Emergency Mental Health Care for Refugees of War

We spoke to our colleagues with CVT Jordan about emergency mental health care. Leah James, CVT psychotherapist/trainer, and Simone van der Kaaden, Country Director-Jordan, discuss what it means to provide care in a situation where refugees face significant ongoing challenges and how they use “vicarious resilience” to counter a dark world view.

Can you describe what emergency mental health means?

Leah James, MSW, PhD: In general, it refers to mental health services implemented in the midst or in the immediate aftermath of an emergency. In some cases, services might also be implemented in the longer recovery phase. There are different opinions about timing and what constitutes an emergency. It could be human conflict or natural disaster or a combination of these two compounded by other factors, such as ongoing poverty and injustice.

People often think about emergency mental health as being short-term and perhaps more psychosocial in nature because it is necessary to serve a large population of people with a lot of different kinds of intense needs associated with stressors in their current environment.

CVT defines emergency mental health slightly differently: we have an intensive therapeutic approach that emphasizes not only helping people to cope with ongoing stressors, but also to process significant traumatic experiences that have been part of the emergencies they’ve endured.

Simone van der Kaaden, MSc: When you look at mental health needs from CVT’s perspective, the focus is on refugees and internally displaced individuals.

But self-care and staff support are very important components of CVT’s ongoing training of the national clinical staff. These are often young professionals in a relatively new field: trauma rehabilitation services. We also integrate this into the external trainings we provide to other local (mental) health and social services providers.

Leah: One of the major challenges in emergency mental health care has to do with operating in a long-term ongoing crisis. When the work is not a few weeks or months but might be years or longer, there is a balance that needs to be struck. We’re providing emergency services where there is an enormous amount of need, but there is also a capacity building component. We’re trying to equip the national staff with a really solid set of skills to serve this population in a comprehensive way not only with CVT but with other organizations throughout the rest of their careers.

Simone: In Jordan, among the Iraqi and Syrian refugees, CVT works with survivors who have very recently experienced a horrific situation. But at the same time, CVT also works with survivors who might have had several horrific experiences that might be related to torture, might be related to war violence, but might also be related to other difficult situations earlier in their life. How do you sort that out? How does that define their mental health needs? The conflict in Syria and Iraq is ongoing, but we’re talking about a very long history violence witnessed or experienced by refugees.

Leah: Refugees seeking services at CVT might say that the emergencies are the wars in Syria and Iraq, and their experiences of losing family members, fleeing their homes, witnessing and experiencing violence. But it’s also the process of settling in Jordan and all of the related stresses: securing resources, adjusting to a very different life style, grieving for those who have been killed, anxiety about others back home, worry about children who often aren’t in school or getting the kind of education parents might hope.

These stressors are compounded by experiences of torture and war violence. It’s clear that it’s the interaction between two aspects – the traumatic experiences that people haven’t been able to process and the current stressors they’re facing – that really exacerbates the distress they are experiencing.

When is it appropriate to provide mental health services in a post-conflict or refugee situation?
Simone: From CVT’s perspective, we look at symptoms that people present, social support for the individual and the level of functioning. That comes with a set of criteria that they are either a torture survivor or experienced war violence or a combination of both. We don’t diagnose because the situation is not stable. We’re trying to support functioning so they can cope better with daily responsibilities.

But that’s a hard question. If you don’t do anything from day one, does that mean they become mentally ill? And how do people perceive mental illness? Many people feel that will stay with you the rest of your life.

Leah: Finding the right ‘window’ to provide mental health services such as counseling is challenging. Refugees who have left Syria typically have some sense of increased physical safety in their current situation. That said, they’re still being exposed to violence, violence in families, from the host community, all kinds of things are still going on and if you wait to provide mental health services, you can wait forever for these things to be resolved. People need to have some reduction in their emotional distress to cope effectively with the ongoing challenges in their life.

What are the goals in terms of treatment in an emergency mental health situation?
Leah: Ultimately the goal is to improve daily functioning. This means both reducing distress so people are doing better emotionally and also equipping people with coping skills in order to function in their current environment. Refugees are facing a lot of day-to-day challenges, and they need their full capacity to survive and take care of their families.

In this sense, emergency mental health should be seen as a basic need or a life-saving intervention. Without it, lives are at risk. We are seeing higher levels of suicidality, and in some cases, increased perpetration of domestic violence and child abuse associated with the stress people are experiencing. In addition, extreme distress interferes with refugees’ abilities to access the resources they need to survive. So in both cases, it’s a threat to life and to livelihood. At minimum, we want to help people to survive and more than that, we want them to live satisfying and hopeful lives.

Simone: They have to have a certain level of daily functioning as individuals. They should feel that they are able to leave their homes, able to reconnect with the people around them, who could be family or neighbors, or go to the market to get the vegetables to cook for their family tonight.

CVT wants to help people to start thinking about tomorrow again. And I express that very carefully. Some people, they really think of tomorrow. Others start reflecting on their situation as refugees, what the impact is for the longer term, and how they can make a meaningful life.

