For residents of the Palestinian refugee camps in Lebanon their prospects for the future are bleak; employment is hard to come by and most suffer difficult living conditions and a precarious socio-economic situation. In such an environment, depression affects almost one-third of patients seen by Médecins Sans Frontières (MSF), while others are affected by anxiety (22%), psychosis (14%), bipolar disorders (10%) and personality disorders.
Within the Palestinian refugee community, mental illness is stigmatised, the term itself equated with ‘being crazy’. This is fundamentally due to lack of awareness about what mental illnesses are and how they can be treated. Mental health disorders are rarely talked about and it is very uncommon to ask for help relating to mental health issues. People suffering from severe mental illness are often discriminated against and isolated by the communities in which they live, including by their families.
The situation is made worse by the fact that mental health services are not generally available in refugee camps. Mental health services are not perceived as a basic health need like reproductive or child health services might be and this, in itself, reinforces the fear and stigma surrounding mental health. It is only recently that the World Health Organisation, among others, has attached greater importance to it and is working to improve access at primary care level around the world.
Mental health providers are generally viewed with some suspicion in this community, especially when care is delivered by people from outside the community. As the science of psychology is not widely understood and psychiatry is associated with the giving of strong medications, this leads to real concerns about ‘medicating the community’ through these services. The methods used to treat mental illness are not well understood and therefore to some extent are feared - which may cause mistrust of the provider. When MSF started its mental health programme in the refugee camps in Lebanon, concerns were expressed that Palestinians should not be branded as a people with high mental illness levels in a country where being Palestinian was already difficult enough. Our challenge was to educate the population about mental illness and provide access to quality services that would make a difference and would be trusted.
Religion and religious leaders play an essential role in health-seeking behaviour in the Lebanese camps as many people seek help from their sheikh as a first resort. Without adequate awareness themselves, these leaders are unlikely to advise their congregations to seek help from people with whom they are unfamiliar and receive treatment which they may be wary of.
Providing sensitive services to Palestinians with non-Palestinian professionals of different faiths (as is necessary in Lebanon in the absence of Palestinian clinicians due to work restrictions posed by the Lebanese government) is difficult. The first challenge is how to build sufficient trust so that people even consider accessing the service at all. Probably the single most important element for the success in the uptake of services was to have Palestinians within the Community Awareness Team to bridge the cultural gap, advising MSF and offering the community itself reassurance regarding the services offered. The Community Awareness Team has played a crucial role in considering – and answering – questions such as: how do the people perceive mental health? how do they deal with a mental health disorder? where do people go when they feel psychologically distressed? who decides when and how a mentally ill individual has to seek treatment?
The complex psychological effects of being deprived of a homeland or sense of belonging have been well documented but can a Palestinian really believe that a non-Palestinian can understand how this feels or how this relates to the challenges of everyday life? What may be construed as condescending or patronising advice or information when delivered by someone from outside the community is interpreted very differently when presented by someone with whom one closely identifies. While the Community Awareness Team was responsible for educating and promoting the services in the community, the management team was responsible for meeting political and religious leaders to build trust and cooperation.
Feedback from the community on how to further improve access to services was divided. On one hand, many Palestinians said they could not leave the camp and would, therefore, need to have services within the camp. On the other hand, there was a strong lobby from the community to have services opened outside the camp to provide some sense of confidentiality away from other camp residents.
In order to make sure that the services were accessible to all, two access points were started in the camp and one established on the immediate outskirts of the camp. With one access point at the UNRWA health centre and a second at the Palestinian Red Crescent Society hospital, patients were able to access services under cover of seeking other health services, if necessary. From the beginning of 2009 until mid-2012, 2,158 patients sought consultations with MSF’s psychologists and psychiatrists; the majority (60%) were women aged between 25 and 40.
Men generally represent the most difficult target to reach. In the specific context of the Palestinian camps in Lebanon this seems to be related to the fact that men tend to consider the unsolved Palestinian cause as the root cause of all their problems, and are less willing to seek medical help that cannot address that root cause. Unexpectedly those men who do seek help have proved to be keener to see a female psychologist. This is linked to the local culture and to men’s unwillingness to show ‘weaknesses’ and ‘vulnerability’ before other men. The camp’s male population appears to be the most fragile group in Palestinian society as culturally they do not have the ‘right’ to show their weakness and their suffering yet they bear the responsibility – very often unmet due to the severe restrictions faced in Lebanon by Palestinians – of being the sole financial provider in the family.
The majority of the consultations are carried out on an individual basis by the psychologists. However, group therapies have proved highly beneficial with regard to patients who presented with similar complaints (sense of alienation from the society, exposure to domestic violence, etc.) as the cause of their psychological distress. Additionally, for beneficiaries presenting with familial problems, attempts are made by the psychotherapist to bring the whole family together in the sessions; this has proved to be successful in several cases as it has reactivated lost ties and triggered dialogue.
One question that we are often asked when we advocate for mental health care to be incorporated into primary care services in the Palestinian camps in Lebanon is: “Is it worth it when you cannot improve the social and economic conditions that cause or exacerbate mental illness?” This question raises one of the main barriers to care, a real lack of understanding of the importance of mental illness. Patients with respiratory problems are treated despite returning to live in damp and squalid conditions; diarrhoea is treated while water sources remain contaminated’ and treatment for mental illness must be considered as important as for these other medical conditions.
Symptoms of disorder
“Living conditions here are very difficult. Houses are overcrowded and built close together; zinc roofs cause temperatures to rise in the summer and drop sharply in the winter; the infrastructure is nearly non-existent; and there is very little privacy in people’s personal lives, which makes everyone seem short-tempered. Sometimes, when someone says hello, you want to start a fight with them.
I was introduced to MSF randomly one day, while at the UNRWA clinic. They were distributing brochures that described the symptoms related to mental health disorders. The brochure said: if you have one of these symptoms, you should consult a therapist. When I read it, I laughed to myself because I realised I had them all. After speaking to the community health worker, she advised me to visit the MSF centre and gave me an appointment, so I went. I was deeply shocked and worried at the seriousness of my illness. If I had continued in this condition, without MSF’s help, I might well have gone on to kill myself and my daughters.” [Hakim]