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Mental Health Interventions in a post-disaster setting :
Exploring the available services, gaps, and possible solutions; to maintain
availability and accessibility of mental health services in Greece
NOHA Master Thesis Written by: Sawsan Kanaan Supervisor: Nadine Voelkner
This thesis is submitted for obtaining the Master’s Degree in International Humanitarian Action. By submitting the thesis, the author certifies that the text is from his/her hand, does not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic practices.
Master program in International Humanitarian Action University of Groningen August 2020
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Abstract
This research question addresses mental health care and psychosocial support in a humanitarian, refugee, and displacement setting. The importance of this research stems from the huge refugee crisis the world is facing lately; where according to UNHCR global trends report (2015), migration rates have raised by 50% within 6 years to reach 63 million displaced persons in 2015. However, numbers of refugees are expected to rise even more in the upcoming years. Traumatic events due to displacement, war, or conflict require a response, in terms of MHPSS. Trauma is linked to mental disorders and is also connected to an inability to easily integrate into the new destination. According to WHO (2001), mental health is an indicator of one’s overall well-being. Mental health, physical health, and social integration were proven to be strongly linked together. However, this research’s goal is to assess the availability and accessibility of MHPSS in Greece, particularly in Athens, after the refugee crisis that occurred in 2015.
Because there was a very limited academic study on MHPSS interventions with refugees’ posts to the huge influx of refugees to the EU, especially through Greece. This research aims at filling the gaps in the previous literature addressed people who suffered from a humanitarian crisis that affected their mental health, in particular, to the research on post refugee crisis. For the sake of collecting primary data, 10 interviews with workers and volunteers in MHPSS were conducted. The research findings indicated a lack of MHPSS and many obstacles to accessing these services. It can be concluded from the research findings, that policies towards refugees, support, well-being, and social integration are all factors that affect their mental health, and ability to be an active part of the society. The research can be a great tool for academics or policymakers, NGOs, and students, who look to know more details and stories about refugees' mental health in Greece.
3 Table of contents
Chapter 1: Introduction……….…...…7
The research process………..………...…7
Research Problem ……….………..…8
Research questions ……….………..….8
Research justification and Relevance to the field of Humanitarian Action ……….………….…10
Methodology……….………….……..11
Reasons for choosing context and geographic location ……….11
Research procedures ……….….12
Sampling ……….……….…13
Interviews………..………..13
Analysis……….……….……14
Challenges and ethical issues ……….……….…….15
Thesis outline………..…….17
Chapter2: The literature review……….………...18
Definitions……….……….….18
2.2 Mental health and psychosocial support MHPSS in humanitarian action………..…………19
Mental health disorders: causes, prevention, and treatment………..…..…20
People at higher risk of developing mental health disorders in a humanitarian situation…………..…24
Responding to mental health issues in humanitarian settings……….………..…...25
Chapter 3: Greece and response to the ‘refugee crisis’……….……….…………..31
A glimpse on the ‘crisis’……….…….……...……32
Availability of Mental health services for refugees in Greece………..………..………34
Chapter 4: Results…………..………..………..38
Availability and sufficiency of MHPSS interventions in Athens………38
Reasons for lack of MHPSS services………40
Accessibility of MHPSS services ………..……41
Who is responsible for providing MPHSS provision for refugees in Greece?...42
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Most vulnerable groups to mental health disorders……….……...44
how to improve MHPSS interventions in humanitarian action in Greece?... 45
Chapter 5: Analysis of the research findings……….……...48
Available MHPSS humanitarian interventions in Athens………..………....49
Reasons behind insufficiency and lack of MPHSS services directed towards refugees……….….….….54
Barriers to accessing MHPSS services……….……..…..56
Integration of MHPSS services………..……….…..57
How to improve MHPSS emergency interventions in Greece?...63
Chapter: 6 Conclusions……….…….……..…67
References ……….…………..68
5 List of Abbreviations
GBV: Gender-Based Violence
MHPSS: Mental health and psychosocial support in emergency Settings
LGBTQ: Stands for lesbian, gay, bisexual, transgender, and questioning (or queer) MSF: Medicines San Frontiers/ Doctors without Borders
NGOs: Non- Governmental Organizations PTSD: Post-traumatic stress disorder
UNHCR: United Nations Higher Commissioner for Refugees WHO: World Health Organization
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Preface
It is my pleasure to be submitting this master thesis in International Humanitarian Action. After the hard work and learning on the research problem. I would like to dedicate my thesis to those who teach life; especially to the courageous ones who left their houses, homelands, beloved ones, and decided to cross the dangers for better tomorrow. For all caregivers and volunteers in the humanitarian action; driven by their compassion, and willingness to alleviate others’ people’s suffering. I will take this opportunity to declare my gratitude to all the amazing people I met in Athens, who shared with me their knowledge, feelings, stories, and experiences in order to educate others about MHPSS.
