The role of war trauma survivors in managing their own mental conditions, Syria civil war as an example

Abstract

War trauma leads to a wide range of psychological consequences and disorders that can be quite disabling to individuals and their families. At times of war, existing resources become strained to cope with all demands of trauma sufferers. The survivors’ role of managing their own mental conditions becomes highly important and relevant as a way of reducing the resulted suffering. Unfortunately, this role is often ignored or trivialized by all concerned. The self-efficacy and resilience of people are the factors not to be underestimated and should be built upon. Reaching solutions are generally more satisfying and long-lasting when the affected person has taken a positive active part in finding them. Encouraging the use of own resources and experiences and using own problem-solving skills can be all that is needed for survivors to feel enabled. Engaging survivors and focusing on promoting recovery and social inclusion along with the use of self-help skills make them feel more positive about their own conditions. Being more involved, taking even small steps reduces the development of learned helplessness and reduces the psychiatric morbidities.

INTRODUCTION

Traumatic experiences in war zones are often widespread and affect large number of exposed people. The negative effects of these experiences are more likely to worsen when survivors are displaced or end up seeking refuge in unfamiliar places.

It is well established that trauma can turn one's world upside down and cause disruption to all aspects of life. A wide range of intense emotions and reactions can ensue in the aftermath of traumatic events. The difficulties of living in a war zone, problems during the journey of displacement, and the experience of torture and trauma of various types[1] are all found to be related to mental health problems among refugees.

People exposed to war atrocities respond differently depending on various internal and external factors. The extent and severity of the trauma, the duration of exposure, their frequencies, for example, repeated torture of detainees and living in a war zone are some factors to be considered. Depending on these various factors, some survivors may only experience the well-documented acute stress reaction and may well recover quickly. Clinically, the stability of premorbid personality and availability of support can make a big difference in terms of reaching a resolution and moving on. Others can have more clinical difficulties, particularly those who experienced previous trauma with on-going stress and who have no support from family or friends. Among the consequences of war, the impact on the mental health of the civilian population is one of the most significant. Studies of the general population in many conflict areas over the years show a definite increase in the incidence and prevalence of mental disorders.[2] These consequences also include other sporadic psychological presentations not necessarily amounting to the diagnoses of mental disorders. A study done on Syrians reveals that 39% of the family members experienced feeling distressed, disturbed, or upset to the point of having serious difficulties with being active. This was higher in camp settings (47%) than in the community (29%). Sixty-eight percent of them (22.5% of the total population) reported problems in properly caring for their children due to feeling disturbed or upset.[3]

In 2012, around 7% of Medicine Sans Frontier's mental health patients in Domeez Syrian refugees’ camp displayed symptoms of a severe mental disorder. In 2013, this number has more than doubled to 15%.[4]

There are not many well-validated studies done on the displaced Syrians looking specifically at the prevalence rate of psychiatric disorders. A cross-sectional study on Syrian refugees in a tent city in Turkey showed 33.5% prevalence of posttraumatic stress disorder (PTSD).[5] However, I normally treat figures produced in refugee camps surveys with caution as these are challenging environments with many confounding factors that can affect the results.

Research also demonstrates a strong link between exposure to traumatic events and substance- and alcohol-use problems.[6] This can complicate the mental health presentations of survivors and need to be kept in mind to be properly addressed.

Mental health service provisions have always faced practical difficulties, and there are often shortages of professional manpower to meet the mental health needs of population at the best of times, let alone at times of war. One of the priorities at times of emergencies is to protect and improve people's mental health and psychosocial well-being (Inter-Agency Standing Committee).[7] In a recent report, the UNHCR recommended that mental health services for refugees has to be increased,[8] but there is no clear mechanism in this report on how this might be achieved.

Amid the chaos of being in a war zone, disruption to operational systems and high demands on existing mental health resources is in commonplace. With lack of resources, the attention needs to be focused on what the survivors themselves and their communities can do in the interim. Therefore, the very important role of the affected individuals themselves should come into play. Unfortunately, this role of trauma survivors in managing their symptoms are often overlooked, ignored, or trivialized by all concerned. This role should be highlighted, encouraged, and supported, and there can be many ways to do this.

