Why do Syrian refugees in Lebanon not use available mental health services?

Authors: Michael Pluess, Patricia Moghames, Nicolas Chehade, Fiona McEwen, Karen Pluess

According to a recent study by the World Health Organisation (1), about one-in-five people from war-affected populations suffer from mental health disorders. Several studies, including our own, suggest an even higher prevalence rate among Syrian refugee children (2,3).

We surveyed more than one thousand families in Lebanon and found that almost half of the children are above the clinical cut-off for any psychological disorder. Many of the families agreed to a referral for mental health services. However, when they were contacted a few months later, nearly half no longer wanted any treatment and, from those that did, more than half did not attend the intake assessment or enrol into treatment. In order to understand why so many did not take up the mental health treatment offered, we visited two informal refugee settlements for group discussions on the topic.

The first meeting included eighteen mothers. When they were asked to describe how their children tended to react when upset, the mothers recalled several problem behaviours, from being angry and aggressive, to being fearful, having nightmares and withdrawing from daily activities. When asked what they would do in these situations, one mother immediately said, “take him to the sheikh” (an Islamic spiritual leader). They elaborated that the sheikh would pray, read verses from the Quran and perform “rukyas” (i.e. spells). Also, the sheikh would not support them in seeking mental health services.

When we inquired further about other barriers to getting treatment, one mother expressed that it would be considered shameful to ask for such services and that they would be judged by neighbours, should they find out. Hence, it was far more common to ask a relative or friend for help. Other major challenges that were mentioned included the high costs of transportation and having to take time off from work to attend the clinic. Several mothers also commented that it would be very difficult for the children to use mental health services without the agreement and support of the father, which is often lacking.

The visit to the second settlement involved nine mothers and one father. As with the first group, the parents reported a range of behaviours when the children were upset and said that they would stop helping around the house and skip school when emotionally unwell. In contrast to the first group, the parents in the second felt that, in general, their children did not have major mental health problems but, if they did, they would tend to deal with the challenge themselves rather than seek help from the sheikh.

When asked specifically about barriers to seeking treatment, one mother highlighted her concerns for the views of other people, saying “people will say we are stupid, so we just don’t go”. Another added “people are always judging and would call us crazy”. They also said that it would be difficult to attend the clinic because transport would be expensive, they couldn’t leave their other children at home, and they did not trust the local taxi drivers (they mentioned the case of a Lebanese taxi driver accused of raping a Syrian woman). Several mothers also mentioned that their husbands were opposed to mental health treatment for their children and simply would not allow them to go. Significantly, all participants agreed that they might feel differently about mental health services if they knew someone from their community whose child had received treatment and had gotten better.

One mother ended with: “You need to have courage to seek mental health support in spite of what people are talking and saying.”

Our visits to these two settlements confirmed some of the known problems such as transport issues and costs, conflicts with work and the importance of having the support of fathers. However, we were struck by the explicit social stigma surrounding mental health problems and treatment in the community. That said, during the visits, we received five separate requests for mental health services (for children and adults), showing just how important psycho-education is. The group discussions also highlighted the need to find alternative avenues of delivering treatment.

To this end, we are running a randomised controlled trial where we compare phone-delivered mental health treatment to standard face-to-face treatment in our clinic. We are currently visiting settlements in the region to invite families to participate in the study. We believe that phone-based treatment should help in reducing several of the barriers, including judgment from the community on the basis that delivering therapy by phone should be more discreet.

References:

1. Charlson F, van Ommeren M, Flaxman A, Cornett J, Whiteford H, Saxena S. New WHO prevalence estimates of mental disorders in conflict settings: a systematic review and meta-analysis. Lancet. Jun 11 2019.
2. Soykoek S, Mall V, Nehring I, Henningsen P, Aberl S. Post-traumatic stress disorder in Syrian children of a German refugee camp. Lancet. Mar 4 2017;389(10072):903-904.
3. Perkins JD, Ajeeb M, Fadel L, Saleh G. Mental health in Syrian children with a focus on post-traumatic stress: a cross-sectional study from Syrian schools. Soc. Psychiatry Psychiatr. Epidemiol. Nov 2018;53(11):1231-1239.