The Syrian conflict is now entering its eighth year. The war feels ever present and I follow it daily in the news, knowing that my clients are connected to it at all times.
The toll on the Syrian people is huge. Since the start of the conflict, 6.3 million Syrians have been displaced internally; thousands have made dangerous sea journeys in search of safety; nearly three million children under five have grown up knowing nothing but conflict, and 4.9 million Syrians, most of them women and children, have sought refuge in neighbouring countries.1
A year ago, I joined the Refugee Council in South Yorkshire to develop a psychological therapy service for Syrian refugees experiencing mental health distress who have been resettled in the UK via the Vulnerable Persons Resettlement Scheme (VPRS). The distress can be linked to the conflict and their flight, difficulties in resettling in the UK or earlier experiences, such as child marriage, violence or torture. Referrals of children, families or adults are usually made directly by project workers based at the Refugee Council, by refugees themselves or by other agencies working with refugees.
Therapy is unfamiliar to most Syrians. To make our service more accessible, we describe therapy as a place to build up resilience after the war and to cope with the stresses of resettlement. It is new to me to be working within a refugee agency, rather than in a clinical team or service. Many of my colleagues are refugees themselves and all have a wealth of both personal and professional experience that they share. Because the therapy service is located directly within the resettlement team, refugees are able to access us quickly and easily. It also means I can trust that all the essential practical resettlement tasks and processes will be delivered by the Refugee Council’s project workers, which frees up our small team to focus on the therapeutic work.
UNHCR resettlement scheme
The VPRS is the UK’s contribution to the UNHCR’s global resettlement programme for Syrian refugees. Many of Syria’s refugees are living in urban settings and camps in neighbouring countries – mostly in Jordan, Lebanon and Turkey.2 The UNHCR’s resettlement programme provides for the most vulnerable to be resettled on the grounds that they have urgent humanitarian or security needs and are not able to return home or integrate safely in the country they have fled to. Those deemed vulnerable include survivors of torture, women at risk, disabled refugees and those with serious medical conditions. I use the term Syrian refugees here to include Kurdish refugees from Syria.
Syrian refugees resettled in South Yorkshire, where I am based, are offered one-to-one support by Refugee Council project workers in the first year to help them settle into social housing, apply for welfare benefits, register with GPs and get any urgent medical needs treated. The adults are helped to register for language classes and to register their children in local schools; they are guided through our public systems and services and helped to orient themselves in this strange land. The project workers’ aim is to gradually taper off the support as people gain confidence. They offer as much help as necessary and as little as possible, to ensure they are empowering the families they work with.
In my role within the VPRS, I manage a small team of sessional and volunteer adult therapists and two part-time child and family therapists. I carry a caseload of adults. Our approach is informed by Judith Herman’s model for working with people who have experienced atrocity,3 and so our first priority is building a therapeutic alliance and establishing safety.
We first conduct a holistic assessment to gather an understanding of the range of difficulties that might be causing distress and explore with clients what might be helpful to them within the 12 sessions of therapy we offer. Our aim is to offer a short-term therapy service, although long-term therapy provision is badly needed across the region.
The themes presented are wide ranging: the atrocities they have witnessed and experienced during the conflict, traumatic loss or disappearances of family members, torture and violence through to historic abuse, including child marriage. Some refugees have endured many years of poverty and oppression in the neighbouring countries where they first fled, and many struggle to resettle in the UK, away from their families and communities, often in a hostile environment.
Many of my clients are traumatised and have felt frightened and overwhelmed by psychological and physical responses to their experiences that they do not understand. In these cases, early therapeutic work will involve some psychoeducation about trauma and its effects and teaching them ways to manage the symptoms, such as grounding and breathing techniques. For many clients, their distress relates to the death of or separation from family members as well as the impact of living through a war. These refugees have found it helpful to talk with me about their losses and for them to be witnessed – what Papadopoulos calls ‘the delicate balance between therapeutic intervention and therapeutic witnessing’.4
With some clients, our focus is on the present and how to build a life in the UK when you are feeling lost and/or dependant on systems that you experience as humiliating. Clients describe how they are afraid that they will never be able to live a meaningful life here in the UK, to be able to fully contribute and feel settled. They can find it reassuring and affirming to have these feelings normalised and to be reminded of what they are doing well.