I want to take this opportunity, to give special thanks for the invaluable support I received from my supervisor Dr. Nadine Voelkner. It was my pleasure to be supervised by this great professor who gave me incredible support and guidance from rich experience.I am also grateful for the great support from the NOHA family at RUG university; represented by NOHA Program Director Dr. Clara Egger and NOHA Program Coordinator MA Ingrid Sennema for their kind support. Finally, sending much love and care back to family, friends, and everyone who supported me in any possible way, to complete this research.
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Chapter 1 1. Introduction
Mental health and psychological problems are very common in any humanitarian emergency setting. The different “stressors” caused by a humanitarian emergency (such as fear, panic, loss, and uncertainty), can result in severe effects in people’s behaviors, psychological well-being, and social interactions. Therefore, mental health and psychological support are needed in “humanitarian emergencies”; and it requires cooperation between multiple humanitarian sectors, as well as focus on both “psychiatric” and “psychological” “treatments” as well as “psychosocial support”. (Sphere Association 2018, P: 333). A humanitarian crisis can expose people to trauma, resulting from events they might have experienced or witnessed; “such as abuse, assault, violence, gender-based violence, human trafficking, immigration, military combat, natural disasters, and terrorism” (Macy et al, 2018). In general, trauma exposure could result in mental health illnesses or “disorders” including:” anxiety, depression, and post-traumatic stress disorder (PTSD)” (Macy et al, 2018). All trauma-related mental illnesses are proved to be reducing the quality of life for the patients, especially PTSD; that was proved to be associated with more frequent and severe traumatic experiences, and more occurrence of symptoms (Gadeberg et al, 2017). According to IASC (2007), crisis ( either resulted from armed conflicts or natural disasters), is one of the main reasons for psychological illnesses or disorders that might develop, whether the traumatizing event has lasted for long or short periods.
In its report on the mental health of refugees, The World Health Organization WHO (2018), have recognized the mental health effects of “migration process” on people who went through it. Such a difficult process can be full of stress, unpleasant experiences, and unexpected events. WHO (2018) also confirms that refugees and migrants are highly prone to mental health disorders (such as anxiety, depression, or post-traumatic stress disorder PTSD), compared to any other group of population.Regardless of the individual differences in terms of personal hardships, crises, and experiences that refugees and migrants might
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come through during their journey. On the other hand, the experience of migration itself is enough to consider the person who went through it, in a need for mental health support, care, and attention. The WHO (2018) has also highlighted that the impacts of migration on “long-term refugees” are considerably high; especially if accompanied by a lack of social support, integration in society, and economic empowerment. The report also pointed out that there is a positive relationship between the number of refugees and the proportion of mental health disorders in the country. This means that; the higher the number of refugees in a country, the higher is the proportion of mental disorders in this country. Moreover, In its strategic plans, assessments, and reports, WHO focused on mental health and psychological support for refugees; and recommended a holistic approach to mental health, especially in refugees’ settings. It is very clear that an important part of WHO’s mission aims to ensure that, refugees’ “well-being” (physically, mentally, and socially) is taken into consideration by humanitarian actors and governments; through access to health support, social integration, employment, and care. Hence, focusing on improving government policies towards refugees can support the prevention of refugees against mental health disorders, and providing accessible and effective treatment of mental disorders when the need is crucial. WHO (2018), (WHO 2013), (WHO 2001) (WHO 2004). The United Nations Higher Commissioner for Refugees (UNHCR 2019), have also recognized the importance of mental health and psychological support during “displacement”.
2. Research process 2.1 Research problem
The so-called, ‘refugee crisis’, has emerged as a result of wars in the Middle-East (especially in Syria), besides the political instability in Afghanistan were considered the biggest causes (“push factors”) of migration after the big migration movement post-world war II. Refugees (especially Syrian) as a result, started fleeing their countries towards European member states. Around 1.3 million refugees have reached and applied applications for asylum in the EU countries, besides Switzerland and Norway in 2015 (Alpes et. Al 2017). This huge influx of migrants and refugees that happened suddenly in 2015,
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was considered to be a red flag for the EU countries who were influenced by this movement of refugees to offer and agree on a deal with Turkey to deal with the “Syrian refugee crisis”. The main broad lines included in the EU-Turkey deal that was officially announced in March 2016, was to create a dismissal to the “Syrian refugee crisis”, and control irregular migration to Europe (Rygiel et al. 2016).
The reviewed literature review led to the following hypothesis: Humanitarian mental health interventions in Greece are insufficient. This hypothesis will be tested in this study. However, the weaknesses (limitations) of the literature found on the context and topic is that there are no answers for the main reasons for that “gap” in mental health services, and how to improve it. Therefore, this research aims at filling the gaps in the previous literature on mental health services provided for refugees in Greece.
The results of the study will contribute to the existing literature on Mental Health Services in Humanitarian Action. The study aims to assess the availability and accessibility of mental health services for refugees in Athens; who experienced traumatic mental health illnesses “including anxiety, depression, and posttraumatic stress disorder (PTSD)”; from mental aid- workers’ perspective. The study tends to answer the questions: What are the main mental health services provided to refugees in Athens? And whether these services are available, accessible, and sufficient to refugees? Only three studies were found on mental health humanitarian interventions in the Greek Islands. Nevertheless, addressing the services on the mainland and the whole system of delivering mental health humanitarian aid was not found in these studies.
