(Formerly IRIN News) Journalism from the heart of crises

  • Brain drain: the neglected mental health of refugees in Europe

    In a hotel set amidst an olive grove on the Greek island of Lesvos, refugees fleeing violence in Syria, Iraq, Afghanistan and other war zones share their traumatic experiences and mourn the loss of their past lives.

    A Syrian woman is haunted by the memory of her husband dying from a cardiac arrest as they tried to cross the Turkish border with their four children. An Iraqi woman is traumatised by her encounter with “The Biter”, a metal tool used by the so-called Islamic State to clip off the skin of women dressed immodestly. And Hayat, another Syrian refugee, arrives on Lesvos to find that her hands are paralysed – a psychosomatic effect associated with post-traumatic stress disorder (PTSD).

    They will only remain on the island for a few days before continuing their journeys to northern Europe, making the provision of clinical therapy for their trauma impossible. A psychosocial support team from an Israeli NGO, IsraAid, offers some short-term coping strategies to help them accept their past and prepare for the future.

    “When they come to us destroyed, we tell them, ‘Look, you have brought your family to safety; you can continue onwards in your journey,’” said Warda Alkrenawy, who heads the team of volunteer psychologists and counsellors, many of them Arabic speakers.

    Lesvos has received 60 percent of the nearly 130,000 refugees and migrants who have arrived in Greece since the beginning of the year. Here, as in other locations on the frontlines of Europe’s refugee crisis, the urgent need to provide new arrivals with basics such as food and shelter means that mental healthcare needs go largely unmet.

    While there is no data available for how many refugees living in Europe are suffering from psychological trauma resulting from the conflicts they have fled, a study published by the German Federal Chamber of Psychotherapists last September estimated that as many as half of the refugees living in Germany – the final destination for many of those arriving on Lesvos – have mental health issues. Besides depression, the most common problem is PTSD. But according to the study, only four percent of PTSD sufferers are receiving treatment.

    To treat or not to treat?

    In most contexts, delving into traumatic memories forms part of the healing process. But Talya Feldman, a volunteer with IsraAid’s psychosocial team, explained that working with refugees in such short timeframes meant that alleviating the symptoms of PTSD was often the best they could hope for.

    “Living in denial is not a good coping method, but if you’re still in [a potentially traumatic situation], and we don’t have the resources to really open the wound and treat it, it can be the best way,” she told IRIN.


    Neal McQueen
    A psychosocial session with a refugee, therapist, and translator at Pikpa camp on Lesvos

    Hayat, the Syrian refugee with the paralysed hands, recovered quickly once medical tests showed that the cause was high levels of stress preventing oxygen from reaching her muscles, rather than any physiological problem. “Just to know that, with all the uncertainty around her, that there was a cause and solution to this one thing, helped her to immediately relax,” recalled Mira Atzil, a clinical psychologist with IsraAid. 

    Atzil encouraged the woman, whose husband had died as they crossed into Turkey, to view the tragedy as an event over which she had no control, in contrast to her future.

    Part of this looking forward to the future involves preparing the refugees for what they will need in the weeks to come, from information on requesting asylum, to the available routes, as well as warnings against the dangers of continuing onwards with smugglers.

    Last chance

    For many of the refugees, Lesvos may be their first and last opportunity to receive psychological treatment. There is currently no mental healthcare network in place to connect refugees with further treatment in other countries along the western Balkans route, although some psychosocial support is available in Serbia, through Atina, an NGO based in Belgrade.

    Rima Alshami, a cultural mediator with the organisation, who moved to Serbia three years ago after narrowly escaping a car bomb that exploded near her home in the Syrian capital of Damascus, noted that refugees in transit have emotional coping mechanisms that allow them to continue onward.

    “When you make the decision to fight, you’re strong,” she said of the refugees she has met. “It’s when you settle that you need to collapse.” 

    “When you make the decision to fight, you’re strong. It’s when you settle that you need to collapse."

    Originally a stockbroker, Alshami spent much of her first year in Serbia in a deep depression that made it difficult for her to get out of bed, let alone process any of her emotions. She said she didn’t seek psychological care because she was too busy finding employment and navigating her new country's bureaucracy. 

    Limited help

    The final destination for more than one million asylum seekers in 2015 and a further 153,000 in the first two months of 2016 has been Germany, according to government figures. 

    The Berlin Centre for Torture Victims (BZFO) – one of only two organisations in the city that offers trauma care free of charge to refugees – is providing short-term intervention to more than 180 refugees and long-term counselling and psychosocial support to more than 700. But BZFO is only able to help about 20 percent of the refugees who request its trauma treatment services. 

    The only other option for most refugees is to seek help through the public healthcare system – a bureaucratic process that can take months and where interpreters are not guaranteed during therapy sessions.