The feedback from our clients over the last year has been that 12 sessions are almost always helpful and meaningful. Despite this, I have ended work with clients feeling sharply aware that there is a need for further long-term therapy to address their trauma from histories of abuse and/or torture, as well as what they witnessed and experienced during the war. The depth of the relationship we have formed has meant that ending therapy can trigger a renewed sense of loneliness. As van der Kolk writes: ‘Social support is not the same as merely being in the presence of others. The critical issue here is reciprocity: being truly heard and seen by the people around us, feeling that we are held in someone else’s mind and heart.’5
Working with refugees
I have learnt so much about Syrian culture from this work and find myself recognising snatches of Arabic now. I work with the same group of four interpreters, who are a crucial part of the team. Because we work together daily and so closely, they have come to capture my way of communicating and understand the way the team works. We meet regularly for a supervision group to explore practice and to provide support, as the issues and themes brought by our clients often echo their own.
Working with an interpreting team who are based within the refugee agency has thrown up challenges too, as it has been almost impossible to ensure that they have no other contact with our clients. It is generally considered best to use interpreters in therapy who have not interpreted for the client in other settings, in order to preserve therapy as a unique and separate space.6 The interpreting team often meets clients at drop-ins and sometimes have even been at the airport when the family first arrives in the UK, as part of the Refugee Council team. The fact the interpreter is familiar has helped on some occasions, but mostly we aim to pair up with an interpreter who is less familiar or not known.
We are confronted by the Syrian conflict daily. My clients watch news reports on their phones constantly and receive a steady trickle of images and film footage from friends and families back in Syria, Jordan or Lebanon. Their families in Syria remain at risk and they follow every outbreak of the conflict.
I have understood and respected the need for clients to keep their phones on in sessions when they are expecting news of family members trying to flee an area being hit. I have even looked at footage from the conflict in sessions. ‘Look, this is my street now, my home and that’s my business… this was it before. Look at our house… our shop.’ It is deeply saddening to witness and connect with what people have lost and what they have/are living through. As a client said recently: ‘I’m here, but we are still in the war.’
It’s crucial for me to know as much as I can about the war, the conditions and treatment of people when they flee to neighbouring countries, as well as about Syrian culture and the importance of family, land and faith.
Many left their homes thinking they would return in a month or so, and few expected the conflict to last. The years in Jordan, Turkey, Iraq and Lebanon were mostly hard. Families were discriminated against and were living in precarious circumstances, often with limited access to medical care and education. Since the outbreak of war, UNHCR estimates that 739,000 registered Syrian refugee school-age children and adolescents have not been able to attend school. Prior to the war, 94% of Syrian children were enrolled in primary and lower secondary schools.1
Dignity and social justice
Kholoud Mansour, a Syrian with a background in humanitarian analysis, research and writing, has written eloquently about the importance of dignity in Syrian culture. He quotes a doctor he interviewed for his research: ‘We feel like lab rats. International organisations come to us with countless needs assessment and questionnaires; they leave, and we never receive assistance from them.’7
When clients talk of those years as a refugee, they express outrage and anger at the attitudes they encounter and the affront to their dignity. I have gone on to read more about dignity and its significance for Syrians. Mansour writes: ‘From the very onset of the popular uprising in Syria, dignity has played a role at both the individual and collective level. One of the earliest and most prominent slogans during the Syrian uprising and the subsequent conflict was “the Syrian people will not be humiliated”.’7 He describes the centrality of dignity in Syrian narratives and explores the impact on Syrians of the humiliation they have felt when dealing with resettlement agencies.
Bemak argues that it is the role of the therapist to be aware and actively engage with social injustice: ‘Inherent in this more active stance is the assumption that social justice is an integral part of psychotherapy. To neglect issues that present themselves regularly to refugees that are inequitable, unfair, discriminatory, or a violation of their human rights is unconscionable.’8
Some of our clients have had some form of psychological intervention after they fled Syria and before they came to the UK. One of my clients described with amusement being taught a breathing exercise as she and the therapist listened to planes circling overhead. My approach is rarely technique driven or symptom focused, but I included these techniques in my description of what I could offer as I was anxious to find a way to be helpful in just 12 sessions. At our assessment, she told me in no uncertain terms that she wasn’t interested in being taught techniques; what she wanted was to talk. She wanted a place where she could say the things that she wanted to say where no one else could hear. She didn’t want to burden her family with her suffering.
Working with families
Many of the people I am working with are in their 50s and older, and many have chronic health problems or are disabled. This has meant I see them in their own homes, as their mobility is limited.
