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For Syrian Refugees, a Mental Health Emergency

A psychiatrist recounts a trip to Jordan, spreading teachable techniques in attempts to arm refugees amid a devestating crisis.

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Syrian refugee woman walks with her kids at Zaatari, near the Syrian border in Mafraq, Jordan [Mohammad Hannon/AP]

When I pause for a moment, they form around me like the shades of the dead come to stand with Odysseus on his visit to the underworld. There are close to 100,000 Syrian refugees in Zaatari, the U.N. administered camp in the north of Jordan. That's almost three times as many as when I visited in November. 200,000 more Syrians live among the Jordanian population. For the last ten days, 3,000 have been coming across the border each day. The U.N. expects a total of 650,000 to 700,00 by the end of June, and at least as many more will fill the camps and live among the general population in Turkey and Lebanon.

Men, women, and the children they carry press faces against the wire fences that limit access to the scattered Zaatari tent and trailer clinics. Gaining admittance, people jam into the small open waiting spaces. Many more--women in long dark coats, heads covered, men in dusty jeans and short jackets--move slowly up and down the dirt tracks that separate the rows of U.N. tents that have provided inadequate shelter in the cold, rainy winter.

Men pull up their pant legs to show me bullet wounds. Women raise listless children towards me, their mouths squeezed open to reveal tonsils swollen with pus. They gesture at others who hide their faces in the skirts of their coats. "She does not sleep and wets herself," one mother says. "He cries every time he hears a man's voice, thinking it's a soldier," another tells me. "This one who has lost his father," says another, gesturing to an eight-year-old boy, "will not leave me, even for a minute."

My team from the Center for Mind Body Medicine includes: Jamil, the Palestinian psychologist who runs our program in Gaza; Lee-Ann, our International Program Manager; and Nisreen, a Syrian psychologist who wants to bring our work to her people. We are hoping to make our program of population-wide psychological healing -- through mind-body techniques like meditation and guided imagery, self-expression in words, drawings, and movement, and group support -- available to the fleeing Syrians in Jordan and to the clinicians and humanitarian workers who are trying to help them.

In Zaatari and in meetings with refugees who live in Amman, I am asked unanswerable questions. "When will there be international intervention?" is often the first one, and "where are the blankets?" the second. "We love the Americans," says one courtly older man, "why don't you love us?" And, almost always, after the questions, they clamor to tell stories in which death and torture seem as commonplace as headaches, hypertension, or anxiety in a U.S. medical practice.

"My cousin," begins an electrician, "told me they stopped the torture from midnight to five in the morning, and in those hours he prayed to die."

"They break the bones of our prisoners," an engineer says, crying. "And they will not let the doctors come. And if a doctor treats them, they break his bones too."

"I had a large family--ten of us," says a man from Daraa where the slaughter has been particularly bloody, "now it is only me and one daughter."

To date 70,000 people have died in Syria. According to the Jordanian Noor Al Hussein Foundation, 60 percent of refugees who show up for their hearing and eye exams and psychosocial programs, say they were tortured.

In this moment, what can I as a mental health professional possibly offer these people?

My group explains our work to Jordanian and international doctors, quoting research from Kosovo and Gaza that shows very real decreases in post-traumatic stress disorder after mind-body groups. Listening politely in starched white coats, many seem as stunned as the refugees who press them for cures or at least relief. They are, however, enthusiastic about the possibility of working with us. "Everything here is psychological trauma," a surgeon, opening his hands in overwhelmed acknowledgement, tells me.

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Syrian children inside their tent at a small refugee camp, in Ketermaya village southeast of Beirut; March 14, 2013 [Hussein Malla/AP]

A young man, I'll call him Hamid, stands apart from a group at the Noor Al Hussein tent. He is tall and slim, honey-colored, handsome, his nose a bit flat against his face. His short hair is carefully combed, and his shirt and pants creased as if they had just emerged from a box. "I do not find rest at night," he answers when I ask why he has come to the tent. His sleep, it turns out, is broken by nightmares that replay his ten months of torture in Syrian prisons. He raises his arms to demonstrate how he was strung up before being beaten; he nods towards his nipples and genitals to show where the electric current was attached.

"I do not want to be around anyone," he says, as if the torture sessions were removing him now, as well as then, from human contact, as if he believed, as many who have been tortured do, that he should be ashamed, that he was somehow complicit in what he had to endure.

"Once," Hamid adds as if it were another life, "I was studying to work in the hospitality industry." When I ask what used to give him pleasure, his face opens just a little bit, "I loved cooking."

Ordinarily when I begin work with an individual like Hamid, or a group or in our training programs, I start simply, by teaching slow deep breathing, in through the nose, out through the mouth, the belly soft. It quiets the mind and body, and after five minutes gives most people who are overwhelmed and powerless a direct, often singular, experience of being able to calm the agitation and anxiety that are hallmarks of post-traumatic stress. I will do it a half a dozen times on this visit -- in tents, standing outside clinics, and in meetings in offices with aid workers.

If we can implement our program in Jordan, there will be weeks of teaching self-care skills in small-mind body groups for Hamid--and everyone in the camp. Right then, I only had a few moments, though. In that situation, searching for any possible way to loosen the hold of Hamid's torturers -- to let him see it is possible to find moments of freedom from the pain and humiliation that's been visited on him -- I thought of an exercise that could seem absurd. By even suggesting it, I worry he'll feel that I don't take his suffering seriously. Still, the intuition, the idea, remains, quickly grows in me.

"You're a cook; that means you must like experimenting with food" I say. He nods. "I have another kind of experiment, one that might help you with your nightmares." He looks skeptical but says he is willing, as a dozen other men, unasked, but curious and hopeful, lean toward me. "I want you to laugh like this," I show him, laughing in explosive barks, my stomach muscles contracting. He looks at me as if I am mad. "I am a bit crazy," I assure him, "but it's an experiment. Will you try?"

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Two Syrian refugees walk among tents at Zaatari [Mohammad Hannon/AP]

"Nothing is funny to me anymore. How can I do this? And why?"

"Force it," I say. "The torturers had you for ten months, and they still have you now, every night and during the day too. You have to see you can break the pattern."

"Yes," he says, "it's true." The men around him murmur agreement and prepare themselves to accompany us.

We begin together, bent at the waist, our contracting bellies forcing the laughter through our throats. "More," I shout, "push it." And they do. Men who smoke too much to "quiet nerves" are coughing as much as laughing.

After three minutes we stop, but many continue to laugh, a bit surprised at it, but naturally, easily, now. "How do you feel Hamid?"

He said, "More relaxed, at this moment."


This is no "cure" for Hamid's suffering, no enduring barrier to the flood of terrible memories. But this type of exercise is one thing that he can do to bring himself a small measure of relief, to overcome at least for a moment, the feelings of helplessness that are endemic among the Syrian refugees. These are things that can be taught, and shared, and make impact at very little cost.

"Do this laughing every day and I believe you will find more moments of relaxation." I say. The chorus around us nods in agreement, "Insha'Allah," they say. "God willing."