To be able to assess the availability and accessibility of mental health services for the treatment of post-traumatic mental health illnesses for refugees in Greece, the research question and research methods have focused on the mental health services provided after the refugee crisis in Greece in 2015. Hence, most of the literature used was from recent studies and articles; but mainly from reports and assessments of international organizations and UN agencies (especially that Academic research was very limited on this subject. Based on the weaknesses (limitations) of the literature found on the topic, this research aims at
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filling the gaps in the previous literature addressed people who suffered from a humanitarian crisis that affected their mental health. From recent studies and reports of well- recognized International organizations and UN agencies.
2.2 Research Questions
By addressing NGO workers and volunteers who interact directly with refugees through psychosocial interventions; this research will tackle the issues of lack of specialized and non-specialized psychological treatments provided for refugees in Greece. Human resource lack in psychotherapists and mental health professionals was documented especially in the Greek islands(Gkionakis 2016), However, this research will try to cover the mental humanitarian services on the mainland particularly in Athens. Moreover. The research will answer the following questions:
1- What types of mental health services are available for refugees in Greece? 2- Are the available mental health treatments sufficient?
3- Are these types of services accessible to refugees who need it? 4- Reasons for the lack of services and inaccessibility?
5- Who is responsible for providing MHPSS intervention for refugees in Greece? 6- is there any gender or age refugee groups, could be considered more vulnerable to mental health illnesses?
7- Are there mental health services for workers in the humanitarian field? Especially volunteers and field workers?
8- What needs to change to be able to meet the mental health needs of refugees? 2.3 Research justification and relevance to the humanitarian field
The research question addresses mental health care and psychosocial support in a humanitarian refugee displacement setting. The importance of this research stems from
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the huge refugee crisis the world is facing lately; where according to UNHCR global trends report in 2015 mentioned in Miller et al. (2017), migration rates have raised by 50% within 6 years to reach 63 million displaced persons in 2015. According to Miller et al. (2017), numbers of refugees will be increasing in the upcoming years, and most refugees are more often “trauma survivors”, or at least in need of mental health and psychological support. Despite Greece is one of the main migration routes to Europe, academic research on mental health interventions provided for refugees in Greece is very limited. The situation in Greece if studied well, can help academics to know much about how humanitarian work is being implemented on the ground; and might help as well in raising awareness of policymakers on humanitarian interventions, especially on mental health and psycho-social support. The numbers of related articles found in the University of Groningen and Google Scholar were surprisingly limited and very few were related to mental health interventions in the humanitarian context. The reality also that there were three academic-related studies found on humanitarian mental health interventions in Greece, is both encouraging to implement research and at the same time very challenging. Only very few research articles were found, particularly a cross-sectional quantitative survey about violence and mental health issues of Syrian refugees in Greece Ben Farhat et. Al (2018), and two medical articles Gkionakis 2016), and (Kousoulis et al. 2016), were found. Most of the data in this research are available from organizations reports, UN agencies (such as UNHCR, WHO, MSF, IOM). Such information from reports (mostly quantitative data) needs a more in-depth qualitative look through, which this research is planning to conduct. This research aims to take part in developing and filling the gaps in the literature review, on mental health interventions in humanitarian settings. It aims at highlighting the importance of providing the needed mental health support, ensuring the well-being of refugees, and to draw attention to this critical issue in humanitarian work; especially to academics and policymakers.
3. Research Methodology
This part explains the methods used in this research, including thorough clarification of research methods, data collection, sampling process, interviewing process, research challenges, and ethical issues. This research is exploring the mental health aspects of
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disaster and displacement settings, and for that, it is using qualitative research methods for data collection and analysis. The qualitative approach is being used because of its ability to expand our understanding, knowledge, imagination, and awareness of a certain issue or a phenomenon; as it tends to share perspectives of people who have been witnessing certain experiences. This allows the researcher to receive not only information they gathered from experiencing; but also, their feelings, believes, and their realizations about those experiences. These perspectives, images, and information can be used to expand our understanding of the research problem, and it is a very suitable tool for humanitarian research (Miller et al. 2002). Moreover, it enables the researcher to make analysis and comparison of the different views on the research topic and allow for comparative analysis of certain political and historical events (Miller et al. 2002).
