How can remote mental health services help meet refugees’ and host communities’ psychological needs?

In the Middle East conflicts and COVID-19 have increased demands for mental health services – and made them very hard to deliver. A new study commissioned by GIZ on behalf of BMZ explores the potential of remote service provision.

This article is also available in Arabic.

In midst of the COVID-19 pandemic, Beirut-based NGO Embrace Lebanon found itself faced with a big problem: Just as more and more people called their National Lifeline for emotional support and suicide prevention, it was losing the volunteers it vitally needed to stay operational. The volunteers were either getting sick themselves or emigrating abroad due to the economic crisis in the country.

‘With COVID-19, everything has become more difficult, both for our beneficiaries and for us” says Lea Zeinoun, Embrace Lebanon’s Director of Strategic Partnerships.

“During lockdown, people could not meet their friends and family when they needed emotional support – the restrictions were prohibitive. In addition, we are now in the middle of an unprecedented economic crisis and the internet connections keep breaking down. The people who call us, Lebanese and refugees alike, feel more and more desperate. We are struggling to provide the psychological support they urgently need.’ In recent weeks, the NGO was even forced to go ‘offline’ for a few days due to power cuts.

Operators working on Embrace Lebanon’s Helpline
Operators working on Embrace Lebanon’s Helpline

The demand for mental health services is on the increase

The psychological impact of the COVID-19 lockdown measures has been felt acutely all over the world and especially in regions torn by war and conflict. Refugees and internally displaced persons (IDPs) are disproportionately affected. According to UNHCR Global Trends 2020 report, they currently number 82 million and this figure is steadily rising. One of the regions that has been particularly affected is the Middle East and the countries surrounding war-torn Syria. The country today has almost 6.6 million people internally displaced by conflict and violence. Neighbouring Lebanon hosts the greatest number of refugees worldwide relative to its population, currently estimated at 870,000 people. In Jordan, there are approximately 670,000 registered refugees, though it is estimated that the figure may be as high as 1.3 million taking into account unregistered refugees. This is a vast number of people for a country with a population of just 10.1 million. 

After they had to leave their homes to escape war, oppression and persecution, the trauma of what they have been through often catches up with them. According to a 2019 World Health Organization report, a fifth of the population living in war zones suffers from some form of mental illness, including depression, anxiety, and post-traumatic stress disorder. 

Middle Eastern countries struggle under a triple burden

Whilst accessing psychological help has always been difficult for displaced persons, COVID-19 has made it even harder. According to a 2020 World Health Organization (WHO) survey of 130 countries, the pandemic has disrupted critical mental health services around the world – at a time when they are perhaps more needed than ever. 

In Jordan, Amira Al Jamal, president of One Step Association, an NGO in Jordan created to represent individuals who suffer from mental health issues, said that the pandemic was a blow to many.  ‘During Covid-19, most of the mental health issues exacerbated, we felt like we were back to square one,’ Al Jamal says. ‘Depression or different disorders, it all was a huge setback, a huge challenge.’ This only adds to the existing problem of stigma surrounding mental health issues in the region. 

In Lebanon, the country’s concurrent economic, political and public health crises have added up to a triple burden that people struggle to cope with, says Zeinoun. ‘For the people who call us these days, the uncertainty is the hardest part,’ she says. ‘What will happen next with this pandemic? How will the political and economic situation develop, both here in Lebanon and in neighbouring Syria? Nothing is certain anymore. There’s simply not much that people can feel hopeful about!’

Given the challenges associated with mental health service provision during a pandemic, interest in the remote operation of mental health services has greatly increased. Can clients benefit in the same way when therapy or counselling is provided via telephone or video call as compared to having a therapist or counsellor physically present in the same room?

To date, little is known about the effectiveness, advantages and disadvantages of running mental health services remotely and even less when it comes to such services in conflict-affected countries in the Middle East.

A new study explores remote mental health services in the Middle East

A drawing depicting the spirit of remote mental health services
A drawing depicting the spirit of remote mental health services

To help change this, the GIZ Regional Project “Psychosocial Support for Syrian/Iraqi Refugees and IDP” and the Sector Project on Displacement commissioned the Airbel Impact Lab Middle East Hub of the International Rescue Committee on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) to conduct an explorative study of existing remote mental health and psychosocial support services in the Middle East. The study involved a review of studies, a mapping of services and key informant interviews with mental health practitioners and clients. The aim of the study was to better understand the current state of remote mental health services delivery in the region: what kind of services are provided, which barriers exist and how could they be overcome?  

