The Need for Trauma-Based Services in The Middle-East; A Pilot Study
Corresponding author: Walid Abdul-Hamid, Honorary Senior Lecturer, Centre for Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London; Consultant Psychiatrist, C&E Centre, Chelmsford, Essex CM2 0QH, UK
A recent paper described the earliest accounts of post com- bat stress disorders as occurring not in Europe and Greece as had previously been thought but in the Middle East and, more specifically, in Mesopotamia (present day Iraq) during the Assyrian dynasty (1300-609 BC). The descriptions in that paper include many symptoms of what we would now iden- tify in current diagnostic classification systems as symptoms of post-traumatic stress disorder, including flashbacks, sleep disturbance and low mood .
Norris et al  indicated that trauma is much more common in developing countries than in the developed world. This is in contrast to the availability of resources to treat trauma. This is also complicated by the fact that trauma in developing coun- tries is more difficult to treat and more complicated to study. Most of the resources for trauma treatment and research are in Europe, which constitutes only 7% of the world’s population. It is a well-known fact that the psychological impact of trauma outweighs the physical by an estimated 4:1 ratio . The psy- chological impact of natural and man-made disasters can be overwhelming for individuals, their families, and communities.
In the Middle East, particularly since the Arab spring, it has become clear that the extent of oppression and torture that the fallen regimes practised on their people must clearly have cre- ated many psychological problems in the population . The fall of these regimes unveiled a high level of unrest and ethnic and sectarian violence . Another complication to tackling trauma in the Middle East is that mental health conditions and psychiatric disorders have a very severe degree of stigma at- tached to them . This stigma was increased in the colonial period as a result of the building of mental hospitals which were built that replaced the small and less stigmatising com- munity oriented medieval Muslim hospitals (Maristanes) that operated in keeping with the principle of Islamic Medicine .
Eye Movement Desensitisation and Reprocessing (EMDR) is an intervention that was developed by Francine Shapiro . She introduced it into the professional and clinical world after she undertook her seminal randomised control study in 1989. From 1997 onwards EMDR has increasingly been recognised internationally and has subsequently altered the majority of national and international post-traumatic stress disorder (PTSD) guidelines as an effective treatment for this disorder. EMDR has been acknowledged as being effective in the treat- ment of PTSD by independent reviewers for many organisa- tions such as the American Psychological Association (APA)
 and, more recently, by the National Institute for Health and Clinical Excellence (NICE) in Britain  and, even more re- cently, by the World Health Organization .
The Humanitarian Assistance Programme (HAP) UK & Ireland (http://www.hapuk.org/) conducted EMDR Part 1 training in Istanbul, Turkey for the first time between 28th Novem- ber and 1st December 2013. The course was open to mental health professionals in the Middle East including psychiatrists, clinical psychologists, psychotherapists, counsellors and social workers. One important criterion for selecting candidates was that of being involved in treating and caring for trauma-relat- ed problems. The group were considered to constitute an ideal sample for piloting the ‘The Need for Trauma-Based Services Questionnaire’, constructed by the authors for the purposes of a larger Trauma-Based Services Needs Assessment.
The Need for Trauma-based services in the Middle-East is a questionnaire that was developed by two of the authors (WA-H and JHH) in order to investigate National and Regional Needs for Trauma-Based Services in the Arab Middle East. The ques- tionnaire contains both quantitative and qualitative items. The quantitative section contains the following questions: What, in your opinion, do you consider to be the 3 most important Public Health issues for Mental Health Services in your coun- try, What are the most prevalent Mental Health problems that present to your practice, What trauma related problems do you see in your practice every week, What is the percentage of cases you see in a month related to trauma and what percent- age of the needs of these patients with trauma related prob- lems are you are able to meet.
The qualitative section of the questionnaire includes the fol- lowing questions; What are the 3 most important mental health unmet needs in your country, Which professional dis- ciplines (e.g psychiatrist, psychologist, social workers and oc- cupational therapist) are needed to meet the needs of patients with mental health problems, Which trauma psychotherapies are available to meet your patients’ needs, What major services are needed to meet the needs of your patients, Can you suggest any other approach to service provision needed to meet the needs of your patients. The questionnaire was then reviewed by the Trustees of HAP and suggestion and modifications were implemented.
The questionnaire was then translated to Arabic by the first author, back translated by an Arabic speaker and then checked by the second author who made further modifications which were made to the final Arabic version that was used in the in- terview.
A pilot study was conducted during the Istanbul HAP EMDR course. Participants were asked to give their consent to par- ticipate in the study and, if this was given, were given the Ara- bic translation of ‘The Need for Trauma-based Services Ques- tionnaire’, with both quantitative and qualitative questions, to complete. Participants’ identity was anonymised to ensure the confidentiality of the study. The results of the study were analysed using the Statistical Package for the Social Sciences (SPSS).
