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Abo-Hilal&Hoogstad

Syrian mental health professionalsas refugees in Jordan: establishingmental health services for fellowrefugees

Mohammad Abo-Hilal &Mathijs Hoogstad

While the con£ict in Syria rages on, one psychiatrist

and several psychologists, all of themSyrian refugees,

have founded ‘Syria Bright Future’, a volunteer

organisation that provides psychosocial and mental

health services to Syrian refugees in Jordan. This

¢eld report describes how the organisation assists

families in settling after their harsh journey, in

adapting to newlivingconditions and circumstances,

coping with di⁄culties they encounter and strength-

ening their resilience.‘Syria Bright Future’does this

by providing short term support and counselling,

and by referring individuals and families to other

international and Jordanian organisations, or to

informal support networks of Syrian refugees for

further assistance.

Keywords: Jordan, mental health and psy-chosocial support (MHPSS) needs, refugees,Syria

Introduction: mental healthwork in SyriaIn Syria, mental health care has been neg-lected to the extreme, even in comparisonto neighbouring countries, such as Iraq,Jordan and Lebanon. The limited mentalhealth care system that does exist is highlyoriented towards medical treatment anduse of psycho-pharmaceuticals. Graduatesin clinical psychology have very limitedexperience working with actual clients. It is

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also uncommon for clients to have access tosocial workers, case-managers, counsellorsor psychologists. In fact, many clients withcommon mental health problems prefer tolook to traditional healers for support.1

Also, psychology is not regarded as a veryrespectable profession. Moreover, there islittle opportunity to train as a clinicalpsychologist, psychiatric social worker, orpsychiatric nurse. Psychology, as a ¢eld ofstudy, is part of the Faculty of Education inSyria. As a result, the only options are tobecome a school counsellor and, therefore,part of the Ministry of Education, or towork with a nongovernmental organisation(NGO), as a social worker dealing withchildren with learning di⁄culties, develop-mental problems or physical disabilities.For more specialised services, or care inclinical psychology, job opportunities arevirtually non-existent. There are very fewways to receive structured and well super-vised education in clinical interventions.Additionally, there is no legal frameworkfor psychologists to become registered asa psychotherapist or clinical psychologist.Procedures for accreditation, licensing oradvanced studies in clinical psychology donot exist. Some motivated students havereceived informal training in clinical psy-chology through a handful of professors,who studied abroad and now train these

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Syrian mental health professionals as refugees in Jordan: establishing mental health services for fellow refugees

Intervention 2013, Volume 11, Number 1, Page 89 - 93

students in their private clinics. However,the mainstream psychotherapeutic methodremains client-centred therapy.During the regime of BasharalAssadandtheBa’ath party, all formal mental health andpsychosocial support (MHPSS) activities fellunder the under scrutiny of the state. It wasimpossible to form, or establish, an indepen-dentmental health organisation or network.In spite of these restrictions, in 2008, aninformal Syrian psychology network wasformed. It consisted of several psychologists,psychology students, two psychiatrists andothers whowere also convinced of the neces-sity of mental health care. The members ofthis network came from all major cities andregions in Syria. Most knew each other fromstudying or working together. One of themain goals of the network was to spreadthe idea that improving mental health isnot solely a job for psychiatrists, but that itrequires a multidisciplinary approach, aswell as attention to cultural and spiritualaspects of the Syrian context. The networkorganised meetings and events, such aslectures, discussions, movie events, andworkshops that focused on speci¢c topics ortherapeutic interventions.In Syria there are many obstacles for peopleto access psychological support, not onlythrough the lackof service providers, but alsodue to the stigma attached to having psycho-logical problems.Traditional beliefs may alsokeep people from seeking psychological sup-port. For example, people su¡ering fromschizophrenia or other severe mental healthdisorders are often believed to possessed by aspirit (djinn). Some disorders, e.g. severeanxiety disorders or conversion disorders,are perceived as being caused by the ‘evil eye’(thought to hurt someone or bring bad luck).With these common belief systems, peopleoften refer to traditional healers known assheikhs.

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The Syrian Psychology network has beentrying to improve the relation betweenmental health care professionals and sometraditional healers whose practices wereacceptable, and did not contradict wellestablished and agreed international guide-lines of psychiatry and psychology. The net-work aimed to reinforce these acceptabletraditional practices, in order to tackle thewidely used, yet unacceptable, practices.After the violent con£ict in Syria started in2011, most, if not all, mental health activitiesin the country came to a halt. It has alsoseriously a¡ected the personal lives of themembers of this informal Syrian psychologynetwork. Some members tried to avoid thecon£ict, where others joined the uprisingagainst the regime. As the ¢ghting intensi-¢ed, people became scattered, to save them-selves and their loved ones. Many of themale members were arrested and su¡eredfrom torture and ill-treatment during theunrest (Anonymous, 2012).

