Órla Ryan reports from Lebanon, where she travelled to in early March prior to the Covid-19 travel restrictions.
THE MENTAL HEALTH needs of refugees are complex – many are traumatised both by previous experiences in their home countries and the daily struggles they face in camps or informal settlements.
In areas where there is conflict or war, women and girls are often mistreated to a greater extent.
Problems that beset every society, such as domestic violence and sexual abuse, are common features in refugee camps too. The difficult conditions people have to face every day can exacerbate an already fragile situation.
It’s estimated that about one in three women globally have experienced physical and/or sexual violence, mostly by an intimate partner. Research indicates that refugee women are at an increased risk of violence.
Children also often face violence in refugee camps and informal settlements. Many of them lose years of education and start to regress from a development perspective.
An expert who specialises in helping vulnerable groups in Lebanon said providing treatment for refugees who are experiencing depression, anxiety, post-traumatic stress disorder (PTSD) or suicidal tendencies has become more difficult in recent times.
Sarah Amhaz, a psychologist at Makhzoumi public health centre in Beirut, explained that the root cause of the issue is often multifaceted and people of all ages, but particularly children, may struggle to articulate what is wrong.
And this is among those who have access to counselling or support, usually through an NGO.
Many more have no such support and, as they are struggling with basic needs like getting food, mental health is often not a priority.
Lebanon, which has a population of about 6.8 million people, has the highest concentration per capita of refugees in the world – an estimated 1.5 million Syrians, hundreds of thousands of Palestinians, as well as refugees and migrant workers from several other countries.
Ahmaz mainly works with Syrians and Iraqis, and sees about eight patients a day.
She works with Unicef to provide free counselling and mental health assessment for vulnerable children, but also works with adults and facilitates family counselling sessions.
PTSD and other issues
Amhaz told TheJournal.ie many people from Syria or other countries experiencing conflict develop PTSD and other issues which are often exacerbated by difficult living conditions in camps or settlements.
“The symptoms that are coming from the war are getting mixed up with symptoms that are being created here in the country because we’re also developing problems [in Lebanon].
“So the child is so overwhelmed with so many difficulties that they don’t know which one to focus on. If we had a child who was only suffering from traumatic symptoms because of the war it would be easier to manage, it would be easier to treat.
But if the child is suffering from traumatic symptoms from the war, and at the same time mommy and daddy are fighting all the time at home, if there are abusive behaviours at home; if I go to school, there’s abusive behaviour there; I go outside, I can’t play. This is creating a completely negative environment for the child.
Lebanon is in the midst of a severe economic recession – the unemployment rate was increasing well before the Covid-19 lockdown closed most businesses, and facilities in many areas are at breaking point.
Unicef is among the NGOs and government bodies operating a cash assistance programme to support approximately 40,000 children from 15,000 Lebanese families amid the recession, as well as other programmes to support refugees, but tensions are rising – in the country as a whole and behind closed doors.
Women and children in need
Amhaz said domestic and sexual violence are very common in refugee camps. In domestic violence cases, she and her colleagues work with all family members who are willing to engage, both parents and children, in order to try to resolve the situation.
Amhaz said an awareness-raising campaign has been carried out in formal refugee camps in Beirut about domestic violence, and several NGOs and shelters provide support for women and children in need.
In her experience, the husband or father is often “willing to engage and actually wants to make a change”. Over a number of sessions, it may come out that the man himself was “abused in his own home (as a child) and this is being replicated”, she said.
In such scenarios counselling sessions, both individual and group, are used for as long as the participants want to attend. If cases require more specialised intervention, they are referred on to outside bodies.
In urgent cases, a social worker can step in and remove a child or other family member who is being abused.
Ahmaz said sexual abuse is dealt with in the same way if it occurs within a family, however it often happens outside the home, making it “very complicated on a legal level” and difficult to get any form of justice.
Police generally avoid refugee camps, as does the Lebanese government. Palestinian organisations like Fatah and Hamas are involved in some of the day-to-day running of camps in Beirut.
Ahmaz said the government “doesn’t have much power” in these areas, adding that domestic and sexual violence is often not reported, making it difficult to monitor or tackle.
In informal settlements in Lebanon, where the toilets are usually located outside the tents, Ahmaz said children are sometimes attacked or sexually assaulted while going to the toilet, particularly at night. Again, there is little recourse when this happens.
Child marriage and domestic violence
Many women who need help try to get it from local NGOs like Médecins Sans Frontières (MSF), Unicef or UNRWA.
Fatima* originally started coming to MSF’s free clinic in Burj el-Barajneh refugee camp in southern Beirut to get diabetes medication.
Over time she started going to therapy sessions with a psychologist at the centre. After building up trust with her psychologist, she recently disclosed that her husband is violent and regularly beats her and their children.
The family is from Deir ez-Zor in eastern Syria but has been living in the Burj camp for several years after fleeing the war.