    A star is born

    Syrian filmmaker and anti-regime activist Firas Alshater, 24, first started receiving therapy at the BZFO when he arrived in Germany in 2013 and was having flashbacks and nightmares about the torture he experienced in a Syrian jail.

    “When I first arrived, I had to start from zero in this new place where I didn’t speak the language. I wanted to talk to someone; still, I need to talk to someone. It’s not over,” he told IRIN.


    Juuso Santala
    Since receiving treatment for his trauma, Firas Alshater has been able to resume his career as a filmmaker

    While he still suffers from occasional nightmares, Alshater has reinvented himself as one of Germany’s most sought-after YouTube stars. His web series “Sugar”, which has gone viral since launching last month, comically muses on German society and culture from his perspective as a refugee. 

    Alshater’s experience of accessing long-term psychological care is rare. He said a number of his friends suffer from sleepless nights, flashbacks and other symptoms associated with PTSD, but that few have sought help. While some are deterred by the stigma still attached to mental health problems in many cultures, others are intimidated by the prospect of divulging their darkest memories to not one but two strangers: a psychologist and a translator.

    The simple approach

    BZFO’s psychologists say they’ve seen positive results from the use of relatively new methods like Narrative Exposure Therapy (NET), first used to treat Sudanese child soldiers. Patients recall their experiences chronologically in order to crystallise the trauma as a past event and prevent it from haunting them in the present. The method’s relative simplicity means it can be administered by professionals with only basic training.

    “It’s a really promising approach for patients here in Germany, especially since we have a shortage of Arabic-speaking therapists,” said Maria Boettche, head of BZFO’s research department.

    BZFO press officer Meltem Arsu said that treating refugees for their trauma is critical for their integration into German society, and that there is an urgent need for the government to provide more support to mental healthcare services.

    “Even short-term support through a social worker and some level of psychotherapy could be enough to stabilise the person so that they can go on with their lives,” she told IRIN.

    Alshater said a big part of recovering from his own trauma has been getting back into filmmaking and “giving a message that all of us refugees are just people”.

    “The most important thing for me was to realise that all that I had before was now gone, and I’m in a new life now.”


    The neglected mental health of refugees in Europe
    How stigma and a lack of help are leaving trauma untreated
  • Turkey’s refugee smugglers adapt and prosper

    In the main square of Aksaray, a neighbourhood in Istanbul densely populated by refugees, Haroun Yamani tries to placate potential clients who are seeking a future in Europe but are anxious about the treacherous boat journey that will take them there.

    The slight, chain-smoking refugee recruiter claims that unlike other smugglers who have been known to run away with payments, he is “a good man” who charges the steep price of $1,300 per person because “there are dangerous ways, and there are safer ones, which must be more expensive.”

    The reality for would-be passengers from Syria, Iraq, Afghanistan and other conflict ridden and economically deprived countries is that they could well be paying for their own death. On Monday, as visiting German Chancellor Angela Merkel called for “swift results” in Turkey’s crackdown on the smugglers and Turkish Prime Minister Ahmet Davutoglu, in turn, appealed for greater NATO involvement, winter winds whipped up the Aegean, turning over two boats and claiming at least 33 more lives.

    Following its recent and controversial deal with the European Union, Turkey has certainly beefed up its anti-smuggling campaign. Yamani’s operation has encountered additional police presence along the road from Istanbul and along the coast, but he assures clients that he has contacts on the inside, “who will inform us” of any need to circumvent checkpoints or pay bribes to security officials.

    See: Turkey introduces tough new border policies for Syrians

    Yamani says the price is about half that demanded during summer months, when the waters are calmer and the likelihood of boat accidents and hypothermia are reduced. But he adds that the winter trips are “comfortable, not dangerous, God willing.”

    If he knows it, he doesn’t mention that since the beginning of 2016, more than 360 people have died or gone missing trying to cross the Aegean, according to the International Organization for Migration. This was up from 82 recorded deaths during the same month last year.

    EU deal brings new measures

    Some 2.5 million Syrian refugees have crossed into Turkey since the war in Syria began, making it the largest host of Syrians in the world. The country is under increasing pressure from the EU to stem the flow of refugees and migrants who have departed from its shores in their hundreds of thousands to reach nearby Greek islands like Lesvos.

    In a bid to fulfill its part of the $3.2-billion aid deal signed with the EU in November, Turkey has made efforts to tighten its borders, crack down on smuggling networks, and improve living conditions for Syrian refugees, in part by issuing work permits to those residents in the country for six months or more.

    On 1 February, government spokesman Numan Kurtulmus told a cabinet meeting that Turkey has “decided to categorise smuggling as a terror crime, an organized crime, and enact legal amendments to that extent, including confiscation of assets used in smuggling.”

