviews	Grounded theory
5	Atallah (2017)	Palestine	N = 30 (Palestinian families; gender characteristics not specified)	To explore processes of resilience in Palestinian refugee families living under occupation	Semi-structured group and individual interviews	Thematic analysis
6	Atari-Khan et al. (2021)	United States	N = 8 (Syrian refugees; 37% males, 63 % females)	To explore Syrian refugees’ concept of resilience and to explore differences with Western concepts of resilience	In-depth semi-structured interviews	Thematic analysis
7	Bolton et al. (2013)	Iraq	N = 63 (Iraqi torture survivors; mixed, gender characteristics not specified)	To identify the psychosocial problems and mental health needs of Iraqi survivors of genocide	Individual interviews	Grounded theory
8	Brownell and Nicole (1999)	Lebanon	N = 24 (Nonimmigrant Lebanese war survivors, 42% males, 58% females)	To identify the most common and helpful coping strategies that Lebanese people used during war	Semi-structured interviews	Qualitative analysis
9	Charani (2005)	Lebanon	N = 6 (Lebanese women war survivors; 100% females)	To explore the war experiences of three generations of middle-class Lebanese women	In-depth interviews	Inductive analysis
10	Cook et al. (2022)	Iraq	N = 35 (Yazidi genocide survivors, 60% males, 40% females)	To explore the lived experience of Yazidis who survived ISIS genocide	Individual interviews	Emotion coding and theming
11	Freh et al. (2012)	Iraq	N = 11 (Iraqi civilians, 54 % males, 46% females)	To explore how people who have experienced bombing attacks make sense of them and cope with them	Individual interviews	Interpretive phenomenological analysis
12	Freh et al. (2013)	Iraq	N = 9 (Iraqi civilians, 44% males, 56% females)	To explore how people who have experienced bombing attacks make sense of them and cope with them	Individual interviews	Interpretive phenomenological analysis
13	Ghnadre-Naser and Somer (2016)	Palestine	N = 10 (Palestinian civilians, 50% males, 50% females)	To explore the psychological effects of the Nakba on internally displaced Palestinians and their lived experiences	Semi-structured in-depth interviews	Phenomenological analysis
14	Hammad and tribe (2020)	Palestine	N = 7 (Palestinian university graduates, 57% males, 43% females)	To explore how economic oppression and structural violence impact the well-being of Palestinians	Semi-structured interviews	Thematic analysis
15	Hammad and Tribe (2021)	Palestine	N = 7 (Palestinian university graduates, 57% males, 43% females)	To explore how Palestinians cope with living in a conflict-affected place and their cultural concepts of resilience	Semi-structured interviews	Thematic analysis
16	Hirad et al. (2022)	United States	N = 30, 21 of interest for this study (Iraqi and Syrian refugees, 57% males, 43% females)	To explore how Iraqi and Syrian refugees process and cope with the trauma they have experienced	Semi-structured interviews	Grounded theory
17	Johnson et al. (2009)	England	N = 9; 4 of interest for this review (Syrian and Iraqi interpreters; 100% males)	To explore how non-Western interpreters perceived their trauma experiences from their countries of origin	Individual interviews	Interpretive phenomenological analysis
18	Khullar et al. (2019)	Kuwait	N = 5 (Kuwaiti civilian war survivors, 40% males, 60% females)	To explore the experience of Kuwaitis in resisting and coping with political violence	Semi-structured interviews	Thematic discourse analysis
19	Matos et al. (2021)	Portugal	N = 39 (Syrian refugees; 51% males, 49% females)	To explore the war meaning-making trajectories of Syrian refugees living in Portugal	Semi-structured interviews	Thematic analysis
20	Matos et al. (2022)	Portugal	N = 44 (Syrian refugees; 48% males, 52% females)	To analyze the determinants of mental health in Syrian refugees affected by war and living in Portugal	Focus groups, in-depth interviews	Thematic analysis
21	Netland (2012)	Palestine	N = 20 (Palestinian civilians, 50% males, 50% females)	To explore Palestinian adults’ experiences of lost childhood due to exposure to political violence	Semi-structured interviews	Thematic analysis, narrative content analysis
22	Oweini (1998)	Lebanon	N = 20 (Lebanese past university students, 10% males, 10% females)	To explore how students coped with the Lebanese war	Individual interviews	Qualitative analysis
23	Sharifian et al. (2022)	Syria	N = 70; 10 for the qualitative analysis (Syrian teachers, 100% females)	To explore the relationship among trauma, resilience, and burnout among Syrian teachers working during the war	Individual interviews	Content analysis
24	Sousa et al. (2014)	Palestine	N = 32 (Palestinian women, 100% females)	To explore Palestinian women’s experiences of home violations within the context of political violence	Focus groups	Thematic analysis
25	Taher and Allan (2020)	United Kingdom	N = 54, 5 for the qualitative analysis (Syrian refugees; gender characteristics not specified)	To explore post-traumatic growth among Syrian refugees in the United Kingdom	Semi-structured interviews	Interpretive phenomenological analysis
26	Veronese et al. (2021)	Palestine	N = 21 (Palestinian women, 100% females)	To explore the specific factors related to Palestinian women’s war experiences	Individual interviews	Content analysis
27	Zbidat et al. (2020)	Germany	N = 16 (Syrian refugees; 50% males, 50% females)	To explore how Syrian refugees in Germany perceive trauma, coping strategies, somatization, and complaints	Semi-structured interviews	Content analysis