The Syrian civil war provides a painful example of such a widespread war trauma with millions being affected by the physical and psychological consequences of it. More than 4.6 million Syrians are now registered as refugees according to the latest figures from UNHCR, December 2015. Over the last 4 years, I have volunteered and visited Syrian refugee camps and communities in Syria neighboring countries in several occasions. Each of these visits lasting for a week at the time, and arranged with other local volunteers to help assess and manage some of the mental health needs of the refugees. During these visits, I saw and interacted with tens of trauma survivors and patients and their families. I also participated in training some healthcare workers and other volunteers in recognizing and dealing with mental health problems of refugees.[9] From my experience and observations, I here highlight what war trauma survivors can do to deal with their own mental conditions and the principles that this role can be based on.

PRINCIPLES OF APPROACH

The way to approach and help survivors is based on the severity of trauma and its effects on their level of functioning. It will also depend on the environment they are in and whether they have moved to a safe place. Millions of Syrian refugees and internally displaced suffer the added negative uprooting effects in the top of the consequences of own subjective traumas. In my view, most people in this situation will experience a varying degree of distress and psychosocial presentations. It is in this group that I think trauma survivors can make a real difference when their role is encouraged and fulfilled. Of course, a smaller percentage will develop more severe dysfunctional mental disorders that require specialist's help in first instance. Still for these sufferers, the individual's role needs to be encouraged as this will help in better engagement with the treatment process.

Self-management and attempting to reappraise own situations, sharing it, and having a rethink about what went on can lead to finding some resolution to problems. Self-management is not a substitute for medical care or individual counseling, but is to help survivors work with their clinicians and others in the road to recovery. The principle of self-management has been developed mostly in the field of psychology, and Bandura's self-efficacy theory is the one most widely referred to. It highlights the individual's belief to successfully learn and perform specific tasks using own resources. The theory specifies the modes of influence for building a resilient sense of efficacy and the processes through which this belief system impacts the quality of psychosocial functioning. Traumatized individuals avoid reality testing and thus insulate themselves from corrective experiences and enabling coping aids that restores corrective reality testing.[10] Strong self-efficacy leads the individual to feeling in control, therefore feeling confident about own ability to achieve goals and its role in posttraumatic recovery.[11]

Another essential principle is the avoidance of learned helplessness in survivors as this can creep in and worsen suffering and psychiatric morbidity. For example, depression and other related mental health problems may result from a perceived absence of control over the outcome of a stressful situation.[12] This learned helplessness in itself can contribute to poor health where people may neglect their diet, exercise, and medical treatment, falsely believing they have no power to change. Various behavioral personal changes start taking place as a result and the more people perceive events as uncontrollable and unpredictable, the more stress they experience and the less hope they feel about making changes in their lives.[13] A perceived bleak situation where there is no end in sight, like the current Syrian civil war, can greatly affect people's mood and productivity and further complicate their negative feelings. One can easily feel the sense of anger and frustration among people in these situations, and the possible psychological effects of this. It is therefore of a paramount importance at such stage to encourage individuals to try and take more active role for maintaining their wellbeing and health to minimize falling into helplessness or hopelessness mode. Offering advice on taking direct positive actions to cope and make some small changes can help, particularly for the nonseverely affected.

Helping survivors to challenge own assumptions about the lack of having any control can often result in better outcomes. This is based on cognitive behavioral therapy (CBT) and its principles, which in turn is based on the scientific finding that how we think about a situation determines our emotions and behaviors. It has to be acknowledged here that a degree of willingness of survivors to participate in this type of approach is essential to begin the road to recovery. Encouraging active participation, whenever possible, will increase the likelihood that the work done becoming more tailored to each individual survivor's current psychosocial needs.

Furthermore, it is vital to invest in the survivor's resilience and capability to recover and build on their personal strengths and resources to develop their own approach to deal with difficulties. Extensive work has been carried out on resilience in the field of bereavement and trauma.[14] The conclusion of this work emphasizes the human ability for rebound and that we should not underestimate human capacity to thrive after aversive events.

EFFECTS ON CHILDREN

Sadly, every conflict forces children to live through some terrible experiences that can affect every aspect of their lives. Children are usually considered more vulnerable to the immediate effects of war atrocities. The impact of displacement, being a refugee, the discomfort of being away from the familiarity of home environment, disruption to schooling and daily routines can have terrible consequences on children. The added stress for children when displaced without their families or when losing a close family member can be devastating. Worst still is the increased possibility of exploitation and abuse, i.e. sexual, emotional and physical, or child labor, which is often overlooked as another type of abuse.[15] During my volunteering trips to Syrian refugee camps, I had hardly seen or heard of any child who was not affected in a way or another by the above. These include loss of family members, injuries, witnessing bombardment, killings, displacement, and so on.