    He added that a special police task force to prevent smuggling is in the works, and that a decree has been signed in order to strengthen coordination between the police, the coastguard, local governments, and other relevant institutions.

    Such measures have made the headlines in Turkey, most recently on 6 February, when Turkish police raided three factories producing unlicensed and substandard inflatable boats used to smuggle migrants to Greece. In recent weeks, Turkey has also deployed additional gendarmerie troops along its Aegean coast.

    Smugglers adapt fast

    But frequent beach sweeps in and around coastal cities are insufficient to catch all the groups. Smugglers have adapted by operating more furtively. They constantly change the hotels or locations in the woods where refugees linger before their departure, and simply wait for the coast to be clear – often in early morning – before giving the green light for the boarding of the boats.

    Since the early 2000s, the Turkish government has appeared almost powerless to prevent people smuggling from ballooning into the multi-billion-dollar industry it is today.

    See: Refugees defy EU-funded crackdown in Turkey

    Fulya Memisoglu, an assistant professor at Cukurova University who studies smuggling and trafficking networks in Turkey, said the transnational nature of the business presents a significant challenge. People smuggling involves “different countries and perpetrators who very easily adjust to the changing dynamics of migration flows,” she told IRIN.

    Secretive kingpins

    According to the refugees, the facilitators are often of Syrian origin and present a “neat and clean” image upon which they build trust, Memisoglu said. But these characters are the just the presentable face of a broader network whose hidden leaders are hard to identify and who are cunning enough to constantly replace their underlings.

    The facilitators are sometimes “saving money themselves to be smuggled through migrant smuggling, so they may no longer be in Turkey after a few weeks, or a few months,” explained Memisoglu.

    Despite the icy waters and government pressures, demand for passage to Europe has only increased since last year, and the numbers of those arriving on European shores, as well as the death tolls, are only expected to continue rising.

    The rise of social media

    Unlike last year, when smugglers recruited out in the open in neighbourhoods popular with refugees, Yamani says most are now shifting recruitment off the streets and further into the depths of social media, amping up their advertising campaigns on an unknown number of groups on Facebook, WhatsApp, and Viber.

    As well as boats, they advertise forged documents that can make registration easier once people get to Greece. Prices range from $50 for marriage certificates to $1,250 for passports.

    A Facebook spokesperson said smuggling groups violate its community standards and are removed once the company is notified of their existence. However, it is impossible to keep up with the rapid pace of new and constantly changing groups conducted in languages that are often not understood by overseers in European or American offices.

    “Facebook is very quick to take down pages that are working to smuggle people, but the trouble is that we’re seeing an extension of sketchy, well-disguised travel agents, exploiting the needs and the huge imperative for desperate people, who are of course using social media – Facebook, Google hangouts, you name it, whatever works,” IOM spokesman Leonard Doyle told IRIN.

    In groups such as the “Smugglers Market,” “Smugglers to Europe,” or “Trips from Turkey to Greece” catering to Syrians in Turkey and elsewhere, competitive winter rates have reached new lows, with smugglers charging as little as $500 per trip.

    The prices have experts concerned that smugglers are taking even more shortcuts than before, sending refugees in lower quality boats and with more counterfeit, non-buoyant life vests that serve little purpose for the many refugees unable to swim.

    Worth the risk

    Ismael, a refugee from Homs, who requested his last name not be used due to security concerns, is in the middle of a 12-hour shift selling one-Turkish-lira (30 cents) tea to provide for his wife and three children. Informal salaries like his are not enough, and he dips into his savings to cover soaring rent and food prices.

    He sees private minibuses full of refugees departing daily, even during snowstorms, from his neighbourhood of Aksaray, and says his countrymen have “seen so much war and destruction, it’s worth it to take one more risk in order to get to a better place.”

    While refugees risk the boat journey to Greece to escape the “exploitation” that is rampant in Turkish cities like Istanbul, “the smugglers live very happily,” Ismael says. “They can make $20,000 per month during a busy month. They have everything: a home, cars, all the possibilities – whereas the rest of us have little.”

    Young men like 29-year-old Mohamad Moussa say they can’t wait any longer to start their lives.

    “When I came to Turkey, I received nothing in terms of human rights,” said Moussa, who paid smugglers $600 to ferry him across the sea to Greece last month, and is now continuing onwards with the goal of reaching Germany.

    The journey from Turkey’s coastal city of Izmir to the Greek island of Lesvos was cold and Moussa “felt the waves,” but he couldn’t wait for the arrival of spring, when prices would be out of reach.

    “In Turkey, any place I worked, anything I did, I felt lost,” he said. “At least in Europe, I will have rights and I will have the chance to make some money to send back to my family still living in Syria.”


    Turkey human smugglers adapt and prosper

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