Fatima said Isis “bombarded the area for four continuous days; at night it would be as lit up as day, that’s how severe the bombs were”.
Fatima (31) married her husband, who is in his 40s, when she was just 14 years old.
Her two eldest daughters, aged 15 and 16, were both married to men in their 20s at their father’s request, and have moved back to Syria.
One of them is pregnant.
Fatima is very worried her two younger daughters, aged eight and nine, will also be married off in the next few years.
During the interview she showed us photos of her children on her phone, becoming emotional.
She said she tries to keep in touch with her daughters in Syria but feels as though she has “lost them already”, adding: “I want to save the lives of my other two daughters.”
Lebanon has no minimum age for marriage, with religious courts instead setting the age so child marriage is common in certain communities. Daughters are often married off to protect their ‘honour’ or safety, or as a result of poverty.
Research carried out by the UNFPA and others concluded that “an alarming rise in child marriages has been seen among the most vulnerable Syrian refugee populations in Lebanon” in recent years.
About 2,400 refugee women and girls living in western Bekaa in Lebanon were surveyed. Researchers found that more than a third of those questioned who were aged between 20 and 24 had been married before reaching the age of 18.
Among refugee girls aged between 15 and 17 at the time, almost a quarter (24%) were married. There has also been a large increase in the number of child marriages in Jordan, which is home to hundreds of thousands of Syrian refugees.
‘He’s selling them’
Fatima wants to escape to a shelter with her children. She fears the day her younger daughters will get their periods “because that’s how my husband thinks they’re ready to be married”.
“When he arranges the marriages, it’s like he’s selling them because he does not allow them to get married unless he gets about 2.5 million Lebanese pounds (about €1,600).”
Fatima recently had surgery on her leg and regularly gets severe headaches and pains throughout her body, something she attributes to stress and anxiety.
She said, the day before we spoke, her husband kicked her out of the house – a regular occurrence.
When this happens, “I stand outside waiting like a dog until he gets calm.”
She said divorce is frowned upon in her community and if she left him people “would say bad things about me”.
He has threatened to take the children away from her or harm them if she leaves him. He recently threatened one of their sons with an axe.
‘Dead in a living body’
Fatima said her husband was always violent but the situation got worse when they came to Lebanon.
He has raped her in the past.
He is also unfaithful and brings other women to the family home.
In 2014, legislation that protects people who experience some forms of domestic abuse came into effect.
However, the law did not cover marital rape and it is not recognised as a crime.
In 2017, Lebanon’s parliament repealed Article 522 of the penal code, which had allowed rapists to escape prosecution by marrying the victim, but left a loophole regarding offences relating to sex with children aged 15-17.
Fatima has had suicidal thoughts but said therapy and medication are helping. She told us the only way she will survive is if she escapes her husband.
“I feel as though I am dead but I’m in a living body,” she said.
“My only hope is getting away from him. I hope that God looks at our situation and helps us escape … that’s the only hope, that’s the first and last hope.”
Her psychologist, who was present for the interview, said Fatima’s experience of domestic abuse is “very common” among women in the camp.
MSF is working with a local shelter in a bid to remove Fatima and her children from the family home. The organisation has helped a number of women get shelter and protection because they faced violence at home.
‘She was breaking lots of things’
Sahar, another Syrian woman living in the Burj el-Barajneh camp, sought mental health support for her nine-year-old step-daughter from MSF.
Her family lived elsewhere in Beirut but had to move into the Burj camp after her husband lost their savings (about €14,000) in a failed business deal.
Sahar said moving into the camp was very difficult for the entire family but particularly for her step-daughter Noor.
“She was breaking lots of things. She was always quite anxious, always shouting around the house. I really wanted to help her, I consider her my own daughter, but I didn’t know what to do. I would have paid money to get her help if I could.”
Ahmaz said this kind of behaviour is common among children and teenagers who are traumatised in some way.
She said bed-wetting and developmental regression are other regular symptoms of distress.
Sahar told us her family is struggling to pay for rent and food.
Debt collectors have threatened to hurt her, her husband and their children. She received support from MSF during her pregnancy with her youngest daughter but didn’t realise they also provided free psychology sessions until a Palestinian neighbour mentioned it.
“The psychologist is helping Noor, she can communicate better now. The psychologist gets through to her, when I tried I wasn’t getting through to her. Her psychologist helps her relieve all that stress, she comes here once a week and for that hour she gets to vent,” Sahar said.
In 2018, MSF carried out over 125,000 outpatient consultations in Lebanon including 11,700 individual mental health consultations.
The same year, MSF implemented the WHO Mental Health Gap Action Programme, which was adopted by the Lebanese Ministry of Public Health, and trained GPs so they could prescribe medication when necessary, under the supervision of an external psychiatrist.
School or paying the bills
Sahar wants her children to stay in school but she’s not sure if she and her husband can afford this.
Sahar has been looking for work but hasn’t been able to get a job.