3.1 reasons for choosing context and geographic location
The research specified Greece as a geographic area and case study; due to the fact, It’s a destination country where many refugees have and are still fleeing war zones reach to seek asylum, or in their attempt to reach central Europe through the Mediterranean (Gassmann et al. 2017), (Das 2019). Moreover, it was reported by Gkionakis (2016) and (Ben Farhat et al. 2018), that people arrived in Greece from their destinations of crisis and war, fleeing through the sea, most probably have faced violence and traumatic experiences after they ran from conflict; and they are in severe need for “mental services”. Migrants influx to Greece from Afghanistan, Iraq, and Africa have been familiar; but since 2015, the floods of Syrian refugees after the Syrian crisis, have increased numbers of arrivals significantly (Alpes et al. 2017). The focus of the research will be in Athens, the capital of Greece, and the city with more established mental health care services and humanitarian organizations. According to the United Nations, Higher Commission for Refugees UNHCR (2018) and Medicines Sans Frontiers/ Doctors without Borders, MSF (2018); Athens contains the biggest number of refugees in Greece (with total 60,000 number of refugees in Greece is between 50,000 - 60,000 refugees in 2018 including around 12,000 - 14,000 in the five Islands). Most of the services provided for refugees are concentrated in the center of Athens which makes Athens the desired destination for refugees seeking asylum in Greece.
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Moreover, majority of refugees arriving in Athens from the islands have passed the asylum procedures and are entitled to be assisted with access to services including established mental health services; while refugees in the islands are still waiting for their asylum status and not allowed before that to leave the islands; facing hard conditions, lack of services and the probabilities of secondary trauma Gkionakis (2016). Choosing Athens as the geographic area of this research for the reasons mentioned above does not interfere with any other research; as none of the studies have tackled services in Athens. According to UNHCR (2020), the estimated number of refugees and migrants in Greece, have increased to reach 121, 500 by the 30th of May 2020, including 84,500 in the “mainland” and 37,000 on the islands.
3.2 Research procedures: Data collection, sampling, interviews, analysis, and ethics Data collection
To collect secondary data, a literature review was conducted using the database SMART CAT and GOOGLE SCHOLAR, and University of Groningen’s library. However, few articles and studies were found using keywords such as ‘mental health in emergency setting’, ‘mental health interventions’, ‘approaches to mental health’, ‘treatment of trauma’, ‘alternative approaches to mental health’. However, most information in this research was derived from reports, assessments, and guidelines from the main humanitarian agencies working on mental health. The methods used for gathering primary data and information for this research; have taken a “narrative approach” taking into consideration the psychological and anthropological nature of the disciplinary origins of this research; which is using qualitative data analysis to implement a comprehensive review, analysis, and explanation of results. As the selection of the research methods should depend on the research objectives, qualitative data derived from the primary data is compared with both qualitative and quantitative data in the literature review. This complementary of data allows us to broaden the results; to include perceptions, behaviors, relationships, practices, and effects of mental and interventions for refugees, that cannot
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be addressed through quantitative surveys alone. a comprehensive review, analysis, and explanation of results from the narrative interviews have been performed.
Sampling procedure
In order to attain the most beneficial information from the semi-structured interviews, during quarantine and closure of all NGOs, the researcher has used one form of non- probability sampling “purposive sampling” (Tongco 2007). The researcher had to use their judgment to select the participants who might be more able to share experiences and thoughts that benefit the research. ETIKAN(2016). The researcher tried to involve participants from both main gender groups, however, considering the limitations of the research during a quarantine, it was not possible to choose the participant based on 50/50 percentage of male/female. However, eight out of ten participants were females, and the other two were males.
Participants first have received an email from the researcher; containing an information document, to allow them to understand the aim of the study and for what purpose it is being taken, also the name of the university and information about the privacy of data. The participants also received a consent form that they have filled and signed, where all participants agreed to record the interviews. Moreover, participants have been informed that they can decide to withdraw from cooperation with the researcher at any point. It was clearly explained to them that all personal information and all information from the interview is confidential. The researcher asked to confirm they are over age 18 and are current or former staff/volunteers of NGOs or INGOs who have worked in MHPSS with refugees in Athens before participating in the interviews. The researcher also made sure that participants were comfortable speaking in English and all of them confirmed positively. Interviews
Instruments used in this research have included informal semi-structured interviews, in which open-ended questions were used based on the results of the extensive literature review that was conducted first. Interviews were the source of primary data to be analyzed and compared to the literature review. in this research, then after doing many
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phases of reviewing and analyzing the preliminary interviews with volunteers, 10 interviews with MHPSS workers and volunteers, have been conducted. Especially as there is lack of resources on the research question, the qualitative data was able to give rich information, stories, social &cultural perspective, and personal perspectives of participants who worked/ volunteered in mental health services; and interacted directly with refugees. For the sake of this qualitative research, the researcher has previously planned to implement at least fifteen interviews with volunteers and caregivers, who interact with refugees daily, through MHPSS interventions. The interviews were implemented in April 2020, a time where a global pandemic occurred (Covid-19), and this made it very challenging to do face-to-face interviews (as previously planned), during the obligatory quarantine. However, due to the mentioned circumstances, the researcher was only able to perform ten online (video calls), semi-structured interviews. Participants selected in the sample were all caregivers, social workers, mental health professionals, and volunteers who worked in MHPSS projects with two humanitarian NGOs (Humanity Crew, and Safe Place International). The researcher has volunteered previously with the two organizations during their master's program internship in Greece, mid-2019- beginning of 2020.
