Caring through talking – An MdM psychologist reflects on her experience with Syrian refugees in Lebanon

In the primary healthcare centres supported by MdM in Lebanon, many Syrian refugees report psychosomatic complaints, which require specific care that cannot be provided by general practitioners. Given this situation, MdM strengthened the medical teams in the healthcare centres to include psychologists.

Noëlle Jouan is one of them. Since August 2013, she has been offering individual consultations to the patients of Kamed el-Loz healthcare centre, a village in the West Bekaa, Lebanon. This region currently hosts more than 41,000 Syrian refugees. In two months, Noëlle received 124 people, mainly Syrian women aged 14 to 30.

What are your patients suffering from?

NOELLE JOUAN: There are, of course, many cases of depression and anxiety, with all the symptoms that go with it. Nearly 15% of my patients have symptoms of post-traumatic stress disorder: for example, they systematically avoid places or people that remind them of past traumatic events.

Many women mention marital problems. In the current context, scarce resources push some parents to seek to marry off their daughters at any cost. Many of my patients are afraid that their husbands will take advantage of this opportunity. They tell me about their anxiety, their fear that their husbands could take another wife.

Degraded living conditions brought about by war and exile are sometimes seen as impossible to bear. One of my patients was a student in Syria. Her studies were her universe, there was never a question of her doing anything else. Today in Lebanon, she had to stop her studies and she now collects apples in the fields. When she remembers the notebook in which she used to write at the university, she starts to cry.

Other cases are much more serious. When I went with the mobile clinic that goes in the villages around Kamed El-Loz, I met four people with psychotic disorders in six days while I had not seen any case like this at the healthcare centre.

One case in particular struck me: a 13-year-old girl who showed no psychotic symptoms before the war in Syria. Today, she is unable to communicate, she isolates herself, and she is very aggressive. This radical change occurred when many bombs fell on her village one week. It seems that the war triggered latent issues and exile in Lebanon puts her in a precarious situation that makes her condition difficult to cure. Faced with her reactions, the girl’s parents are totally powerless. When I met the mother, she told me: ‘Take her with you, I don’t want her anymore.’I was shocked. What this child needs is precisely a feeling of security, a family who supports her. If she feels that her mother wants to get rid of her, this will not encourage her to reconnect with reality but to stay in her world.

Under normal circumstances, her family and relatives would have probably been able to provide her with the support she so desperately needs. But today, in Lebanon, her parents have nothing: they live in a tent, in a country which is not theirs, they have no work, it is hard to find food… And on top of this, they must live with the psychotic symptoms of their child. In this context, it is very difficult for them to accept her condition and to support her.

According to the World Health Organisation, ignorance and stigma are associated with mental disorders in the Middle East[1], as elsewhere in the world. Psychotherapy or psychology approaches are relatively unknown. How do you deal with this in your daily work with Syrian refugees?

NOELLE JOUAN: When I started to work at the healthcare centre, it was hard. Syrian refugees are not used to meeting psychologists and talking to them. It is not very socially acceptable. Apart from the stigma associated with mental disorders and thus with resorting to psychology, there is, in this context, a conscious or unconscious will to ‘stay strong’. For example, the men who had been referred to me by doctors of the centre believe that mental healthcare cannot help them. Because they are men, they must be strong, and they must accept their situation and fight for their sake and for the sake of their families. More generally, I would say Syrian refugees have an unconscious collective resilience. When my patients are telling me about their problems, it is as if they could endure anything. This could be because everyone around them has the same problems: they have all lost a relative, they have all been separated from part of their family, they have all left their country, they have all given up their social position… and yet, they fight and appear strong. It is also a defence mechanism, but for me it shows a strong resilience.

At the same time, there is a deep need to talk. Precisely because everyone has problems, because the situation is difficult for everyone they cannot find anyone to talk to within their family or their community. So, little by little, more and more patients come to see me at the centre. Some women even came back several times and I now help them regularly. And everybody talks, despite their reluctance and ignorance of psychology! They talk, talk, talk, I cannot stop them. They really need to be listened to, because listening is no longer present in their daily environment.

I’m greatly satisfied to have patients coming back and to see positive developments. One of my patients told me she’s feeling a real change from our first session. She is more combative, she has a new desire to liberate herself as a woman. In one of my last home visits, I saw again a young  girl with strong suicidal tendencies. Even though she was barefoot and the physical toll of her work and the mud were not easy to hide, she had tried to hide her misery behind a tiny bit of makeup.  This makeup, for me, is a good diagnostic, a sign of hope.