Quality Appraisal

We assessed the quality of the 27 studies using the CASP checklist. Quality did not determine whether studies were included in this review due to the limited research around the topic in question. The quality checklist results can be found in Table 2. All the studies presented valuable research. The majority of the studies had a clear aims statement with an appropriate corresponding qualitative methodology. The main quality limitation was a lack of appropriate reflexivity on the relationship between researchers and participants in the majority of the studies. Some studies lacked reflexivity altogether (Abdulah et al., 2022), while others briefly addressed it without explaining how the authors’ backgrounds would impact the interpretation of the data (Atallah, 2017). Other studies clearly discussed this impact, recognizing the research team as an instrument in the collection and analysis of the data (Atari-Khan et al., 2021).

Table 2.

Full Quality Assessment of the Selected Studies.

CASP Questions	Study Numbers
	1	2	3	4	5	6	7	8	9
	Abdulah et al. (2022)	Afana et al. (2020)	Al-Natour et al. (2022)	Arenliu et al. (2020)	Atallah (2017)	Atari-khan et al. (2021)	Bolton et al. (2013)	Brownell and Nicole (1999)	Charani (2005)
1. Was there a clear statement of the aims of the research?	T	T	T	T	T	T	T	T	T
2. Is a qualitative methodology appropriate?	T	T	T	T	T	T	T	T	T
3. Was the research design appropriate to address the aims of the research?	T	T	T	T	T	T	T	T	T
4. Was the recruitment strategy appropriate to the aims of the research?	T	T	P	P	T	T	T	P	T
5. Were the data collected in a way that addressed the research issue?	T	T	T	T	T	T	T	T	T
6. Has the relationship between researcher and participants been adequately considered?	N	T	N	N	P	T	P	P	T
7. Have ethical issues been taken into consideration?	T	T	T	T	T	T	T	P	T
8. Was the data analysis sufficiently rigorous?	T	T	P	T	T	T	P	T	T
9. Is there a clear statement of findings?	T	T	T	T	T	T	T	T	T
10. How valuable is the research?	T	T	T	T	T	T	T	T	T

CASP Questions	Study Numbers
	10	11	12	13	14	15	16	17	18
	Cook et al. (2022)	Freh et al. (2012)	Freh et al. (2013)	Ghnadre Naser and Somer (2016)	Hammad and Tribe (2020)	Hammad and Tribe (2021)	Hirad et al. (2022)	Johnson et al. (2009)	Khullar et al. (2019)
1. Was there a clear statement of the aims of the research?	T	T	T	T	T	T	T	T	T
2. Is a qualitative methodology appropriate?	T	T	T	T	T	T	T	T	T
3. Was the research design appropriate to address the aims of the research?	T	T	T	T	T	T	T	T	T
4. Was the recruitment strategy appropriate to the aims of the research?	P	T	P	N	P	T	T	P	T
5. Were the data collected in a way that addressed the research issue?	T	T	T	T	T	T	T	T	T
6. Has the relationship between researcher and participants been adequately considered?	N	P	P	T	T	T	T	N	N
7. Have ethical issues been taken into consideration?	T	T	T	N	T	T	T	T	T
8. Was the data analysis sufficiently rigorous?	T	T	T	T	T	T	T	T	T
9. Is there a clear statement of findings?	T	T	T	T	T	T	T	T	T
10. How valuable is the research?	T	T	T	T	T	T	T	T	T