To allow the space for participants to give their perspectives and information on the subject; the researcher tried not to influence the answers, and to give each participant the needed time to express their personal experience and perspective. The researcher started by asking them to describe their role in the organization and the services they provide that are related to MHPSS. This question was very helpful as a start for the interview, which made the participants able to connect to their daily work experience in MHPSS and answer the interview questions based on their knowledge, information, experience, and perspectives.
Analysis
Interviews were recorded, reviewed, and transcribed. Preliminary qualitative data analysis of the narratives has been performed to extract data. The interviews’ transcriptions were reviewed many times objectively, to grasp key elements that form the basis of the
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coding scheme used by the researcher to analyze the responses. Interviews responses were identified, labeled, and codes of certain repeated patterns of answers were identified according to these categories. Other kinds of analyses were performed (such as comparing perceptions of the staff and volunteers). The coding was found very helpful to break down the interviews into categories that have common denominators. Following analysis, the researcher had incorporated the results into abstracts, presentations, and/or manuscripts. Those manuscripts were compared to the theoretical findings of the ligature previously reviewed and that have encouraged some more theoretical research on some psychosocial support tools (yoga for example) as it was mentioned by many participants. and to the research questions.
Challenges and ethical issues
The research interviews were performed during a critical time (which was the main challenge for this research), where a global pandemic (Covid-19) started just at the beginning of the research. As a result, some barriers appeared facing the researcher, including time scope and ability to collect primary data. Because there were a compulsory quarantine and closure of all NGOs and all public life; it was only possible to perform the interviews online. Since the researcher has volunteered previously in Greece, it was very helpful to contact people who might be willing to do the interviews especially online. The participants were from multi-cultural settings, all have worked or volunteered in Athens in MHPSS. To respect the privacy of participants, they were not asked any personal questions, and the interview timetable was determined based on each participant's preferred time. The researcher was very flexible with the interview timetable and assured each participant that they can choose anytime that suits their schedule. The researcher has accommodated all time differences, did interviews in the morning, during the day, or at night was not an issue as long as it works for the participant. The participants' previous knowledge of the researcher (even those they met few times) has helped to build trust and rapport with them; especially that some of them also know that the researcher is enrolled for a master's degree in humanitarian action and doing research on mental health. This familiarity with participants and organizations have also helped in creating the space for participants to
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discuss things from their point of view and also encouraged them to give examples from their work. As mentioned previously another challenge to the research was the lack of academic literature and resources on the topic, but this was overstepped and compensated by reviewing reports, assessments, and training guidelines produced by related NGOs and UN agencies.
Thesis outline
This thesis includes six chapters. The first chapter contains aim of research and justification for it, and the research methods. The first chapter also includes ethical dilemmas and describe in detail, the research process and methods used. The second chapter consist of review of literature on MHPSS humanitarian interventions. The chapter include review of MHPSS in the humanitarian action, the most vulnerable groups to mental disorders, with more in detail review of psychosocial interventions. The third chapter is reviewing the literature on the MHPSS interventions in the research context. The fourth chapters presents the results of the research, and the fifth contains a qualitative analysis of the research findings. Finally, the sixth chapter of the research contains conclusions.
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Chapter 2: The literature review 2.1 definitions
Humanitarian crisis: might be an incident or several incidents that have had caused the feeling of fear on “lives, safety, security, health, or wellbeing of a large group of people or community, usually over a wide area” (Ajdukovic 2004).
Mental health is “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can contribute to his or her community”. (WHO 2001)
Mental and behavioral disorders are defined as “clinically significant conditions characterized by alterations in thinking, mood (emotions), or behavior”; to be considered a “disorder” the behavioral or mental “abnormal” reactions must be occurring quite often and not based on one incidence. (WHO 2001).
Migration: is the movement of people beyond country boundaries to settle permanently or temporarily in a new location (Massey et al. 2001).
Trauma: according to the Substance Abuse and Mental Health Service Administration SAMHSA (2014) trauma refers to “experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual’s physical, social, emotional, or spiritual well-being”.
Psychosocial interventions: UNHCR (2013) defined psychosocial interventions as, “activities with the explicit goal to change aspects of an environment or situation, which impacts the social and psychological well-being of the affected population. Usually achieved
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by working with the local community, sectors, and organizations to advocate for improved access to community supports and basic services and restore everyday recreational, social, and vocational activities to promote psychosocial well-being”.
PTSD: “post-traumatic stress disorder is a mental health condition that's triggered by a terrifying event — either experienced or witnessed by the patient. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event” (Macy et al, 2018).
Well-being: “refers to the condition of holistic health and the process of achieving this condition. Well-being has physical, cognitive, emotional, social, and spiritual dimensions. The concept includes ‘what is good for a person’ such a participating in meaningful social roles, feeling happy and hopeful, living according to good values as locally defined, having positive social relations and a supportive environment, coping with challenges through the use of healthy coping mechanisms, having security, protection, and access to quality services and employing” (UNHCR 2013).
Yoga: is an eastern method that uses a combination of stretching movements and “mindfulness”. Yoga has proved its ability to reduce body and mental stress and increase physical and mental energy. (Sharma & Haider 2013), (Rhodes et al. 2016).
