By Fahrinisa Oswald
Already traumatised by loss and conflict, stranded refugees face further trauma without mental healthcare.
Athens, Greece - It was just another day for teenage brothers Ismael and Isa Achekzai at the local market in Herat, Afghanistan, where they went daily to sell potatoes from their family's modest plot of land on the outskirts of town. Their earnings from the market were not much, but they were enough to help the family of five just about get by.
But as the brothers pushed their wheelbarrow towards their home, a powerful explosion ripped through the market, leaving behind a cloud of dust and chaos, and a family who would forever be changed.
As the debris began to settle, Ismael stood up and looked to the spot where his brother had been standing just moments before. The wheelbarrow carrying their vegetables was overturned, its contents a splattered mess everywhere. Isa had not survived the blast from the roadside bomb.
Bending down slowly, Ismael started collecting his younger brother, piece-by-bloody-piece. He collected as much of Isa as he could find, placing the pieces in a plastic bag. He then carried the bloodied plastic bag home, placing it on the kitchen table for his mother who was busy making dinner. That was 10 years ago.
"Ismael has not been the same since," says his father, Ibrahim Achekzai, who is now in his mid-50s. Neither has his mother, who recently gave birth to a premature baby boy in a camp on the outskirts of Athens, Greece. Though she claims to be in her mid-30s, Bibi Achekzai is missing almost every tooth in her mouth and has the appearance of a woman in her late-40s.
The Achekzais are one of thousands of traumatised refugee families now stranded in Greece since the beginning of the mass influx of refugees to Europe in mid-2015.
They are also one of the many refugee families in desperate need of mental health services, which, though exist in small numbers, are incredibly difficult to access.
Prior to the ratification of the EU-Turkey deal on March 20, 2016, very few refugees who arrived in Greece stayed for more than a few days or weeks. With the EU-Turkey deal, however, followed by the closure of the Macedonia border and the Balkan land route to central Europe, more than 62,000 refugees from Syria, Iraq and Afghanistan are now stranded in Greece, a large percentage of whom are in desperate need of mental health services.
The EU-Turkey deal and the sudden closure of the Greek-Macedonian border meant that many people who had planned on continuing onwards to central and northern Europe were forced to quickly reassess their plans. Not only did this cause chaos in the asylum system in Greece - by suddenly overloading it with thousands more cases over night - it created a fresh trauma for many refugees whose futures became instantly uncertain.
"It was really abrupt what they did," explains Anastasia Papachristou, who works for Doctors Without Borders (known by its French initials MSF). "They just stopped their movement and the majority of our patients had to plan their lives all over again." Because of this, she continues, "they experienced yet another trauma."
'We share patients'
Since 2014, MSF has run a joint programme with Babel DC - a local Greek NGO that offers mental health services and support to the refugee and migrant community currently stuck in Greece. "We share patients," says Anastasia.
"They [Babel] have a psychiatrist on their team and they provide psychological services to our patients and we cover the holistic rehabilitation of them."
Between the two organisations, refugees and migrants who have access to these services have "full support: social, psychological, medical and mental support," says Anastasi.
For the first 10 months in Greece, the Achekzai family lived in a camp in Oinofyta, a small town on the outskirts of Athens.
Despite the camp manager's continuous attempts to relocate them to central Athens where they would be able to access mental health services for Ismael and Bibi, and school for the younger son Yacoub, 16, the cries for help fell on deaf ears. For 10 months, the family sat in their tent day after day, with little clarity about their asylum process, and unable to begin a rehabilitation programme - further traumatising the entire family.
"Because of the living conditions here in Greece, the lack of safety and clarity about their asylum cases, they [the refugees] are being re-traumatised and rehabilitation takes longer. We have a lot of relapses," explains Anastasia.
In January 2017, 10 months after their arrival in Greece, the Achekzai family was finally identified as highly vulnerable and moved to an apartment in central Athens where Ismael and Bibi would have access to much needed mental health services.
"The UNHCR gave us a list of seven points of vulnerability - these are seven vulnerabilities we are looking for in a person," explains Lisa Campbell, the manager of the camp in Oinofyta where the Achekzai family was living. "In the end, in the Achekzai family of five people, there were 20 vulnerabilities - multiple vulnerabilities per person."
The Achekzai family are only one of the many cases that mental health practitioners are now facing in Greece. More and more they are dealing with problems directly caused by the increasingly desperate plight of refugees stranded in Greece.
"Because we don't have the right social services and psycho-social services available, people are getting severely depressed. People are turning to alcohol and drugs, spousal abuse and violence," explains Lisa. And the longer they sit in the camps with nothing to do and no clarity about their situations, the worse the problem gets.
"For those who have been so traumatised - either by war, by the trip or by sitting here for the last seven, eight, nine months - some of them over a year - in hopelessness without the support system that they need, they are turning to things that are going to be detrimental to society," she continues.
Mental health and rehabilitation services
The most recent case that Campbell referred to a mental health unit in her camp was of an Afghan woman who had been there for several months, was eight months pregnant, and was becoming near suicidal. She was so depressed that she had become violent towards her own family, shouting at her husband and son on a daily basis. Out of pure desperation, the husband reached out to Lisa for help, and she was able to make a referral immediately.
According to Lisa, European politicians may be "shooting themselves in the foot" by not addressing the mental health issues of the current refugee population in Greece as well as throughout the rest of Europe. "They are going to try to integrate into European society and they are not going to have the coping skills to do what they need to do to become productive members of society," she says.
But, offering mental health support and rehabilitation is complex, time-consuming and expensive, and the challenges that organisations and practitioners face are enormous. "There are challenges linked to the specific problems with which they come to us, and these are very complex problems - problems that have come with them from their country of origin," says Nikos Gionakis, president of Babel DC, a Greek mental health unit for migrants and refugees.
"Other [challenges], relate to the way they have moved, and many of them are related to the conditions of living here, from lack of perspective and lack of information about their situation," he continues.
There are also cultural challenges relating to the stigma of seeking mental health support. "When people come from countries where the mental health system is stigmatised - for example, it is identified with big mental hospitals - people believe many times that if they go to a psychiatrist they will end up in a mental hospital," says Nikos.
They are very reluctant, he adds, and it often take months to build trust to the point that these people are able to open up about the trauma they have experienced or are currently experiencing.
Due to the heavy nature of the work, Babel also offers mental health support to volunteers and professionals working with refugees and migrants. "We say that in order to care for someone, someone else must care for you," says Nikos.
Mental health and rehabilitation services will not bring back Ismael's younger brother, Isa. It may not even be able to improve Ismael's condition. But, for Isamel and Bibi - and for the thousands of refugees like them - it may help to prevent further trauma. It may even provide them with better and more effective coping mechanisms.
"It's a complex thing for us," says Anastasia. "Rehabilitation is not that you can focus on one thing. You need to have a holistic approach, so you need to follow their progress throughout the whole rehabilitation process. You have to focus on their total improvement."
This article was published on Al Jazeera's website on March 22, 2017.