CASP Questions	Study Numbers
	19	20	21	22	23	24	25	26	27
	Matos et al. (2021)	Matos et al. (2022)	Netland (2012)	Oweini (1998)	Sharifian et al. (2022)	Sousa et al. (2014)	Taher and Allan (2020)	Veronese et al. (2021)	Zbidat et al. (2020)
1. Was there a clear statement of the aims of the research?	T	T	T	P	T	T	T	T	T
2. Is a qualitative methodology appropriate?	T	T	T	T	T	T	T	T	T
3. Was the research design appropriate to address the aims of the research?	P	P	T	N	T	T	T	T	T
4. Was the recruitment strategy appropriate to the aims of the research?	T	P	T	P	T	T	T	T	T
5. Were the data collected in a way that addressed the research issue?	T	T	T	N	T	T	T	T	T
6. Has the relationship between researcher and participants been adequately considered?	N	N	N	P	N	T	N	N	P
7. Have ethical issues been taken into consideration?	T	T	P	N	T	T	T	T	T
8. Was the data analysis sufficiently rigorous?	T	T	T	T	P	T	T	T	T
9. Is there a clear statement of findings?	T	T	T	T	T	T	T	T	T
10. How valuable is the research?	T	T	T	T	T	T	T	T	T

Note. CASP = Critical Appraisal Skills Programme; T = Totally met; P = Partially met; N = Not met.

Themes

The meta-synthesis led to the identification of four overarching themes (see Table 3).

Table 3.

Overarching Themes.

Key Themes	Subthemes
1. War and violence as a life-defining experience	1.1 Disillusionment
	1.2 A change in life as they knew it
	1.3 Anger and resentment
	1.4 Loss of hope
	1.5 Loss of trust
	1.6 Loss of identity
2. War and violence experiences: accounts of hardship	2.1 Constant threat
	2.2 Normalized war
	2.3 Unfair experience
	2.4 Inhumane violence
	2.5 Painful memories
3. Coping with painful experiences	3.1 Accepting reality
	3.2 Avoidance
	3.3 Social support
	3.4 Family support
	3.5 Faith
	3.6 Resilience
	3.7 Patriotism
	3.8 Resilience
4. Positives out of a painful experience	4.1 Positive meaning-making
	4.2 Positive self-growth

War and Violence as a Life-Defining Experience

This theme represents how the experience of going through war or political violence was a major life-defining experience for the participants. As this experience can be multifaceted, this theme was divided into six subthemes: disillusionment, change in life, anger and resentment, loss of hope, loss of trust, and loss of identity.

Disillusionment

Many participants reported that going through war or violence led to disillusionment and made them realize that the world is not as peaceful as they previously thought it was. It made them realize that people are capable of hatred and violence against each other. Disillusionment was conceptualized as the shattering of assumptions that people were generally good and that the world was a peaceful place. A Syrian war refugee mentioned that:

We lived in a lie. That we are a unity, we are one piece. Actually, people hated each other, inside, deeply. We were just not allowed to say it (Matos et al., 2021)

Individuals also started to perceive the world as evil and dangerous after going through political violence, such as a bomb attack in Iraq. An Iraqi bomb attack survivor noted that his world assumptions were shattered:

Danger is everywhere, there is no safe place. People were not evil like nowadays, life was not miserable like now (Freh et al., 2012)

A Change in Life as They Knew it

Other than being disillusioned, individuals also reported that war or political violence concretely changed their lives. They mentioned that it changed their daily lives, as well as their life plans. A Syrian refugee noted how the war forced him to leave his country:

I was very worried about my future—What should I do? Will I have a job?—It was very hard to continue life [in Syria]. So, I started to think about how I could leave (Matos et al., 2022)

Another way in which war changed the lives of participants was through changing their life opportunities, as a Palestinian individual under military blockade reported:

I’m a graduate and it’s not suitable for me to work as a cleaner, for example. Nonetheless, because of our real situation, I’m obliged to do that to offer myself an income (Hammad & Tribe, 2020).