2.2 Mental health and psychosocial support MHPSS in humanitarian action
To recognize the importance of mental health and psychological support in humanitarian settings, this research reviewed the literature on MHPSS interventions in humanitarian work. The review was for the “sphere handbook” (Sphere Association 2018); which is being used by humanitarian actors as the basic reference of standards for emergency humanitarian support. The sphere handbook has highlighted the need and necessity to focus on mental health and psychological support in emergency and humanitarian settings. First, the Sphere handbook has established “core standards” for all service “sectors” that provide humanitarian assistance to refugees and migrants; and the
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first core standard is “people-centered humanitarian response”; this means that humanitarian actors must put the refugee’s well-being at the center of their work. Secondly, the standard guidelines have considered mental health and psychological support, as one of the main intervention areas under the “Essential health services” (Sphere Association 2018). Furthermore, the World Health Organization has considered mental health as “a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and can make a contribution to his or her community”. This definition; as an important aspect of WHO’s main goals, delivers the message that mental health is beyond “the absence of mental health disorders” and it’s related to people’s well-being, and ability to function in the society in healthy ways (Galderisi et al. 2015). It also indicates that mental, physical, and social well-being are interconnected; meaning that social factors as poverty and absence of education, cultural, biological, factors among others that increase “vulnerabilities” are certainly affecting mental health (WHO 2004), (Galderisi et al. 2015). However, according to WHO (2013), there is a huge global gap in responding to people who need mental health treatment or support. The gap is a result of two factors: lack of resources and “services”; that made it impossible for up to 85% of people who suffer from mental disorders to receive treatment in low and mid-income countries, while this percentage is up to 50% in the high-income countries. According to WHO (2013), the gap in the care system is also present in the unsatisfactory quality of mental treatments. The deficiency in human resources is very clear, with only one psychiatric serving around 200,000 people on average around half the world. The percentage of mental health legal coverage for people living in high-income countries is way higher (92%) than in low-income countries (36%).
According to WHO (2018), policymakers must consider the following eight main areas of intervention with refugees; to improve refugees well- being and treat mental health disorders:
- Integrating refugees in the society and promotion for mental health - Provide the needed information about accessing care services
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- Depicting the available service provision and developing them
- Provide “cultural mediation” and translation services for refugees to ensure they have
access to the needed information and services. - Putting efforts to integrate health care system, social, and mental health. - Training mental health service providers on treating refugees and migrants.
- Follow- up on service provision, through continuous research, evaluation, and strategic
planning.
- Recognizing and sharing good practices and recommending commitment to it. To have more understanding of mental “disorders” that refugees might be prone to, the research will elaborate on mental health disorders in the next section.
2.3 Mental health disorders: causes, prevention, and treatment
Mental disorders (besides substance addiction) are said to have made 13% of the diseases around the world in 2004, while depression has made more than 4.3% of total diseases (WHO 2013, P:7). Mental and behavioral disorders are “common and universal”; the increasing signs of depression and nonfunctioning, have made up to 11% of health conditions around the world; and were expected to increase 15% by the year 2020 (WHO 2013, P:7).
WHO (2001) has declared that “Mental and behavioral disorders” must be clinically diagnosed by “professionals”, like any other health condition. The clinical diagnosis methods through which the mental and behavioral disorders are being identified consist of historical background about the patient’s family and environment, clinical diagnosis, as well
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as examining mental tests (WHO 2001). Moreover, in its mental health plan 2013-2020, WHO (2013 p:7), stated the reasons behind mental and behavioral disorders; and explained that there are two types of “attributes” or reasons that can lead to it. The “individual attributes”, such as the ability to manage one's thoughts, emotions, behaviors, and interactions with others”. And on the other side “social, cultural, economic, political and environmental factors”, “such as national policies, social protection, living standards, working conditions, and community social supports”. “Exposure to adversity at a young age is an established preventable risk factor for mental disorders” (WHO 2013, P:7). Also, in its mental health action plan 2013-2020, WHO (2013), has defined "mental disorders" as a” range of mental and behavioral disorders that fall within the international statistical classification of diseases and related health problems”. These include disorders that cause a high burden of disease, such as “depression, bipolar affective disorder, schizophrenia, anxiety disorders, dementia, substance use disorders, intellectual disabilities, and developmental and behavioral disorders with onset usually occurring in childhood and adolescence, including autism.” WHO (2013).
