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.
By Todd Stump
Everyone in Arbaz's family is dead.
One brother disappeared more than two decades ago and another died after losing a leg in a bombing and an arm to the Taliban, who sawed it off at the shoulder.
Arbaz's hosts have generously provided for his material needs and attended to his physical injuries, but after 11 months as a refugee in Germany, this is the first time the 23-year-old Afghani opened up about the trauma he experienced in his home and during his journey.
"Nobody knows my heart is crying," he told Dr. Shaifali Sandhya at a Red Cross refugee center in Berlin. "When I would tell people at home, they'd treat it as an ordinary thing."
To people in his homeland his experience is unexceptional, common enough not to be examined or thought about too much. The same is true for people in his new home. His fellow refugees lived through their own traumas and the staff at the resettlement centers have heard many similar stories.
Sandhya -- a Delhi-born, Cambridge-educated psychologist -- has counseled hundreds of immigrants in her career. She says the psychological effects of trauma from war -- loss, privation and social isolation -- may be a better indicator of an immigrant's ability to successfully adapt than characteristics governments tend to focus on, like country of origin and religion.
Sandhya left her home in Chicago in November 2016 to conduct a 10-day fact-finding trip in Germany, the first part of a study of how trauma among refugees manifests itself in individual and group behavior. Sandhya, 44, speaks five languages and is learning German as well. She financed the project herself.
She visited four cities, spoke to government ministers, visited refugee centers and met more than 100 refugees, videotaping interviews with some of them, including Arbaz. Names of the refugees have been changed to protect their identities because they fear the recent backlash against Muslim immigration in Europe and are concerned that President Donald Trump's travel ban will force them to return to their home countries, where they likely will face retribution and even death.
At the outset of the trip, Sandhya considered herself well-suited for the research. An immigrant herself, she has lived in five different countries, including Muslim ones, and studied the interpersonal dynamics of non-Westerners in Western countries. She counsels immigrant families confronted by colliding cultures, but while examining the physical and psychological journey of refugees, she began a journey of her own.
She arrived at the first refugee center in a bustling Berlin neighborhood dotted with ethnic restaurants, where 40 percent of the residents are immigrants.
The refugee center is in a recently converted department store, the exterior of which was decorated with children's drawings -- it could have been a school or a recreation center. The elevator was covered in graffiti, but not the kind an American city-dweller might expect. Instead, these were images of dinosaurs with kitten's heads and other fanciful children's scribblings.
Germany's refugee population is primarily from Afghanistan and Syria and is mostly male. All the residents at the refugee center have experienced some form of trauma.
The scar that runs down the face of Ferhad, a 20-year-old unmarried Syrian immigrant from Aleppo, is a lifetime reminder of the torture he suffered under interrogation. Arbaz contracted an infection during a long boat journey, causing severe abdominal pain and blood in his urine.
"These are clear signals to health professionals that they are in need of help. But what of the wounds that can't be seen?" Sandhya asked.
With Sandhya next to him, Arbaz sat patiently while questions and answers were translated from English to German to Urdu and then back again. Frustrated, he finally turned to Sandhya and surprised her, asking in her native Hindi, "How do I explain what goes on in my heart?"
In her years of counseling immigrants and helping them to cope with new environments and personal relationships, Sandhya learned that what might seem to be a matter of the mind to a mental health professional is frequently a matter of the heart to a patient.
"I've learned that you can't help a person if you ignore culture and family considerations, but until now, I've seen it mostly from the female perspective," she says. "This new experience has taught me that the traumas women suffer are often related to the traumas experienced by the men in their lives. But men in these cultures are reluctant to talk about them, so the problem goes untreated."
Hassan – whose name, like Arbaz's, has been changed to protect his identity -- told Sandhya that he had been a darji, a tailor. He was born to a Kurdish family of seven siblings in Afrin, a land wild with olive groves known as "liquid gold" in northern Syria.
"I had a normal life," the 32-year-old refugee said. "After my marriage, I stayed with my wife and children."