It has been argued that “one of the most significant war traumas of all, particularly for younger children, is simply separation from parents – often more distressing than the war activities themselves.”[16] Thus, unaccompanied children constitute one of the most vulnerable groups. “The physical, sexual, and emotional violence to which children are exposed shatters their world. War undermines the very foundations of children's lives, destroying their homes, splintering their communities, and breaking down their trust in adults.”[17]

Various psychological responses are observed in children such as increased clinginess, mutism, attachment difficulties, anxiety, behavioral problems, sleep disturbances, bed wetting, and PTSD. When it comes to recovery, there are a number of factors that determine the extent to which children are traumatized as a result of wars. The nature, duration, and intensity of the event need to be taken into account.[18] The characteristics of a child have a mediating effect on how well the child survives and thrives after single or chronic traumatic events. Also, relevant here is the child's previous experience of violence, the degree of resilience, knowledge, skills, and abilities.

It is important to remember that children are often incredibly resilient. Given the right environment and protection, they can remarkably recover from a really tough start in life. Re-establishing familiar routines of home and community life, i.e., going to school wherever possible can help children achieve a sense of normality.

Various nongovernmental organizations have developed programs to help children who witnessed trauma or have been in a conflict zone. These valuable resources and the practical advice they provide need to be learnt from and widely spread. For example, the children's charity, War Child[19] work focuses on empowering children to overcome the impact of conflicts and provide emotional and practical support. The principle for this as mentioned above for survivors, in general, is meant to make the affected children feel a sense of control and finding a way around things. Also of note is the valuable work of Children and War Foundation program of teaching recovery techniques.[20] The aim of the program is not to “cure” symptoms but rather to give children better coping strategies so that they would feel sufficiently more in control of their reactions. I have taken part and participated in some of this work on Syrian children refugees in Jordan. Its positive effects on children and benefiting from the support of their families and the opportunities available in schools were quite significant. Teachers, parents, and other volunteers can be trained on these programs and with supervision, the benefits can be widely spread.

Play and art groups may be all that is needed to help some less affected children cope better.

SPECIFIC THERAPIES

When the trauma survivor becomes dysfunctional, as a result of it, effects of trauma and where diagnoses of severe mental disorders are made professional help needs to be sought. Here, proper assessment of symptoms, risk, and needs are required. Depending on the individual and specific cases, various therapies can be recommended but this understandably requires qualified therapists and resources.

There is a strong evidence for the use of eye movement de-sensitization and reprocessing (EMDR) in the treatment of PTSD and this was showed in a meta-analysis.[21] EMDR, from my own experience of working with Syrian trauma survivors, can make a huge difference, in particular, reducing the intensity of flashbacks and to improving the general wellbeing of survivors. To remind a survivor of their current relative safe environment that they might be in and they are not under current threat, can shift their attention to the here and now and to gradually start seeing past events as they are in the past. From my observation, even one or two sessions of EMDR at the time can make a significant improvement. A recent pilot randomized controlled trial indicated that EMDR may be effective in reducing PTSD and depression symptoms among Syrian refugees located in a camp.[22]

Certain therapies such as trauma-focused CBT to treat posttraumatic stress and related emotional and behavioral problems in children are also of proven benefits. It is a well-validated child and parent psychotherapy approach.[23] Finding a qualified therapist to deliver this can be an issue though particularly when resources are overstretched.

Medications also may be indicated in some cases of PTSD to treat the symptoms of accompanying depression and anxiety and this will require a specialist follow-up.

There is also a potential role for the use of telepsychiatry in providing supervision, education, and consultations to local mental health providers and clinicians in conflict areas, such as the Syrian conflict.[24] Telepsychiatry may also be useful in capacity building and training of other health care workers to help in managing common mental health problems in areas where specialist's help might not be available. Further evaluation and studies of such potential use may be needed.