It is important to note that Psychiatric interventions to treat mental and behavioral disorders have been considered outdated by some researchers (Smothers & Koenig 2018). According to a “systematic review” conducted by Smothers & Koenig (2018), such approaches to mental treatments have proven to be successful with only half of the cases, while the other half-percentage for patients are not considered as successful. Smothers & Koenig (2018) have explained the reason behind that, that these treatments do not influence improvement in physical well- being, which if not combined with mental treatment is not provoking long-term responses and improvement. For instance; some mental treatments are usually recommended for PTSD, these treatments usually include some or one of the following: “cognitive-behavioral therapy (CBT), cognitive processing therapy (CPT), pharmacology, psychoeducation, relaxation, eye movement desensitization, and reprocessing”. For that, some scholars such as Ajdukovic (2004) have recommended that in dealing with mental disorders including PTSD in humanitarian crisis settings; it must be taken into consideration that victims of such events must be granted what so-called,
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“comprehensive treatment”. The “comprehensive treatment” includes physical activities and social integration; as an integral part of the treatment both on an individual and collective basis. Macy et al (2018), stated that it is important to recognize and take into consideration that professional mental health treatments usually take a long time and require follow-up; opposite to most humanitarian services provided on a quick and short basis. The main goal of treatment for PTSD for example is to enable the patients to get back to the normal base of life, feeling healthy both physically and mentally, and being able to be integrated with society and become an active member within it. This point is very important to be taken into consideration when trying to design humanitarian mental health programs; which means there is a need to examine the sustainability of such programs. It is important as well, to ensure that policymakers and humanitarian program planners are considering this when planning mental health interventions Macy et al. (2018).
The evaluations and assessment taken by WHO (2013), indicate that attention towards mental health compared to physical health is very small, due to the stigma about it and to the misunderstanding of mental health as the “absence of serious mental behavioral disorders”, and not as an interconnected system that supports individuals’ well- being. This means that mental health is related to self- “realization”, self- esteem, “autonomy” and the ability to control one’s personal life. It is also important for “patients” to have a healthy interaction with their environment, and the ability to create “positive” and “happy” experiences (WHO 2004) (Jahoda 1958). It is important here to highlight the “Stigma” around mental health illnesses; which have been reported as one of the main reasons for people with mental disorders not to seek treatment or try to “drop it”, due to cultural or social stigma about it (Corrigan et al. 2014). According to WHO (2001), effectiveness in managing the treatment of behavioral and mental disorders is crucial to improve the results of treatment and to adhere to it. The relationship between therapist and patient must be based on trust, the treatment plan must be agreed on by the patient too, and the patient must be aware of the goals agreed to achieve with the therapist to the process. Support from family, friends, and community is very supportive. In fact, WHO (2001), have drawn borderlines for the effective treatment of mental and behavioral
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disorders, which must include three phases: first: prevention, or so-called “primary prevention” which comprise certain policies and tips to help protect from mental disorders. Second: treatment (considered a “secondary prevention measure” ) in the case of disorder that occurred already. Treatments usually aim to prevent increasing the symptoms. Third, rehabilitation “tertiary prevention”; that usually includes follow up and support for individuals on environmental and social levels to improve the situation or maintain the progress (WHO 2001). According to WHO (2001), the most important intervention is “primary prevention”, since it helps to avoid reaching the point where treatment is needed.
2.4 People at higher risk of developing mental health disorders in a humanitarian situation Some people in certain Gender and age groups seem to be more prone to mental disorders according to studies and reports. For example, the WHO (2009) indicated that women are at higher risk than men of developing mental health illnesses, as they are being discriminated at work, carrying burdens of household and economic participation, they are more likely than men to be “victims” of Gender-based violence GBV, and less likely to have access to resources, and to the “protection factors”; such as education and decision- making. According to WHO (20130) famous worldwide statistics, (WHO 2013 cited in Hilhorst et al. 2018); there are more than 33% of women considered “GBV survivors”. Meaning that there is at least one woman in any group of three women, who have been a victim of gender-based violence for at least one time in her life. Furthermore, women's reproductive health is linked to mental health in many ways as the WHO (2013) report highlighted, but unfortunately, less attention to women's mental health in treatments related to reproductive health. In this regard also, it is important to mention that Gender-based violence can happen through an “intimate partner” or by others. For that, it’s important to recognize that, some incidents can increase in occurrence during a humanitarian crisis, and that lies under the title of “GBV”. Such occurrences include: “rape, child marriage, forced marriage, harmful traditional practices (such female genital mutilation), physical violence, economic violence, sexual violence, psychological violence,
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and Human trafficking” (Hilhorst et al. 2018). And although the word “gender” is not only entitled to women, still GBV is famous to be highly reported to be against women although there are other gender groups who suffer from that (Wirts et. Al 2014). Gender-based violence humanitarian interventions are being integrated into all sectors working in the humanitarian field; after producing the Inter-Agency Standing Committee (IASC) Guidelines for Integrating Gender-Based Violence Interventions in Humanitarian Action in 2015. These guidelines have specific procedures on psychological and psycho-social mental health support, and they are connected to health, protection, and mental health humanitarian working groups but mainly under “protection cluster”. These guidelines were advocated and globally trained for, to make sure that all frontline humanitarian workers in international agencies, NGO’s and even community grassroots organizations, can identify such incidents, and take the right action through referral pathways (IASC 2015). Many international organizations and UN agencies have brought into light the importance of mental health response for victims of gender-based violence and took high measures and procedures to provide the needed mental health support for them, as one of the urgent humanitarian responses in crises. A mutual report (Ezard et al. 2012), conducted by UNFPA (United Nations Populations Fund and leading of Gender-based violence sub-cluster), WHO, UNICEF, and Stop the Rape Now (A UN agency specialized in aid for sexual violence; the report highlighted the importance of mutual work and coordination between different actors, and the importance for mental health support among others to people who suffer from any kind of Gender-based violence in disaster settings (Ezard et al. 2012).