That changed in 2006 when Syrian President Bashar-al-Assad's forces pulled Hassan from his shop and out of his normal life. He was detained in a secret prison for his "political activities" and his quest for a new life began.
Upheaval in the lives of refugees like Hassan can cause trauma that manifests in ways having profound effects on both refugees and the countries where they settle.
Sandhya said psychologists know that when no constructive outlets are available for mental anguish, symptoms can emerge as what they call "somatic" pain, or pain related to the body and distinct from the mind.
"Somatic pain can manifest itself in many guises including malaise or chronic bodily aches, but has no diagnosable medical cause," she explains.
Further disguising the problem is that these trauma manifestations may be shaped by culture, so they deviate from the typical ways Americans, for instance, may experience PTSD, Sandhya said.
"Salvadoran female civil war refugees can suffer from "calorias"-- a perception of intense heat in their body. For Cambodians, it is sometimes manifested as hallucinations of vengeful spirits," she said.
Headaches, Sandhya learned, was how Syrian men here are experiencing the phenomenon.
"I have huge headaches. I feel sad but I don't cry . . . I am living with men and I cannot have them see me cry," Hassan said.
"Have you spoken to Aliya and Imran since you left?" Sandhya asked, inquiring about Hassan's children.
Rubbing his temple, Hassan replied, "I have a headache. I am sorry. I want to tell you more… but I cannot."
Another coping mechanism is unwavering faith. Many refugees credit Allah with their survival. Yet another is dissociation, a term psychologists use to describe the separation of normally related mental processes, which results in one process functioning independently from the rest.
"It is a coping mechanism to help the person continue to function in the aftermath of emotionally traumatizing life events," Sandhya said. She sees it regularly when refugees tell their stories, describing horrific events in anodyne, emotionless ways.
Arbaz told his story as if he was reading a telegram; short declarative sentences delivering horrifying news and ending abruptly.
"I saw little children take pictures of the war, of dead corpses."
"People were being flagellated, strung up as chickens with their flesh torn up."
Even before he turned 13, four of Arbaz's siblings died, lost to bombing and Taliban attacks. When he was 16, another sibling died. His parents, unable to cope with their misfortune and without treatment for their own trauma, died in quick succession, grief-stricken.
Left out of his retelling was any description of his own horror at having witnessed such events, the terror he must have felt under constant fear of death, or the heartbreak of watching his parents die.
By the time a refugee arrives in a host country, he has spent an average of $9,000, traveled through six countries and many cities, endured two years of intense hardship, and attempted unsuccessfully to settle in a safe haven at least twice. But, most significantly, he has likely witnessed repeated brutalities to family members, loved ones and traveling companions.
"What an outsider might see as a casual acceptance of death is the brain coping with overwhelming trauma," Sandhya said. "Dissociation limits and alters the access to intense sensory and emotional memories that would otherwise inhibit basic functions."
While this protective mechanism alters the impact of terror on our bodies, it does so at the price of silencing victims whose experiences are vital to understanding the effects of trauma. Sandhya recommended that refugees be encouraged to share these traumatic episodes both for their own health and for their successful integration into their new communities.
Through her study, Sandhya said she hopes to gather knowledge of civic innovations that lead to more successful integration with less conflict. She said the lessons can be applied to refugee settlement in the U.S.
While there are misgivings among the general public about the level of resettlement in Germany and a growing political backlash, Sandhya said that everyone from the most senior elected officials to the caregivers in the refugee centers were united in their unwavering belief that the experiment will succeed. Frequently, the commitment is quite personal; many Germans involved in the resettlement efforts are married to immigrants or are immigrants themselves.
But their efforts on behalf of the refugees can be suspect. In their home villages, many were told that Germany is a dangerous place where Muslims were unwelcome. Rania, an 8-year-old from Syria, at first refused to believe one of the center's workers was, in fact, German.
Rania said to her, "I can't believe it because you smile all the time."
This article was published on US News' website on February 15, 2017.