A Kuwaiti occupation survivor summarized how life shifting the violence was by stating:

It became a landmark in your life (Khullar et al., 2019)

Anger and Resentment

Faced with unfair war or occupation experiences, individuals reported feeling anger and resentment toward opposing forces. After his home was demolished by the occupying forces, a Palestinian man expressed his feelings:

anger mixed with hatred, because they destroyed our house and dream for no reason at all . . . If I had the ability, I would burn them down. (Netland, 2012)

A Lebanese woman expressed resentment against the corruption in the ruling class after the war:

All the sons of the leaders however, who are still in their twenties, own places and have steels in their own names . . . how did this happen? From robbing people of course (Charani, 2005)

Loss of Hope

Participants described the war or violence as an experience that made them lose their hope in life and dreams for the future. A Palestinian individual reported a loss of hope after experiencing political violence:

It was sadness mixed with fear of the future and of the mercilessness of our enemy, combined with our hopelessness (Netland, 2012)

Iraqi bomb attack survivors also echoed this loss of hope in their reports, as one of them noted:

[Laugh] future?!! I can’t imagine there is a future after that day (Freh et al., 2012)

Loss of Trust

Participants reported that the experiences they went through made them lose trust in people around them. This was evident in Lebanese civil war survivors, as they witnessed their own people turn on each other:

I don’t trust anyone anymore. No matter what religious group they belong to. (Charani, 2005)

In addition, surviving a bombing attack induced a lack of trust in individuals, as they were afraid it would happen again and felt like anyone could be carrying a bomb. An Iraqi bomb survivor noted:

The bombing could happen again. So, I decided to stay away from people (Freh et al., 2013)

Loss of Identity

Individuals having been through war or having witnessed violence reported that they felt like their experiences made them change and lose who they were. These experiences therefore profoundly impacted the way they became. A Palestinian war survivor noted, 59 years after the war:

It means I don’t recognize who I am. I’m present here in the country but absent like those who fled to Syria and Lebanon (Ghnadre Naser & Somer, 2016)

Genocide also had a profound impact on Yazidi survivors. One of them noted how it felt like their hearts died with the genocide:

Genocide changed our hearts and ourselves, our hearts died after the death of our people in Sinjar (Cook et al., 2022)

War and Violence Experiences: Accounts of Hardship

The experience of going through war or political violence can be a terrifying experience for individuals. Many participants from the included studies reported the horrible things that they witnessed and recounted their feelings of worry, fear, and pain. They mentioned always having been under the threat of war, normalizing war, feeling like life is not fair, witnessing inhumane violence, and having painful memories.

Constant Threat

Individuals reported that they had always been under the threat of war or violence, or always having been through war. Threat was a constant, as per a Syrian refugee’s account:

We were raised to know that we were living near the enemy, which is Israel. So, we always knew that there was going to be a war (Matos et al., 2021)

In addition, Palestinians reported that war is part of their daily reality. A Palestinian woman highlighted that war has been a constant across three generations of Palestinians:

The Palestinian reality is this: when children play they reflect on what they see and learn in theirs, their parents’ and grandparents’ experiences: assault, injuries, murders. That is what we have in our existence (Veronese et al., 2021)

Normalized War

Being under constant war or political violence made the survivors become desensitized to war. It became a normal experience that they got used to. A Syrian refugee noted:

The first time I saw people dead was hard. But the worst was when I got used to [emphasis added] seeing people dead (Matos et al., 2021)

Another Syrian refugee described seeing dead bodies in Syria as “normal” (Atari-Khan et al., 2021). Similarly, when asked about coping with 15 years of war, a Lebanese woman reported that Lebanese people “got used to it” (Brownell & Nicole, 1999).

