Why cultural context is vital when treating women traumatised by war

A culturally informed and socially acceptable psychological support programme for a group of refugee and war affected women can result in 68.75% of participants experiencing reduction in PTSD, or 93.75% in depression. Yet, most refugees do not get any kind of mental health support.

In fact, the vast majority (85%) of the world’s refugees live in countries where annual median per capita funding for all mental health services ranges from $0.02 in low-income countries to $1.05 in lower-middle income countries.

Refugees are the largest single group of people in danger of developing mental health issues because they are often exposed to traumatic experiences before, during, and after the actual ordeals they have endured.

For those who do get access to mental health services, it is questionable how adequate and effective they are, because the mental health needs of refugees and other people affected by war are often more complex and demanding than of the rest of the world’s population.

All these issues demand our urgent attention, but I first want to advocate the development of psychological intervention programmes which are culturally and socially aligned with the specific needs of these people.

To illustrate the case, I will use the examples from our work in the Middle East and with Arab populations. However, our solutions are not only restricted to Arab societies but can be beneficial to any region with high rates of refugee and war affected populations and a culture which stigmatizes mental health.

Today, nearly half (48%) of Arab youth, aged 18 to 24, say that seeking medical care for mental health issues is viewed negatively by most people in their country.

Despite such a cultural setting, even if a young Arab person decided to seek psychological support, 56% of young Arabs would find it difficult to get quality medical care for mental health issues in their country.

Furthermore, in Arab countries currently or recently affected by war – as well as in less developed, more poverty-stricken Arab regions – barriers to mental health care are even more unsurmountable. While Lebanon and Jordan have the highest refugee population per capita in the world, with 156 and 72 per 1,000 residents respectively, some data suggests that not so long ago there were only 1.1 psychiatrists per 100,000 residents of Jordan, and only 1.2 psychiatrists per 100,000 residents of Lebanon.

In Arab countries, mental health support is often associated with forced stays at mental institutions and criminal activities, and people often allow mental health issues to transform into somatic manifestations which leads to a medical intervention as opposed to a psychological or psychiatric intervention.

When it comes to Arab women impacted by the trauma of war and violence, it’s a very grim picture.

Generally, women are more vulnerable to the psychological impact of war and violent conflicts, as they are often the most badly affected and least likely to be the perpetrators of violence. When seeking psychological support, Arab women in particular are faced with numerous cultural obstacles.

They are expected to have fewer interactions in public spaces (including hospitals) than Arab men; therefore, accessing psychiatric facilities may be highly unsafe for many Arab women. Arab women traumatised by war and violence may also find spending an hour with a therapist in a closed room deeply distressing, even if it was with a female and Arabic speaking therapist.

These insights suggest that in certain regions of the world we should transition away from more commonly used mental health interventions for refugees and war affected populations, such as talk therapies.

With an aim of alleviating trauma in all women affected by war and violence, I would like to explore psychological approaches which are non-stigmatizing, engaging, and above all, fitting to different cultural contexts.

For instance, psychological programmes that are offered as arts-based cultural activities, rather than mental health programmes, make providing psychological support more feasible and efficient in certain Arab cultures. This could benefit those who might suffer from internalised stigma, and remove the fear of social settings where people could ostracize or discredit them for seeking mental health support.

In addition, a group-led process instead of an individual-focused activity can foster a sense of belonging and dialogue among participants. This is particularly important in societies with a lot of friction as it nurtures their ability to communicate.

We at Intisar Foundation have found these important features in drama therapy. Developed by Jacob Moreno, drama therapy has been taught and researched in universities across Europe and the US, but it is still gaining ground as a psychological intervention in other parts of the world, including the MENA region.

Having adjusted drama therapy to suit the social and cultural context of Arab women living in refugee camps across Lebanon and Jordan, we have witnessed their incredible transformation in terms of the psychological and social betterment.

Interestingly, we have seen drama therapy proving itself capable of changing deeply entrenched cultural narratives, such as Arab women ending the practice of child marriages due to a newly adopted belief that they can protect their daughters by encouraging them to gain education instead of marrying them off. Or female victims of domestic violence whose unhealed trauma resulted in them becoming prone to physical violence towards their children now displaying composure and mental and emotional control. We seem to have found a way to end a cycle of violence in Arab families traumatised by war.

While the world’s approach to providing mental health support to refugee and war affected populations needs be re-examined on many levels, our first goal could be to be more accepting of cultural and social differences of these people.