Even when specialist help is available, there is still an important role for the affected person to play. This here includes being open about experiences and feelings and how they progress. Engaging in the process, making the effort to achieve tasks between therapy sessions, and adhering to prescribed medications are essential steps to achieve improvement. Without this individual engagement and active participation in the process, there might not be much progress made.

WHAT CAN BE DONE

Fortunately, for the majority of people, the effects of war trauma are mild to moderate in severity and there is often plenty of room for improvement if the role is adopted by survivors. From my perspective and noting the above-mentioned principles of approach, it is important to remind survivors that there is no right or wrong way to think, feel, or respond to what they have experienced. Here, it helps to encourage the acceptance of own feelings, no matter what they might be. Doing so can go a long way to remove some of the pressure of certain expectations which can be disabling and counter-productive. Working with Syrian refugees, I found various activities that war trauma survivors may do which can lead to improvement on how they feel. Of course, this may not be suitable for everyone, particularly those who are severely affected requiring some form of specific therapy first as highlighted above.

Helping survivors to put things into perspective and by acknowledging the difficulty to think beyond the moment can assist them in moving on. This concept can be explained at individual, family, or a small group level, and can be arranged in refugee camps.

I found giving a brief general explanation of this to groups, for example, in a community center or in a focus point at in the camp, i.e., a mosque, can put people at ease and encourage them to start talking to each other and to better understand their feelings. Many do not seem to understand the psychological experiences they go through and a simple explanation of the psychological consequences of trauma can be a real relief to them. Family cohesion and community gathering, where possible, are of high importance in providing a sense of belonging, particularly when people are displaced at times of war. A study by UNHCR of the psychosocial needs of displaced Syrians in Jordan[3] strongly recommends supporting community-based interventions that promote resilience, skill building, functioning, and a sense of productivity to enhance wellbeing.

Delivering the aforementioned principles might require some trained professionals and this can be done by implementing some training programs gleaned to this purpose, i.e. training the trainers. Another good example to follow is the WHO mental health Gap Action Program[25] that can help train health professionals and volunteers to adopt some components of this approach. This focuses the training on nonspecialized health settings to increase capacity in meeting the mental health needs of people and help them find ways to cope with the consequences of trauma.

Programs like the one developed by Trauma Survivors Network, TSN NextSteps[26] for trauma survivors help people become good self-managers. The goal is to build their confidence and skills to better manage problems such as pain, anxiety, and depression, and it helps them have better relationships with family, friends, and clinicians by improving their communication skills.

Here are some examples I found of benefit for survivors of war trauma to do. Although they might seem small, it is about taking some initiatives and building on them. This can also be promoted by trained healthcare worker who may come in contact with survivors as well. They include:

• Actively learning about trauma and its effects by attending educational sessions, where possible, computer-based information, and reading leaflets, and this can help survivors be better informed of what to expect. Improving patient health literacy help people make appropriate decisions about their health care[27]

• For the displaced persons to try to connect with the new community, where possible, i.e., as a refugee this can give a better feeling of belonging, particularly when the receiving host country is hospitable[3]

• Re-establishing some daily or weekly routine is important as there is comfort in the familiar, for example, encouraging exercise such as walking where safe to do so, i.e., in refugee camps

• Challenging own sense of helplessness and negative thoughts, i.e., survivors probably cannot control war activities but can control things in their daily lives

• Talking to family and friends to ventilate and accept help when offered can reduce the sense of isolation and alienation

• Being kind and helping others, where possible, may be as a volunteer, and participation in social activities such as attending funerals, assist others when possible can help survivors connect with reality

• Self-help books can be of benefit as they address a wide range of problems that survivors might experience. These books provide tips and can teach various coping and problem-solving skills

• Asking for help when necessary and not shying away, it was not your fault anyway.

CONCLUSION

The psychological effects of war trauma are common and present in many ways at individual level and affect communities as a whole. The unaddressed consequences on survivors can be disabling and beyond what existing local services can cope with. It becomes highly important here to focus on what the affected people can do to help themselves cope with their predicaments. Various principles are highlighted in this article supporting the importance of this role and how it can be fulfilled. Human resilience and ability to recover after traumatic events should not be underestimated. Besides specialized therapies that might be required for specific cases, there are many things that can be done at personal and community levels to help regain confidence and feeling of being in control. The role of trauma survivors in self-managing their mental wellbeing needs to be better understood and encouraged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.