Co-authored by Justin Hett, clinical advisor for mental health, and Noor Al-Sagher, tele-mental health trainer/therapist, both based in Amman, Jordan. This article was written for a year-end presentation about CVT’s tele-mental health work in the Middle East North Africa (MENA) region.

For many years, CVT has extended range of clinical services globally to beneficiaries living in both camp and community settings. This remains at the heart of what we do as an organization. However, we are always thinking about those who are not able to access services. This is what led to the development of CVT’s first tele-mental health service in the Middle East, which was officially launched in 2021.

However, we are always thinking about those who are not able to access services.”

In several CVT projects across the Middle East and North Africa, we work with human rights defenders, documenters, former detainees, torture survivors and families of missing people, many of whom are deeply impacted by past traumatic experiences or the challenge of working in low-resourced contexts where they face opposition from governments or their own community on a daily basis. Many of these people are unable to access much needed face to face support because they live in a place where such services do not exist, or where there is a language barrier, or even because accessing them may compromise their security in some way.

As our psychosocial support work became more meaningfully integrated with our longstanding engagement with human rights defenders, we deepened trust and credibility with new activist communities. We began to get requests for support from people located outside of the region, and this is when we first started providing remote services in a limited way. However, as the number of requests increased, we realized that a more structured approach was necessary, and this is when our team in the region began to think about how to offer remote therapeutic services in a more robust way. Significant work was needed to adapt existing clinical approaches, develop assessment tools, identify secure communication platforms and establish secure storage and transfer protocols for sensitive beneficiary information. All this needed to be in place before staff recruitment, training and advertising the service could begin.

As our psychosocial support work became more meaningfully integrated with our longstanding engagement with human rights defenders, we deepened trust and credibility with new activist communities.”

So how does the service work? Those interested in accessing tele-mental health contact CVT using a secure messaging service. They are then offered an assessment session which looks at both their needs and suitability for this type of support. Based on this assessment, and after informed consent has been obtained, individual treatment goals are identified and the person is offered up to five psychosocial support sessions. Upon completion of these sessions a follow-up assessment provides the participant with the chance to reflect on learning and progress made towards their goals. Sessions are conducted using a HIPAA-compliant platform, and files are stored securely.

We have had to navigate a number of different logistical challenges in delivering this service. Sometimes beneficiaries are not familiar with the platforms we are using or cannot find a private space to take the call. Electricity outages and internet connectivity are issues in some locations. In one workshop we even faced a situation where bombs were falling close to where the trainees were located. Despite these difficulties, since the service was launched, we have provided support to 72 individuals located in 11 countries.

With the success of this approach, we have also continued to innovate and expand beyond individual psychosocial support sessions. Some beneficiaries struggling with physical symptoms have been able to receive remote physiotherapy sessions for example, and we have also provided training workshops to over 150 individuals working with civil society groups in Syria, Yemen and Turkey. These workshops have focused on the importance of self-care, as well as trauma-informed interviewing skills for those working in the field of human rights documentation. Looking ahead, through collaboration with other projects, especially those related to justice, accountability, and human rights activism, we are hoping to further support witnesses and victims participating in universal jurisdiction cases.

And how do individuals respond to this form of care? Here are stories from two people who have benefitted from the tele-mental health service. Names and some details have been changed in order to respect confidentiality.

Ahmad is Syrian. He was arrested alongside many other men during a raid on his village by government forces in 2015. He was detained in prison for six years, during which time he experienced psychological and physical torture, and was not able to see his family. Many of those with him in prison did not survive; however, he was released in 2015 and reunited with his family in a neighboring country. After his release, he struggled with physical pain in his body as well as flashbacks and sleep problems.

He also had great difficulty reconnecting with this family. While he was in prison they had to fend for themselves, escape Syria and settle in a new country. His wife had to quickly learn how to manage her family on her own, find work and begin learning a new language. She became much more independent. This was a surprise to Ahmed, and he struggled to find his place in this new dynamic. Not only did he feel disconnected in his home, but also in his community. His physical pain and not knowing the language meant it was hard for him to find work. On top of this he faced discrimination as a Syrian, and the residency he was given did not allow him to move between towns to look for work. He said “I was released from the small prison and put in the big prison.”

He said ‘I was released from the small prison and put in the big prison.’”

Ahmad first received support through attending a workshop run by CVT. This gave him the chance to begin understanding the impact of his experiences in his mind and body. During the workshop he heard about the tele-mental health service and knew that he needed some individual support. This service was perfect for him since he lived far away from any center that provides care. During the sessions he learned techniques to help him manage his emotions and build connections with his wife and children. As a result, he is now able to enjoy spending time at home much more than before. Establishing a healthy daily routine also meant that his sleep improved. Although he still does not have work, he feels more hopeful about the future and better able to set manageable and meaningful goals for himself.

Tala is a Syrian human rights defender who also benefitted from the tele-mental health service. She escaped from Syria and now works from exile with an organization that documents violations experienced by detainees in prisons. For Tala her work is much more than a job. It is her life. She works long hours and finds it hard to establish any sort of boundaries between her professional and personal life. She cares deeply about what she does, but is also weighed down by the enormous stress of her work. As a survivor herself, hearing many difficult stories brings up painful memories of her own experiences. She feels exhausted but unable to stop. She lives on her own and her friends don’t really understand what she does. She often feels alone.

Tala heard about CVT’s tele-mental health service from a friend. She was skeptical at first, especially about having sessions online, but she knew that there were no options for Arabic language support in the town where she lived, so she decided to give it a go. It was so nice to speak to someone in her own language who understood what she had been through and the pressures she was facing in her work.

She quickly felt comfortable in the first session and reassured about how her information would be kept confidential and secure. In the second session Tala was encouraged to think about her wellbeing in a holistic way using a visual tool representing different domains such as psychological, physical, financial and social. This helped her to identify some gaps and consider new resources that were accessible to her. She also discussed the issue of boundaries and how she might create some realistic lifestyle patterns which would help her work feel more sustainable. Through receiving CVT’s support, Tala now understands that looking after herself is not an indulgence or a luxury, but rather a strategic way of her being more effective in the important work that she is doing.

The CVT team is deeply committed to this kind of care and eager to continue developing it and to further extend the reach of CVT’s support to those in some of the least accessible contexts in which we work.