With regard to Palestinians, war also became something normal for them, as they have been under occupation for several decades. When asked about their experiences, a Palestinian noted:

We are used to these events; it becomes part of our daily life (Afana et al., 2020)

Unfair Experience

Individuals affected by war and political violence reported feeling like life is not fair. They wondered why these things were happening to them and felt like they did not deserve or choose these experiences. A Syrian refugee illustrated this by saying:

Why us? Why me? Why my family? Why are these things happening? (Matos et al., 2021)

Palestinian individuals also reported feeling like their experience is unfair and that they did not choose it, as per this Palestinian’s account:

This is not a life . . . people are obliged to deal with this life, not one of us would like to live such a life but we are obliged to (Afana et al., 2020)

Inhumane Violence

Many participants reported witnessing inhumane murders and violence. They reported experiencing torture or hearing the torture of their loved ones. A Syrian refugee recounted how entire families would be murdered in front of each other:

So they didn’t just kill the mom and dad, they killed them like five times, because they killed their children before them (Atari-Khan et al., 2021)

A Syrian woman mentioned how she witnessed her friend being violently killed:

She died immediately. I saw that the intestines of my friend came out. (Abdulah et al., 2022)

Kuwaiti occupation survivors also reported witnessing inhumane violence. A Kuwaiti woman recounted how babies would be killed:

They took babies out of their incubators, and just let them die (Khullar et al., 2019)

Similarly, Palestinians recounted their experiences of constant violence throughout their occupation. A Palestinian woman noted:

When the 14-year-old son walked out, the father became nervous and urged him to come inside, but snipers saw the father peering outside the window and shot him in the head and he fell onto the kitchen table. The whole family saw him die (Atallah, 2017)

Painful Memories

Witnessing or going through inhumane violence left individuals with painful memories which stayed with them afterwards. A Yazidi genocide survivor recalled:

They raped me and after two years I managed to escape from there and I remember the tragedy that happened to me every day (Cook et al., 2022)

Other individuals reported that they still cannot forget their war experiences decades after they took place. A Palestinian woman noted:

A person can’t forget [. . .] we can’t forget (Ghnadre-Naser & Somer, 2016)

Coping with Painful Experiences

After going through the painful experiences mentioned and witnessing violence and murders, the individuals had several ways of coping. They coped through accepting their reality, avoidance, social and family support, faith, resilience, patriotism, and resistance.

Accepting Reality

Feeling like they had no other option, some participants felt like they had to accept the reality of war or violence they were living in to carry on. A Palestinian individual noted having to accept living under occupation:

Simply we accepted this situation anyway we have no other choices (Hammad & Tribe, 2020)

Individuals in Lebanon under 15 years of war also had to accept their situation to cope, as echoed by a Lebanese participant:

To cope with it you had to accept it (Brownell & Nicole, 1999)

Avoidance

Other participants utilized avoidance as a coping strategy, as they preferred not to think about their painful experiences. An Iraqi bomb attack survivor noted:

One must keep away from the place of the incident and avoid thinking about the incident; otherwise he will be an easy prey to depression (Freh et al., 2012)

Individuals would also avoid hearing about the war if it were still taking place and they had escaped it. A Syrian refugee reported that she would avoid news about the war:

So my complaints do not get any worse, I avoid listening to the news and watching TV (Zbidat et al., 2020)

Social Support

Individuals reported how social support helped them cope through their difficult war or violence experiences. A Syrian refugee noted how war brought the community together:

The war made us more emotional towards each other, more supportive of each other (Matos et al., 2021)

Lebanese war survivors also highlighted the importance of community support in dealing with war, as one participant mentioned:

To help everyone was what helped each of us make it through (Brownell & Nicole, 1999)

Family Support

Family support was also noted as an important support factor which helped war or violence-affected individuals in coping. A Syrian refugee highlighted the importance of family support:

The tough situation made us stronger to come together as family and stand by each other (Arenliu et al., 2020)

Other individuals mentioned how their family was a source of security for them during times of war. A Lebanese woman reported how laying in her mother’s arms made her feel protected:

I used to feel a sense of security and feel safe when she used to hold me (Charani, 2005)

Faith

Individuals’ faith helped them endure and be patient in the face of painful war and violence experiences. Many participants mentioned their faith in God as an important coping factor for them. After being physically beaten, a Palestinian man reported:

My strength to overcome this came from God. Only from God (Atallah, 2017)

Other individuals mentioned how their experiences strengthened their faith as it gave them hope. A Syrian refugee mentioned how a strengthened faith gave them hope in justice:

I become—let me say, I have a stronger faith that we have an afterlife because most of innocent people, they just die, and most of the bad ones remain and they’re having a good life. So I believe in the hereafter. (Taher & Allan, 2020)