Refugees building a mentalhealth and psychosocial supportteam for fellow refugeesAt the end of 2011, several members of theSyrian Psychology network were able to £eeto Jordan, where they founded an MHPSSteam for other Syrian refugees. This wasanything but easy. At that time, the begin-ning of 2012, there were no speci¢c inter-national funds allocated to provide mentalhealth services to Syrian refugees.2 Beingrefugees, it was complicated for the Syriansmental health professionals to obtain work-ing permits, to get formal approval to prac-tice as a licensed medical or mental healthprofessional, and to obtain o⁄cial approvalto register as an organisation. Regardless,they started ^ without an o⁄ce, car or fund-ing. Right now, as the group of Syrian refu-gees in Jordan and the number the people

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Abo-Hilal&Hoogstad

who need support and/or assistance is grow-ing, as more and more members of theSyrian psychology network are £eeing toJordan, and more and more other Syrianrefugees learn about this group and chooseto volunteer.3

The founders choose the name Syria BrightFuture (SBF). SBF is an independent, non-political Syrian organisation, that strives toprovide psychosocial care in an integratedway, through a multidisciplinary approach.This approach is one where the psychiatrist,psychologists and social workers cooperateand o¡er both basic psychosocial servicesand specialised clinical care for people withmental disorders. The team currently con-sists of a psychiatrist4, ¢ve psychologists5

and 10 community volunteers, while morepeople would like to join6. At present, SBFtries to act as the entry point for mentalhealth actors in Jordan and aims to visit,screen, detect, assess, refer and follow up onpeople from the Syrian refugee community.The organisation is a currently operatingin and around Amman and Irbid.

Working with volunteersThe community volunteers have no formaleducation in MHPSS work. They arerecruited based on personality, motivationand commitment. All have, at least, a highschool diploma. The current team of com-munity volunteers consists of physician, aspecialised surgeon, engineers, a kindergar-ten teacher and various students. Beforebecoming a community volunteer, thesecandidates receive training from the psy-chiatrist and psychologists about signs andsymptoms of mental disorders, communi-cation skills and providing psychological¢rst aid. During their ¢rst days at work,the potential community volunteers gothrough a sort of selection and trainingprocess. They pair up with more

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experienced sta¡ and learn by observationwhile they visit families. They attend teammeetings and case discussions. As soon asthey have acquired enough basic skillsand gained enough self-con¢dence, theyformally become community volunteers.In their daily work, a small group of two orthree community volunteers and/or a psy-chologist visit families they know or havebeen referred by other people or colleagues.During each ¢rst visit to a family, they meetwith the client and the family members, foraround two hours. During these visits, theytalk with all members of the family andmay, for example, o¡er recreational andplayactivities for the children to help build trustand support. Such a ¢rst meeting is typicallyused to assess (basic) needs and problemsof the family. This can vary and includes:(urgent) medical needs, educational orhousing di⁄culties, psychosocial issues, ormental health problems. The MHPS teammembers arewell aware of existing resourcesand organisations, and try to refer clients toappropriate organisation whenever possibleand needed. Sometimes, community volun-teers may encounter a person who needspsychological help.They then ask a psychol-ogist, or the psychiatrist, to assess the situ-ation and, if required, to provide severalbasic counselling sessions.The psychologistscan o¡er counselling at the person’s homeor from the SBF o⁄ce. If more specialisedcare is needed, theyarrange a referral.Manypsychological problems the teamtries to dealwith are strongly linked to the con£ict inSyria, and the newly acquired life of a refu-gee, such as adjustment problems, insecurityabout the future, loss of hope, feelings of sad-ness, anger, fear, or frustration, frequentlyresulting in family problems. In addition,the team meets people su¡ering fromdepression, schizophrenia and posttrau-matic stress disorder (PTSD). In the few

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Syrian mental health professionals as refugees in Jordan: establishing mental health services for fellow refugees

Intervention 2013, Volume 11, Number 1, Page 89 - 93

months they havebeenworking, the psychol-ogists have assisted about 100 patientswith mental disorders, screened about 200wounded people for psychological needs,and referred about 45 of those for specialisedpsychological and/or psychiatric care. Thesocial team visited over 200 families, with atotal number of more than 1000 people(including both children and adults).