31 participants of the Istanbul EMDR training were asked to complete the Arabic translation of ‘The Need for Trauma-based Services Questionnaire’ in the last two days of the training. All participants completed both the quantitative and the qualita- tive questions with the following results:
Demographic characteristics of the participants:
There were 19 (61%) males and 12 females (39%) partici- pants. The professions of these participants were 19 psychol- ogists (61%), 7 psychotherapists (23%) and 5 psychiatrists
(16%). 13 participants were from Syria (42%), 10 were from Iraq (32%), and 2 each were from Egypt, Jordan, Libya and Pal- estine (7%).
Mental health problems:
The participants were asked to list the three most prevalent mental health problems in their country. The results, as expect- ed from recent events in the Middle East, showed that PTSD was the most common major problem in countries as listed by 58% of the participants. This figure was even higher in the two countries that most participants came from: Syria, from which 42% of the participants came and where 75% reported that PTSD was the major problems in their country and Iraq,where 75% of the Iraqi participants (who constituted 32% of the course participants) reported PTSD as the major prevalent problem in their country.
|Problems||As the First Problem||As the Second Problem||As the Third Problem|
|1. PTSD||18 (58%)||2 (6%)||2 (6%)|
|2. Depressive Disorder||2 (6%)||7 (23%)||5 (16%)|
|3. Neurotic Disorder||1 (3%)||7 (23%)||11 (35%)|
|4. Childhood Disorder||2 (6%)||5 (16%)||3 (10%)|
|5. Substance Abuse||2 (6%)||3 (10%)||1 (3%)|
|6. Psychotic Disorder||2 (6%)||0||1 (3%)|
Table 1. Most important 3 Mental Health Problems in Participants’ Countries
The other question asked about the most common three prob- lems in their place of practice. The number of participants who stated that PTSD was the major problem was even higher, and this was reported by 65% of the participants. PTSD was the most prevalent problem that the Iraqi participants encoun- tered in their practice, being reported in 80% of their partici- pants. PTSD was also reported as the major problem in Syrian participants’ practice, being reported by 69% of these partic- ipants.
|As the First Problem||As the Second Problem||As the Third Problem|
|1. PTSD||20 (65%)||3 (10%)||3 (10%)|
|2. Depressive Disorder||4 (13%)||11 (35%)||3 (10%)|
|3. Neurotic Disorder||4 (13%)||8 (26%)||9 (29%)|
|4. Childhood Disorder||2 (6%)||3 (10%)||4 (13%)|
|5. Substance Abuse||1 (3%)||0||4 (13%)|
|6. Psychotic Disorder||0||5 (16%)||1 (3%)|
Table 2. Most important 3 Mental Health Problems in Participants Practices
Participants reported that they were seeing between two to 20 cases of trauma-related problems, with a mean of 7 cases (SD=5.3) per day. (5 cases (SD=2.4) in the case of the Syrian participants and 14 cases (SD=6.6) in the case of Iraqi partic- ipants). 20-80% of the monthly client case-load was found to be trauma-related with an average of 48% (SD=19.7). This was 48% (SD=6.1) in the case of the Syrian participants and 50% (SD=18.5) in the case of the Iraqi participants.
Participants considered that they were only able to meet 39% of trauma clients’ needs (SD=22.4). The Syrian participants felt that they were only able to meet, on a mean average, 35% (SD=18.1) of trauma clients’ needs while the Iraqi participants felt that they were only able to meet, on a mean average, 30% (SD=14.1) of trauma clients’ needs.
There was therefore a reported unmet need for trauma psy- chotherapy of any type in 97% of participants (100% in Syrian and Iraqi participants) and an unmet need for EMDR in 100% of participants. In the absence of EMDR, when practitioners were asked which treatments they used in the absence of EMDR, only 42% mentioned CBT, which is the other therapy recommended by NICE for Post-Traumatic Disorders (CBT was used for trauma patients in 30% of Syrian participants and 40% of the Iraqi participants). The remainder used different forms of therapy such as analytic (3%), behavioural (3%), art therapy (3%), counselling (3%), family therapy (6%), problem solving therapy (3%), TRT (Teaching Recovery Technique) 3%, ‘religious therapy’(using the Quran and Islamic teachings) (3%) and medication (10%). (The latter was the case in 15% of the Syrian participants and 10% of the Iraqi participants and these were mainly by psychiatrists).
With regard to the interventions that were not available and which are badly needed, social work came first, which was re- ported by 41% of participants (23% of Syrian participants and 78% of Iraqi participants) followed by a need for psychother- apy stated by 21% of participants (31% of Syrian participants and 11% of Iraqi participants), psychiatric medication in 21% (15% in Syrian participants and 11% in Iraqi participants) and occupational therapy, reported as needed by 10% (23% of the Syrian participants).
The way forward:
We asked the participants for suggestions to improve trauma services. Training and supervision of qualified staff were the most important and frequent themes, creating trauma services and psychological service for refugee camps were others and creating trauma first aid programmes in Arabic was also men- tioned as was using telemedicine in order to get help in coun- tries where transport and security are problematic.