Resilience

Despite the war and violence experiences they went through, many participants showed notable resilience. A Palestinian participant highlighted the resilience of his community despite living in a constant war situation:

The ability of the community to live in such an abnormal situation is considered one of our main strengths as Palestinians . . . If you bring “Western” people to live here they would not last even a few months mmm no I think they would not even be able to live here for a few weeks (Afana et al., 2020)

Other individuals living in war zones also showed resilience and a continued drive for pursuing life goals. A Syrian teacher working during war noted:

Our current living condition is very bad; however, I do not care. My aim is to pursue my goal in life to continue learning even during war (Sharifian et al., 2022)

Patriotism

Many individuals mentioned how their experiences strengthened their attachment to their countries. Experiencing war or occupation made them feel more patriotic and helped them persevere. A Kuwaiti woman who survived occupation reported feeling attached to her country and needing to protect it:

it’s our country. . .If everybody left then who’s going to stay here? It’s like you’re protecting your country. . .. If everybody leaves, then it’ll be harder for them [Iraqis] to leave (Khullar et al., 2019)

A Syrian refugee noted how she was more attached to Syria after the war:

I feel more connected to my homeland! ( . . . )My [Portuguese] boyfriend knows that, for me, Syria is my final destination (Matos et al., 2021)

Lebanese women also noted how despite several years of war, they still love their homeland and do not want to leave it:

We were not going to leave the land to those people. . .. we saw what happened to the Palestinians, . . .we were not going to leave. (Charani, 2005)

Resistance

Acts of resistance helped individuals cope with trauma experienced from war or political violence. Ways of resistance were multifaceted, but they helped the participants feel empowered in the face of oppression. A Palestinian man recounted his way of resistance:

When my brother was killed by the occupation, an energy exploded out of me. I began organizing strikes and throwing stones. Every stone I threw was like a building stone for freedom. I felt my brother was with me. Not left behind. (Atallah, 2017)

Another Palestinian man perceived his education as a form of resistance:

Our education, when we learn and develop ourselves . . . even in the war, we tolerated more than them . . . I consider this resistance. (Hammad & Tribe, 2021)

Positives out of a Painful Experience

Despite the traumatic experiences that the individuals went through as a result of war or political violence, many individuals either created a positive meaning out of their experiences, or experienced positive self-growth.

Positive Meaning-Making

Some participants reported finding a positive meaning out of their experiences. A Syrian teacher reported on how working in the war zone made her feel like she was serving her country:

I am proud that I am a school principal and teacher in the war zone. This is an exceptional opportunity to serve my country. I work very hard to educate this generation and keep them safe. (Sharifian et al., 2022)

An Iraqi refugee noted that he perceives his traumatic experiences as part of life’s lessons:

Sure it was hard. But it was all just part of an experience in life. Life lessons (Hirad et al., 2022)

Positive Self-Growth

Many individuals reported that experiencing traumatic events made them stronger and more resilient. A Palestinian woman noted how war experiences were not only negative, as they also made her a stronger person:

These events affected my personality both positively and negatively. They did not break me down but rather made me stronger. (Netland, 2012)

A Syrian refugee highlighted her positive growth after the war, as she became a stronger person:

I think that these events were good for me, because without the war I couldn’t be a strong woman (Matos et al., 2021)

Another Syrian refugee noted how war experiences made her more independent as a person:

In the past I was not able to take responsibility of handling things by myself. Now slowly I am depending on myself. (Arenliu et al., 2020)

Discussion

This review was the first, to our knowledge, to explore the experiences of individuals from Arab countries in the Middle East in going through and coping with war or political conflict. Through the meta-synthesis of the 27 studies, we identified four main themes related to these experiences: (a) war and violence as a life-defining experience, (b) war and violence experiences: accounts of hardship, (c) coping with painful experiences, and (d) positives out of a painful experience.

It is important to note that the results of this review must be viewed in context, as individuals from Arab countries in the Middle East have had different experiences with war. For instance, the Lebanese civil war was a result of sectarianism and internal religious conflict, while the ongoing war in Palestine has been a result of protracted external conflict and occupation (Dimitry, 2011). However, these countries still share the same culture, with similar religious roots and concepts of community and family (Dimitry, 2011).