Learning English becomes harder as we grow older and many parents describe being left behind by their children. My clients have usually led full and relatively good lives in Syria and have lost everything they took years to build. They have had to leave behind land and businesses that have been in their family for generations. I witness daily the ache for home and the life that was before. I will always remember the words of an older Kurdish client, who told me: ‘I will never be who I am here, because who I am was there and part of that life.’ She had been the centre of her small village; that life was gone and her future would never be the one she had hoped for and expected.
Yet, only a week later, as we approached our final session, another client told me that he now realised he still had the same qualities and was still the same man; he was just in a different place. He now believed he could forge a life here, despite his losses.
Most of the refugees I have worked with have come to the UK with their immediate family, although, sadly, older children may have been left behind. As could be expected, roles and family dynamics are changed by resettlement. But while displacement can be the trigger for disruption of family life and traditional gender relations, for some families these disruptions were already occurring.9 Sometimes the family system is affected by displacement and families are in crisis; at other times, a traumatised individual causes confusion and concern as their family struggles to understand what has caused such a change in the person they knew.
Sometimes male family members have felt threatened that their partners are confiding in me; some are curious about what we talk about. Flexibility and a willingness to meet with families/partners and explain what I do and why are crucial. Families are keen to support struggling members and sometimes the family can build on and re-enforce the work I am doing if they become involved. I have found so far that, even when one partner has concerns about therapy, this changes over time and the privacy of our work is respected.
Key to this is my respect for the families I work with and my genuine curiosity about the differences in how we might think and understand the world around us.
Some therapy takes place in other venues. I see clients at a community centre in a small town and at a GP practice, as well as at our Sheffield base. Offering therapy from a nurse practitioner’s clinical room might feel familiar to many NHS therapists, but offering therapy when seated on a huge white leather sofa in a snooker hall was a first for me. I find it is possible to create a unique and private space wherever you are. I have also learnt to accept the gift of specially made food when I visit clients in their own homes – the trick is to eat little and fast, in order to progress the session without losing too much of the therapy time.
Receiving visitors with food is at the heart of most cultures and it is certainly very important for the Syrians I am working with. I have grown to love the sweet treats and the ritual of the strong Syrian coffee that starts or finishes a session.
My work is full of sadness and distress, but there is also often laughter at the frustrating aspects of resettlement and their impact on clients’ lives.
Many clients have angrily described the ridiculous hoops they have to jump through to access their rights, or laugh after they have attended an assessment for therapy with a statutory service and been sent home after one session with leaflets in English on panic attacks or managing stress. Their amusement and outrage at the UK’s failures and incoherent, clunky systems is infectious and I am reminded of another quote from Kholoud Mansour:7 ‘Dignity is how much you reject humiliation and how strongly you react to it.’
Jude Boyles is a BACP senior accredited therapist. She established the first Freedom from Torture (FFT) rehabilitation centre for survivors of torture outside London and managed the service for 14 years until April 2017. She is now VPRS Therapeutic Services Manager at the Refugee Council, working with Syrian refugees. She edited the book Psychological Therapies for Survivors of Torture (PCCS Books, 2017) and is co-author of Working with Interpreters in Psychological Therapy (Routledge, 2017).
References
1. UNHCR. Regional Refugee and Resilience Plan 2017–2018 in response to the Syria crisis: regional strategic overview. Geneva: UNHCR; 2016. http://reporting.unhcr.org/node/16434
2. Al Hussein N. Foreword: Syria in 2018 – in search of solutions. Forced Migration Review 2018; 57(February): 4.
3. Herman JL. Trauma and recovery: the aftermath of violence – from domestic abuse to political terror. New York: Basic Books; 1992.
4. Papadopoulos RK. Therapeutic care for refugees: no place like home. London: Karnac Books; 2002.
5. van der Kolk B. The body keeps the score: mind, brain and body in the transformation of trauma. London: Penguin Books; 2014.
6. Boyles J, Talbot N. Working with interpreters in psychological therapy: a right to be understood. Abingdon: Routledge; 2017.
7. Mansour K. Protecting the dignity of displaced Syrians. Forced Migration Review 2018; 57(February): 5–6.
8. Bemak F, Chi-Ying Chung R, Pederson PB. Counselling refugees: a psychosocial approach to innovative multicultural interventions. London. Greenwood Press; 2003.
9. Lokot M. Syrian refugees: thinking beyond gender stereotypes. Forced Migration Review 2018; 57(February): 33–35.