Both the qualitative and quantitative parts of the study drew a picture of a very difficult situation, particularly in Syria and Iraq, where the lack of security and the deteriorating situation have had a great impact on the mental health of the population. A recent study by Sadik, et al published in 2010 showed that al- though the perceptions of the people of Iraq of mental illness, and their attitudes towards care and treatment of people with mental illness, are both broadly compatible with scientific evidence, the understanding of the nature of mental illness and its implications remain negative in general. This makes it even more important to train mental health professionals in the lat- est therapeutic techniques that will help them to demonstrate the fact that psychological problems and psychiatric disorders are treatable .
At this stage we must highlight some methodological limita- tions related to some of the results of this paper. This paper is not an epidemiologically-based study where the results reflect population rates of prevalence but, rather, health service re- search that looked at the ways in which trauma related mental health problems are being treated in countries already experi- encing high level of traumatic events. The answer to the ques- tion of the perceived most prevalent problems in the country is not intended to give a prevalence rate but, instead, is a way to compare participants’ own practices with what they consider to be the practice in the country as a whole. This is particularly true as the sample was drawn from professional s who are in- volved in treating and caring for trauma related problems, so the percentages found do not reflect what might be reported by other mental health professionals in that country.
The responses to our survey clearly demonstrated an extreme theme of trauma with ‘loss of relatives after explosions or as- sassinations’ and the presence of ‘victims of political imprison- ment’ in addition to the ‘terrorism and kidnapping’ that con- tinues to endure.
This extreme trauma is associated with an increased num- ber of mental health problems but this is compounded by a corresponding reduction in the number of professionals and facilities that can help because of the emigration of qualified medical and psychological staff due to the security situation. One participant wrote that (the number of …) ‘psychologists in the whole of Iraq is less than 10’ Many mental health staff are unqualified with a lack of knowledge of both pharmacolog- ical and psychotherapeutic treatments and non-existence of specialist mental health centres or mental health assessment tools.
The Syrian refugee crisis has created massive psychological health problems but, for those therapists who try to help, the major problem was stated as: ‘Lack of appropriate place to hold psychotherapy sessions’.
One Syrian participant suggested: ‘We need all the specialities in mental health’.
However, the main immediate need is ‘to train more psycho- therapists who can help trauma victims’. Participants, even those who spoke good English, appreciated being given the opportunity to learn a trauma therapy in Arabic and were very grateful to be able to be trained in a technique that could enable them to help their countrymen and women using this approach.
The training was judged to be well received by the participants, as summarised by many of the heart-warming comments re- ceived in the last day feedback session of the training, such as:
For the first time we have been given a new complete approach for therapy, and not a disorganised approach that added to our disorganisation.
The Arabic examples and experiences (cases) given by lectur- ers and facilitators enriched the course. The course has given us the motivation for change and cooperation with others.
I came from Iraq where I have experienced a lot of stress, but this course has made me able to feel happy that I will be able to help my fellow Iraqis. I liked being in this group.
I felt for the first time that we (Arabs) are O.K. In spite of our differences, we managed to work together.
This course’s scientific rather than the emotional dialogue might help us overcome crises in the same way (i.e. being en- abled to use scientific rather than emotional methods).
There is a desperate situation in the Middle East in relation to the magnitude of exposure to trauma and of trauma-related problems and the paucity of resources to meet the needs of trauma suffered and of the professionals working with them. Recent conflicts have increased the need for psychological health professionals and services but these have, paradoxical- ly, been driven out of the area as a result of war and adversity.
We have calculated that by the time of the next EMDR course we will have probably trained all of the few mental health pro- fessionals in Iraq! The way forward lies in providing training in mental health for primary care providers and (non-clinical) psychologists and in encouraging the development of mental health knowledge and specialisms in social work and occupa- tional therapy.
There is also a need to train lay people and community work- ers and leaders in the fundamentals of mental health in order to provide psychological health education and first aid, and these professionals and others can be trained in providing EMDR and then early adopters of EMDR in the region could then be trained to provide supervision to those others working in their area.
The ethos of HAP UK & Ireland is the “teach a person to fish“ principle. This means that the main aim is that, in countries and regions where we embark upon projects, local mental health professionals are supported over a period of up to 5 years in their education, training and development in the treatment of trauma, particularly EMDR, so that they, in turn, can train their colleagues and compatriots. Eventually we anticipate that countries will be able to found their own EMDR national and regional associations. This has already taken place in an ongo- ing project begun in 2009 in Bosnia-Hercegovina .
If EMDR HAP UK and Ireland is to fulfil this challenging objective more funds will be required and more Arabic speak- ing mental health professionals in the UK, who have trained in EMDR, will be required to conduct future training and super- vision.
Declaration of Interest: none
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