As the social community and family play key roles in the lives of people from the Middle East (Dimitry, 2011), it is not surprising that this review found that social and family support are the main coping strategies for conflict survivors. As war and conflict are not individual but rather collective experiences, sharing these experiences with family and community could help universalize them and give them a bigger meaning. Universalizing these experiences helps individuals in coping with protracted conflict, such as the case of Palestinians (Afana et al., 2020).

The exposure to organized conflict and violence can be a significantly demoralizing and life-defining experience for survivors. Individuals reported feeling like they lost themselves, lost hope in life, and the future after surviving their experiences (Charani, 2005; Freh et al., 2013; Netland, 2012). A loss of self can arguably get in the way of the healing process for survivors, as a coherent sense of self would be needed for them to make sense of their experiences and to process them (Janoff Bulman, 1992).

Given that the homeland has particular significance in Arab culture (Sayigh et al., 2013), it was not surprising that patriotism and strengthened homeland attachment were noted by individuals from different countries, such as Kuwait and Lebanon (Charani, 2005; Khullar et al., 2019). Previous research has argued that the concept of homeland for refugees or individuals in exile transcends the geographical meaning of the homeland (Al-Rasheed, 1994). This concept becomes more symbolic and takes the shape of ethnic and national belonging (Al-Rasheed, 1994). Therefore, this can explain why some participants reported preferring to stay in areas of conflict and risking their lives (Khullar et al., 2019; Veronese et al., 2020), as their homeland represents an integral part of their identity which they felt the need to protect.

Despite the significant distress that the individuals reported experiencing due to exposure to war or conflict, they also reported positive outcomes. “The war made me a better person,” reported by a Syrian refugee in Matos et al.’s (2021) study, can summarize how some individuals perceived their experiences as positive occurrences in their lives which made them stronger and more resilient. Experiencing both distress and growth after war has also been found with other war-affected populations, such as Vietnamese veterans (Steger et al., 2015). Gaining a cultural understanding of the way individuals make sense of and interpret their experiences is important for the development of evidence-based practices of trauma healing in refugees (Hassan et al., 2015; Kevers et al., 2020).

The intersubjective dynamics of the research process is an important factor to note when conducting qualitative research (Probst, 2015). With a lack of reflexivity being a major quality limitation in a number of the studies reviewed, this could highlight a potential interpretation bias in the analysis of results. While this does not necessarily mean that the researchers were not reflexive at the time of conducting their studies (Gringeri et al., 2013), documenting reflexivity is considered an important aspect of validity in qualitative research as it adds transparency and trustworthiness to the findings (Probst et al., 2015). As the findings of these studies could potentially inform social work and practice that would affect vulnerable populations, consumers of this research should be able to trust the authenticity of the knowledge presented.

Strength and Limitations

This study is the first to systematically review and meta-synthesize qualitative data on the experience of individuals from Arab countries in the Middle East of going through and coping with war and armed conflict. Its use of qualitative data helps to gain an in-depth understanding of this population’s particular experiences. This review summarizes data on individuals from five countries who have been through conflict: Syria, Iraq, Kuwait, Lebanon, and Palestine. Another strength and novel feature of this review is that it focuses on civilians.

Some limitations must nevertheless be noted. The analyses in this review were limited to the qualitative data presented in the articles selected, rather than the original transcripts of the interviews reported. This presents a limitation to the breadth and depth of the interpretation of the data. However, to address this limitation, no qualitative accounts were left out of the final analysis, and they were all taken into consideration during the theme development process. Another limitation of this review was that it excluded studies not published in English or Arabic, and there might be potentially relevant studies conducted with refugees published in other languages, such as German or Turkish. In addition, the majority of the studies focused on individuals from Iraq, Syria, and Palestine, which could have limited the diversity of the experiences reviewed.

Implications for Practice and Future Research

This review has significant implications, which can be found summarized in Table 4.

Table 4.

Summary of Implications.

Implications for Practice

Implications for Research

The results can guide the therapeutic approach of both non-Arab and non-Middle Eastern mental health professionals and social workers in countries where refugees have sought asylum. The results suggest that psychosocial support interventions building on social and familial support could be beneficial. The results suggest that professionals could benefit from building trust through the therapeutic relationshipto restore trust for individuals. The results suggest that helping individuals derive a positive meaning out of their conflict experiences could be beneficial.