Strengths of SBFand challengesSBF is well connected to the Syrian refugeecommunity and can reach people andfamilies easily. After decades of oppression,widespread corruption and involvement ofsecret police in every aspect of life in Syria,many families do not easily trust formalorganisation or structures, as they fearmembers of the regime may have in¢ltratedthem. Recently arrived refugees often areunaware of the potential sources of supportin Jordan, or from international serviceproviders.7 The threshold for requestingassistance for psychological problems is veryhigh. SBF workers are often from the sameareas or cities as the families they assist,and therefore experience fewer obstacles tobuilding trust. Families tell SBFworkers theyfeel understood and safe working with SBF.The workers provide guidance and infor-mationabout existing resources, both formaland informal. They also organise recrea-tional activities and psycho-education. Thiscommunity work lowers the threshold toaccess to counselling and more specialisedassistance. In the future, SBF hopes tobecome a main actor in Syria in MHPSS,using a community based approach insteadof the narrow medical psychiatric approachthat now prevails in Syria. Meanwhile,SBF would like to build their organisation,so they can serve people in various placesthroughout Jordan, such as Ramtha,Amman and Irbid, where the majority of

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Syrian refugees are hosted. A next stepwould be to o¡er training to Syrian, andother organisations, on the speci¢c MHPSSissues and needs occurring in the Syrianrefugee population.

AcknowledgementsThe authors would like to thank their colleague

Omar SyidYousef, the Syrian psychologist who is

co-founderof SyriaBrightFuture.Theyalso thank

all other members of the Syrian psychology net-

work: Mohammad AlHamwi, Hala AlGhawi,

Mahmoud Othman, Hanan Allakoud, Hania

Kutabi, Hala Alkhateeb, Alaa Zaza, Obada

Altebi, Jala Noufel, Asma Ziadeh, QamarA. and

others, who wish to remain unnamed. The Syria

Bright Future organisation is also grateful for the

support from Syrian expatriates, in particular

the US based Syrian Expatriate Organization

and the Arab Foundation for Care of Victims of

War andTorture in the United Kingdom.

ReferenceAnonymous (2012). A request to support the men-

tal health needs of Syrian refugees. Intervention,

10(3), 234^236.

1 The mental health system in Syria consisted of

several clinics, as part of the government system

and services. There are two mental health hospi-

tals in Damascus and Aleppo, each with around

100 beds for in-patients, with very poor quality

of service.Two university hospitals had a psychia-

try department, with around 10 beds for inpati-

ents, and an outpatient service a few days per

week. Community mental health centres do not

exist in Syria. It is estimatedthat Syriahas around

100 psychiatrists for a population of over twenty

million, which is around 0.5 psychiatrist per

100,000 persons. A national approach to integrate

mental health into primary health care centres

was developed, but not implemented in practice.

This contributed to the situation where the

medical sta¡, at primary health care level, lacked

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Abo-Hilal&Hoogstad

the required skills andtraining to e¡ectivelyman-

age and treat mental health disorders. As a result,

people with common or severe mental health dis-

orders were denied e¡ective treatments and ser-

vices within their community. As well as the

aforementioned services, there were private

clinics, and governmental organisations.2 Funds had been earmarked for Iraqi refugees

from past con£icts, therefore programmes only

recently started to include Syrian bene¢ciaries.3 With the continuous in£ux of new refugees in to

Jordan,SBFhasaconstant supplyofmentalhealth

professionals and other interested groups. Several

Jordanian psychologists are assisting the team as

volunteers. Some are still studying, nearly gradu-

ated or have graduated with some clinical experi-

ence. They work and assist several hours a day.

Additionally, within SBF, professionals from all

major cities and regions in Syria are represented.4 As a refugee, the psychiatrist is not allowed, by

Jordanian law, to practice medicine and/or psy-

chiatry. Therefore, having a master degree in

business administration, he currently manages

and provides technical guidance, consultation,

assists in referrals, and assesses the level of skills

of teammembers.5 One with a Masters degree in clinical psychol-

ogy, four with a Bachelors degree; all have a few

years working experience.

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6 SBF receives technical and ¢nancial support

fromMe¤ decins duMonde (MDM). MDMassists

in building their organisation, work and capacity,

and acts as a liaison to other agencies. Technical

support by a clinical psychologist includes weekly

case discussions with psychologists.

7 Currently, SBF is establishing relationships

with other actors working in Jordan and with

Syrian refugees. Their main partner is Me¤ decins

du Monde. Other organisations that SBF is cur-

rently starting to work with, concerning MHPSS

services, are: Center forVictims of Torture, Inter-

national Medical Corps, International Rescue

Committee, and the health centre funded by the

Saudi Arabian government in the Zatari refugee

camp.

Mohammad Abo-Hilal, MD, is a psychiatrist

fromSyriawhohadhisownprivatepracticethere

until the end of 2011. He is now a refugee in

Amman, Jordan, where he founded the non-

governmentalorganisation‘SyriaBrightFuture’.

email:Mahilal3@gmail.com

Mathijs Hoogstad, clinical psychologist, worked

withMe¤ decinsduMonde inJordanand, through

it, supported the work of SBF with training.

email: m.a.hoogstad@gmail.com

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