I think that these are the most realistic goals we can have given the circumstances. The first step of healing is to assist people to function.

Leah: Clients are not going to forget what happened, they’re not going to leave CVT services symptom-free, and in most cases, their lives are going to continue to be very difficult. But we hope they would leave CVT with a sense of some potential, some confidence in their ability to cope and survive. To view themselves as survivors with strengths and abilities as opposed to victims who are entirely powerless in the face of their current circumstances.

Are the mental health services in an emergency context very different than the kind of mental health care that can be provided when, say, a refugee is resettled in a third country?
Simone: Both types of care are doing very different things, in very different situations. It’s hard to compare. They might have similar symptoms, but how you work on these depends on context. We are limited and not just because we are emergency funded and don’t know how long we’ll be here. We also want to provide services to as many individuals as possible.

Leah: One of the ways that we aim to reach as many refugees as possible is through use of group rather than individual services. The group model  is important not only because it is an efficient way to serve a large number of people but also because it makes sense clinically. Refugees with trauma histories really benefit from the opportunity to connect with others who had similar experiences and to feel understood in this sense. Refugees seeking services at CVT experience a lot of isolation, shame, and self-blame and these issues are better addressed in a group setting rather than long-term individual psychotherapy setting.

Another aspect of the group model is that it gives people an opportunity to provide help to each other. This can be incredibly empowering. It puts a new spin on their perception of themselves - they’re not just victims receiving care but survivors with expertise about how to make it through genuinely awful experiences, who can use this expertise to support others.

You can even see the helping dynamic develop with kids. Initially, kids are kids and they want to tell their own story and they’re not always quiet or listening when others are talking. But as the groups develop, you see them really get excited about giving feedback to each other: “You’re courageous,” “You’re patient.” We focus on how it feels to get that positive feedback from your peers and how it feels to give that support. I think that this exchange of support is one of the active ingredients in healing.

What’s really nice is that, even after CVT groups end, there are often opportunities for kids and adults to meet up again. These supportive dynamics can be maintained well beyond the 10-week group counseling cycle.

Simone: I met a group of men last week, former CVT group participants, and they are so extremely proud. They show their mobile phones and say, “I have Malik from CVT in my mobile;” “I have Ahmad from CVT in my mobile.” They ask questions, contact each other between sessions. All of them say, “If I know something is going on in someone else’s life, or if there is something in the news, I’ll check on you to give you support”. I have heard it many times but every time they share that, I think, this is one of the reasons why we’re working in the groups and these are such achievements. To see their reconnection with life, with each other, and their desire to do good things in their lives.

Leah: I observed a teen boys group and during the last session, they wrote letters to participants who would come in the next group counseling cycle. They had these powerful pieces of advice about what they learned in the group and what they learned from surviving what they survived. They were excited to put their ideas on paper, knowing this was something future participants could look at and learn from. It turns the tables regarding how people perceive themselves and what they have to offer.

What are the challenges for therapists?
Leah: There are enormous challenges. Part of this has to do with secondary trauma and being exposed to really horrific survivors’ narratives, sometimes seeing pictures on cell phones, and seeing things in the news and knowing our clients were exposed to this.

There is also a burnout piece in addition to secondary trauma, which has to do with working in this intense, exhausting context. Staff are running all the time trying to meet needs and we’re never sure that we’re meeting these needs adequately. There is the feeling of just barely keeping your head above water.

Our staff struggle with recognizing that we can’t solve all our clients’ problems or fully heal them in the way we’d like to heal them. First of all, we are only working within the realm of mental health – we can’t prevent torture or war violence from happening to our clients in the first place, and we can’t solve their financial or housing problems. And even our mental health work has to be brief. So ultimately we can only hope to equip them with confidence, hope and some skills that they can use to move forward, but they must navigate the majority of their challenges independently.

It’s easy to see the world as a very dark place. We try to combat this with the knowledge that we can at least make a difference for the subset of people who we treat – however, it is extremely difficult to accept that we can’t help as much as we would like.

Simone: The most difficult part is to acknowledge we can’t help each and every individual who comes to CVT. We do a brief assessment and based on the outcomes at that moment, we have to make a decision: see them now, ask them to come back in the future, or refer to another organization. I like Leah’s description of the dark world view. You want to do good work with each and every person you meet. And people come to CVT and sometimes you have to say no.

Leah: Still, there are many benefits to doing this kind of work. As part of staff support efforts, we are trying to emphasize that there is a flip-side to secondary or vicarious trauma. Our clients’ stories are extremely painful, but they are also stories of survival and determination and faith and amazing instances of helping other people. Just like vicarious trauma, there is also a vicarious resilience process. As clinicians, we try to see the refugees we work with not only as victims of this very dark world but also as amazing sources of human kindness and strength. And we can learn and grow from our time with them. Although we can sometimes be traumatized by their experiences, we also have the opportunity to be inspired and strengthened by their resilience.