One of the key findings of the study is that COVID-19 has been a catalyst for the expansion of remote mental health services in the region. Respondents to the survey reported a 48% increase in the use of telephone and a 79% increase in the use of online video conferencing as means to deliver mental health services.  

Al Jamal’s organisation in Jordan, for example, switched to providing counselling via a hotline when meeting clients face-to-face was no longer possible. She and her colleagues were surprised how well this alternative worked: ‘Our organisation is led and managed by people who at some point in their lives needed and received psychosocial support themselves,’ she says. ‘They know first-hand what many of their clients are going through and can respond with empathy – irrespective of whether they are talking to them on the phone or in person.’ 

Embrace Lebanon, which has been operating a national emotional support and suicide prevention hotline since 2017, recently launched a clinic providing funded psychotherapy and decided to move psychotherapy online when the lockdown started. Lea still believes that psychotherapy can be more beneficial in person but concedes that ‘under COVID-19 lockdown conditions we have had to put such preferences aside. Given our beneficiaries’ needs it would be much more harmful to not do anything and just leave them on their own- we at Embrace always work towards the phrase so that no one suffers in silence.’ 

What are the main challenges for remote mental health service provision?

Based on their interviews with practitioners and clients, the study authors identified three main challenges for remote provision of mental health services in the Middle East. The first concerns the lack of a coherent framework for practitioner training and supervision:

‘Seyma’[1], for example, a psychologist working remotely in Syria, says that she feels lost when it comes to providing services remotely to quite different client needs (trauma victims, children etc.). Because she has relied mostly on her own adaptations of techniques usually delivered in person, she is unsure as to whether what she is doing is the best approach. She would appreciate more guidance and support, the study notes. The authors recommend that training programmes should be co-developed with practitioners and that clients’ experiences of remote services should be taken into account. 

Secondly, the study reports that mental health practitioners who work remotely express a need for greater support. ‘Adam’, for example, a caseworker in a rural area whom the authors interviewed, feels overwhelmed with the workload that accumulated since the start of the pandemic and worries that he can no longer handle it.  The study authors recommend that organisations ensure sufficient rest and recuperation for their practitioners, for example through rotation mechanisms and self-care slots.    

Thirdly, the study finds that more research is needed on remote mental health provision in the Middle East. To have an impact on practice, it should be responsive to, and informed by, practitioners’ and clients’ needs and interests. The authors suggest that opportunities should be created for researchers to work in the field with practitioners.

The way forward and how German Development Cooperation can contribute

“The study findings do not only show a rapid shift in modes of service delivery but also highlight with how much creativity and flexibility practitioners and clients made counselling and therapy work remotely.  We hope the findings will help practitioners to feel more secure in their daily work and inform organisations and policymakers alike when setting up services that work well for both the therapist and the client”, says Miriam Tabin, advisor at the Sector Project on Displacement at GIZ. 

According to her, it is of crucial importance that German development cooperation fully recognises the need for mental health and psychosocial support services. The Special Initiative on Displacement of the German Federal Ministry for Economic Cooperation and Development (BMZ) therefore considerably stepped up its efforts in recent years and commissioned around 70 projects worldwide that address the mental health needs of displaced populations and their host communities: For instance, the regional project “Psychosocial Support for Syrian/Iraqi Refugees and IDP” in Jordan, Lebanon, Turkey, and Iraq, supports research and innovation around remote mental health service provision. In Jordan, German development cooperation supports the Ministry of Health in the provision of mental healthcare services and staff care. In Syria, it provides remote trainings for health workers in the provision of mental healthcare services. 

 “Over the past two years, we have experienced an unprecedented health crisis and an increase in economic hardships, all on top of conflict and displacement”, says Elke Löbel, Commissioner for Refugee Policy at BMZ, “It is thus more important than ever that we continue to advocate for mental health and psychosocial support services and step up our collective efforts. Investing in care and wellbeing of those who live in insecurity will help to strengthen societies and create prospects for development.” 

Inna Laz and Anna von Roenne, September 2021

The study will be published shortly on the BMZ Website.

For further questions, please refer to johanna.lechner@giz.de or miriam.tabin@giz.de

© @EmbraceLebanon
© Naser Jafer/GIZ

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