On one occasion she sought work in a sewing factory.
“I asked for a job and the guy told me ‘Okay, I close at 8pm, so you can come at 8.30pm. I told him I didn’t want to become a prostitute and left,” she said.
Ahmaz said the fact refugees often don’t have official documents and are barred from working in many sectors leads to some employers taking advantage of them.
“Most people, if they do get a job or two jobs, they’re not receiving what they deserve, which also creates a lot of frustration. The father could be out of the house from 8am to 11pm working six days a week, only getting $100 (about €90) for the month. So again, this creates friction.”
The cheapest rent in a camp like Burj or Shatila would be about $200 (€300) per month – for poor quality accommodation.
Ahmaz said many children are forced to drop out of school in order to work to help support the family – getting jobs in supermarkets or bakeries, wherever they can.
They too are taken advantage of by employers, she noted, saying some people simply “don’t respect any refugee, whether they are a child or an adult”.
“It’s become a choice between school and working for the child,” Ahmaz said.
Parents who have taken their children out of school tell her, ‘We don’t have money. The issue right now is to survive, we need to eat.’
Public schools in Lebanon usually offer classes for Lebanese students in the morning and Syrian students in the afternoon.
Ahmaz said the schooling refugees receive is often subpar, as are the materials used to teach them.
Sometimes children are taught in French or English, rather than Arabic, and don’t understand their lessons.
“These children have no background in English, no background in French, and you see the books and they’re actually very difficult for the child to grasp,” Ahmaz said, adding that the child’s parents may be unable to help them because they don’t speak the language either.
Brother and cousin killed
Sahar said her parents paid for her and her sister to leave Syria after Isis took over the area where they lived.
“The war started and people were telling [my parents] that ‘ISIS are going to come and they might hurt your daughters or rape them’,” Sahar recalled.
She met her now husband in Lebanon and they got married. He has two children, a girl and a boy, from a previous marriage and Sahar raises them as her own. They also have another young daughter.
Sahar was six months pregnant when they moved into the refugee camp because of their debts.
“It was very difficult moving from my previous house – it was spacious and big, whereas here we live in a room. I wouldn’t even call it a house because it’s very tight, the kitchen is very small and you can barely fit one person into the bathroom.
“Living in the camp is difficult but I’ve had to accept it because we have so many debts.”
Sahar also started to go to counselling, telling us: “I got to a point where I didn’t want to live anymore.”
She said her husband supports that she goes to therapy because it is helping her. She said part of her issues stem back to the war in Syria. Her brother and cousin were both killed.
Her brother was killed in an air raid. She said he was part of a wider group who were moving from area to area in a bid to stay safe.
“They moved into one area and there was a raid. People told us a Russian airplane had dropped the bomb but nobody really knows.
The bomb hit a building and it fell on my brother. He died instantly.
Separately, Sahar said her cousin was shot while trying to cross the Turkish border with his wife and children.
She said people were being allowed to cross in groups, women and children first.
“His wife and daughters, they were in the first group and they and they let them pass.”
Sahar said the second group was full of men, she was told the Turkish military shot them all.
Sahar’s family lived close to the Turkish border in an area that was “very much affected by war” and saw fighting between Syrian government forces, ISIS, rebel groups and Turkish forces.
“The Turkish government started bombarding the area because it was on the border. It got to the point that there was no other way, we had to escape. It was impossible for us to stay.”
Her parents paid the equivalent of €1,000 for Sahar and her sister to get to Damascus and then a few hundred euro more to cross the border into Lebanon.
“The whole journey was very scary. There were landmines and we saw a whole family get blown away in front of us,” she told us.
Sahar’s parents are still in Syria. She said she’s very worried about them because “there’s always something happening, it doesn’t stop”.
A few weeks before we spoke, they had to move to a different area because of another outbreak of violence.
She said her parents think she is “living a good life” in Lebanon but don’t know the reality of their situation.
“I don’t want to go back there and I don’t want them to come here because we are not living a normal life and we are not happy. They are miserable there and they would be miserable here,” Sahar said.
She told us she would love to emigrate – to anywhere “that would treat me with respect”.
“I’m an Arab and I’m living in an Arabic country, but I don’t feel that I’m being treated respectfully, and I’m worried that people will harass and abuse me,” she said.
She said that is the reason so many refugees want to go to Europe or North America – they have heard of other people who made it there and now have a better life.
“In a foreign country, they treat you respectfully and they care for you,” she noted.
Sahar said she wanted to share her story because she knows “lots and lots of people who are not getting the chance to talk”.
“They’re silent, and they are suffering like me and even more so, some people have to sleep on the street. I want people to know my story, our stories, so they know that we exist and these things are happening.”
*Fatima’s name has been changed to protect her identity.
This article is supported by the Simon Cumbers Media Fund. It is the second article in a three-part series on the reality of life for refugees in Lebanon, part one can be read here and part three will be published tomorrow.
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