>> A Recurring Global Syndrome: Challenges in Treating an Epidemic of Communal Trauma

According to Mercy Corps (2016) report on the Syrian refugee crisis, every minute, 24 more people in the world are forced into migration by war, poverty, violence, or environmental issues, amounting to over 30,000 per day and sixty five million people total (para. 1). Mercy Corps (2016) states the refugee crisis is truly a global one, with the Syrian refugee crisis accounting for the largest and fastest growing displacement of peoples in the world (para. 2). The Syrian civil war is the backdrop for the sheer magnitude of displacement, death, and breaking down of social structures down to the family level: most refugees are women and children due to men lost at war (UNHCR, 2015), adding to the criticality of increasing access to resources for an already vulnerable population (p. 1).

Since the beginnings of the conflict in 2011, the U.N.H.C.R. (2015) estimates that over 400,000 people have been killed and well over half of the Syrian population has been displaced either internally or externally (p. 1). UNHCR estimates 6.5 million are externally displaced, although this does not reflect the massive number of undocumented refugees that significantly increases the real figures. Of these the vast majority have settled into the four closest neighboring countries of Jordan, Lebanon, Turkey, and Iraq.

Resources in these host countries are limited and severely stretched. The massive influx of refugees is adding stress to the political and economic situations in each of these countries. The situation is especially dire for women and children languishing in these new lands. U.N.H.C.R. (2015) reports four out of five refugee households are led by women, with most struggling for basic resources to survive (p. 3). In general, refugees are not allowed to work in host countries already burdened by large-scale unemployment. According to the U.N.H.C.R. (2015), over half of refugees are children under the age of 18 (p. 3). Many girls under age 18 must confront the burden of being married off, often as parents believe doing so reduces their child’s chances of being victimized by exploitation and rape. The UNHCR (2016) reports girls as young as 11-12 are being married for these reasons (p. 14). Financial stresses have led to child labor, prostitution, and black market economic activity that undermines both the host and refugee communities.

While the priorities humanitarian aid services typically concentrate on are the most concrete and immediately visible needs, increasingly, organizations addressing refugee health issues are identifying widespread trauma and expressing the critical need for psychosocial services. The World Health Organization (WHO) Doctors without Borders, International Medical Corps, and others have released reports on the degree of distress found amongst the refugees. The Migration Policy Institute (2015) research of Syrian refugees in Turkey found among female led families: 1/3 report being distressed and disturbed to the point of being unable to carry out activities of daily living in the last two weeks, 1/3 reported this being an all the time occurrence, and 2/3 felt unable to care for their children. It is estimated less than 13 per cent of these families receive any form of even limited psychosocial support services (p. 11).

Children are the most vulnerable to the immediate effects of war and atrocities. They have witnessed bombardments, destruction, killings, torture, loss of family members, and have experienced displacement and the loss of the familiarity of family, home, school, and community. In many cases, they have been tortured themselves. Machel (2000) argues, “One of the most significant of war traumas of all, particularly for younger children, is separation from parents – often more distressing than the war activities themselves.”

In attempting to assess the psychosocial impact of mass exposure to displacement and trauma that the Syrian refugee population has experienced, it is important to understand the role of cultural influences in shaping the collective experience of extreme stress. Wilson (2005) argues that culture shapes the way individuals form trauma complexes after a traumatic experience. He argues that emotional experience (such as hyper-arousal, startle response, irritability, and depression) may have different effects based on cultural overrides. Smith, Lin, & Mendoza (1993) state:
Humans in general have an inherent need to make sense out of and explain their experiences. This is especially true when they are experiencing suffering and illness. In the process of this quest for meaning, culturally shaped beliefs play a vital role in determining whether a particular explanation and associated treatment plan will make sense to the patient.

Husain, Nashwan, and Howard (2016) point out the influence of cultural traditions in the Middle East discourages verbal displays of emotion, and traumatic stress manifests as somatic complaints. Complaints such as chest constriction, heartache, bedwetting (children), attention deficit disorder, sleep disturbances, and eating difficulties may be somatic indicators of how they experience their traumatization. They go on further to explain the critical role of gender dynamics in providing care. Examples of this were male professionals maintaining appropriate physical distance with a female Arab client, and, for female professionals working with an Arab male, to take the time to develop rapport and establish themselves as an expert in the field.

According to U.N.H.C.R. (2015) on refugee psychosocial needs various psychological responses have been observed in refugee children such as attachment difficulties, increased clinginess, sleep disturbances, bedwetting, easily startled by loud noises, anxiety, chronic stomach aches or headaches, mutism, and eating difficulties (p. 20). According to our own experiences in SHC psychosocial clinics, parents most commonly bring their children in with complaints of bedwetting, nightmares, stomach aches, inability to stay still, or difficulty getting them to eat. Additionally, signs of unhealed traumatization witnessed in our clinics include: numerous reports of refugee children being bullied at school by children from the host countries; reports of intrusive negative and hostile thoughts; panic response to jets flying over the area; aggressive acting out behavior by young and adolescent boys; and self-mutilation/cutting.

Increasingly Syrian refugees are referred to as a “lost generation.” Education Cluster (2016) reports prior to the civil war in Syria, school attendance was universal and the country as a whole had an upper 90% literacy rate, ranking amongst the highest in the world. The Migration Policy (2016) research found there has been some improvement in school attendance since the beginning of the mass forced migration, in general, attendance rates are sporadic and overall quality of education is inadequate (p. 11). As a result, Education Cluster (2016) found Syria to be currently ranked second-lowest educationally globally. All the countries where the refugees have migrated report overwhelming psychological/mental health needs amongst the refugees.

Only a small percentage of refugees receive any form of psychosocial services to address the severe and pervasive depression, anxiety, post-traumatic stress disorder (PTSD), and other mental health disorders service providers are witnessing throughout the population. An exact figure of how many refugees are receiving psychosocial services is difficult to assess. In many cases, due to reporting criteria among various humanitarian aid organizations, a service that is reported as psychosocial may simply be documenting an assessment of needs, with no capacity to actually offer direct treatment services. Additionally, there are cultural stigmas which restrict refugee participation in accessing even extremely scarce psychological and psychiatric services. A typical response at SHC field clinics would be “I’m not crazy, why were we sent here?” The loss of family and community, education and employment possibilities, cultural self-identity, and festering, unhealed psychological wounds raise serious concerns about the transmission of these unresolved traumas into future generations as transgenerational trauma.