Future research should aim to explore the experiences of underrepresented populations in current research, such as Kuwaiti and Lebanese people who have experienced wars. Future research should develop and assess the effectiveness of acute culturally sensitive interventions for populations still under protracted conflict, focusing on contextually specific aspects of resilience.

Our evidence suggests that professionals working with these populations would benefit by taking into consideration the way they experience war or conflict and could build on their particular coping strategies. For instance, the results of this review can shape the therapeutic approach of both non-Arab and non-Middle Eastern social workers or other professionals in countries where refugees have sought asylum. These professionals could take into consideration the semantic meanings they might allocate to war.

The results of this review suggest that individuals from this population might be experiencing distrust of those around them as a result of conflict and betrayal. Professionals could therefore benefit from utilizing strategies such as building trust through the therapeutic relationship to restore trust for individuals (Laughton-Brown, 2010). Professionals and service developers could also build on social and familial support being main coping strategies in these populations. This could lead to the development of interventions centered around psychosocial support, building on coping mechanisms known to be relevant and helpful for this culture. Professionals could also, where possible, utilize thought-challenging and positive meaning-making strategies with individuals having experienced conflict to create new meanings for these experiences.

Nevertheless, it is important to highlight that individual differences between refugees could still be evident. For instance, Al-Rasheed (1994), highlights that not all refugees are attached to their homeland and strive to return to it in the same way. Therefore, the results of this review can serve as a guide and not a one-size-fits-all approach for mental health professionals. The results of this review could also help in the development of evidence-based practices for trauma processing and healing with war-affected populations in Arab countries in the Middle East or in refugee populations. Collaborations between opinion leaders and national psychiatric associations, such as the Arab Psychiatric Association, have previously been recommended for culturally sensitive assessment and treatment of mental health problems in Arab conflict settings (El-Khoury et al., 2021).

Future research should further investigate the war experiences of these populations. As the majority of the studies reviewed focused on individuals from Iraq, Syria, and Palestine, research should aim to explore the experiences of underrepresented populations, such as Lebanese or Yemeni civilians who survived protracted wars. Research should also aim to develop and assess the effectiveness of acute interventions for populations still experiencing conflict in their daily lives, such as Palestinians. These interventions can focus on contextually specific aspects of coping and resilience, which were reported in this review. The results of this review can guide the development of these tools, as it can inform future researchers on the particular ways these populations process and cope with war and political violence. It is important to note that research in the context of conflict presents ethical and logistical difficulties, which can lead to inconsistencies in offered interventions (El-Khoury et al., 2021). Research could therefore investigate alternative paradigms to established classification systems and traditional care models through collaboration between relief organizations and academic institutions (El-Khoury et al., 2021; Sibai et al., 2019).

Conclusion

This systematic review and meta-synthesis highlight the particular war experiences of individuals from Arab countries in the Middle East. This review revealed the culturally informed experiences of individuals from Arab countries in the Middle East in processing their war and conflict experiences. The findings can inform mental health professionals in planning and delivering interventions for this population.

Author Biographies

Ayah Hamadeh, BA, MSc, is a graduate from the Clinical Mental Health Sciences at University College London. She has experience of working with survivors of mass trauma and refugees. Her research interests cover refugee and war experiences, as well as trauma experiences.

Farah El-Shamy, BSc, MSc, is a graduate from the Clinical Mental Health Sciences at University College London. Her research interests relate to exploring different aspects of mental health in the Middle East, with a focus on qualitative methods to investigate help-seeking behaviors.

Jo Billings, BSc, MA, MSc, MSc, DClinPsych, CPsyhol, is a consultant clinical psychologist and an associate clinical professor in the Division of Psychiatry at University College London, with over 20 years of clinical work experience and in research with trauma survivors, including refugees of war and conflict.

Aisha Alyafei, BN, MSc, is a doctoral candidate at University College London, Division of Psychiatry. She has clinical and research expertise in adult psychiatric-mental health care. She focuses on qualitative scientific research and evidence-based practice. Her research interests include family caregivers of people with severe mental illness in Qatar and in the Arab/Middle East region.