Children might also be more prone to mental health issues because of their vulnerability to “adverse experiences” according to Das (2018). Acknowledging that refugee’s journey might have included danger, physical effort, exhaustion, stress, poor accommodation, separation from other members of their family, or their beloved ones, among others. However, if children flee their home country due to war or armed conflicts, they might have suffered besides that, from more problematic types of trauma such as “ violence, sexual assault, emotional or sexual abuse, domestic violence, or losing loved ones Das (2018). For example, “Unaccompanied minors” are considered to be more vulnerable
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to such experiences than adult refugees, as well as in any other community (Hart 2009). While Hodes (2000) have mentioned an important point to be taken into account when dealing with refugee children; that they are vulnerable to “greater social instability” due to the continuous movement, fear of losing family members, experiencing loss of family members or someone they love, continuous anxiety, isolation, and others. As children are more vulnerable to the suffering and changes correlated with seeking asylum, they might be more able to develop child PTSD (Hart 2009), While Hodes (2000).
2.5 Responding to mental health issues in humanitarian settings
In this part, the reader will be able to have an idea of how international organizations and humanitarian actors respond to mental health and psychological well-being. The “Intervention pyramid for mental health and psychosocial support in emergencies” is one of the most important tools for humanitarian agencies to respond to mental health and psychological well- being in humanitarian contexts. The “ intervention pyramid” that was introduced first in the Inter-Agency Standing Committee Guidelines (IASC 2007); have been designed specifically for ” mental health and psychosocial support in emergency settings” interventions. According to the IASC (2007), the WHO is the leading organization in the “global mental health cluster”, and the guideline is supposed to be the main MHPSS guideline for all humanitarian actors working on integrating mental health and psychosocial support in their humanitarian work. The most important thing highlighted by this guideline (that contains “minimum standards for mental health interventions”, is that mental health interventions in humanitarian settings must depend mainly (especially in the beginning of intervention) on community and social support. The “intervention pyramid” suggests strongly, that most MHPSS services can be provided through community social support, with the help of field coordinators, social workers, and cultural mediators. The guidelines take into consideration the power of social relations and community support in increasing people's resilience and suggests that such types of interventions can be adequate to solve many mental health issues and increase the sense of security, social well-being, and
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mutual support. It is important to enhance this process more and more through psychosocial activities provided by trained staff or volunteers and supervised by professional mental health service personnel; as it will help to respond to the majority of people who need mental health support. Therefore, professional mental health interventions are left at the top of the pyramid; where professional diagnosis, treatment and follow up is required (Sphere Association 2018, P: 333-335), (IASC 2007).
The IASC (2007) guidelines, invite both humanitarian “actors” as well as governments to more coordination and cooperation in providing mental health and psycho-social support-based interventions post to any humanitarian crisis. The “pyramid” suggests that the first interventions must be providing “basic” community needs, by designing first aid programs to provide services that enhance feelings of safety, security, and fulfillment of basic needs (in a way that enhances and maintain human “dignity”). According to the guidelines, after providing basic needs; community-based approaches must be thought of, as a solution to mental health illnesses. And after the community- based approach comes the focused support, such as emotional and livelihood support (which can be implemented through trained social workers and field coordinators and case-workers), before reaching the top layer which is specialized psychological services provided by “professional mental health providers such as psychiatric nurses, psychologists, and psychiatrists, etc..”. However, although this guideline has been developed and published in 2007, and is found to be a (basic reference) for much international humanitarian organization; nonetheless, it has not been updated since then (Sphere Association 2018, P: 335). The United Nations Higher Commission for Refugees UNHCR also have introduced their own “approach to mental health and psychosocial support in displacement” (UNHCR 2019). According to UNHCR, mental health and psychosocial support lie under the “protection” role for refugees and displaced people. The UNHCR has also clarified in there MHPSS guideline that mental health services are necessary for refugees and displaced people, even after reaching a safe destination; this is due to the tension and frustration they still feel, even after the hard times of displacement journey have finished. Earlier in 2012, the United Nation higher Commission for Refugees has worked alongside the World Health Organization on
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developing a guideline with tools for assessing the mental health and psychosocial support ‘needs and resources’ in humanitarian settings (WHO, UNHCR 2012). The UNHCR recognizes the importance of mental health services as part of the health care provided for refugees, and is supporting the integration of mental health and psychosocial support in the “national health system”. The leading UN agency supporting refugees around the world, have designed their approach to mental health and psychosocial support (UNHCR 2019); that includes the following criteria:
- Involving the health workers who provide general health services; in the process of identifying, and “managing” mental health conditions. To implement this, the UNHCR trained doctors using a tool they developed for this training, called; ‘Humanitarian Intervention Guide MHGAP’.
- “Engaging mental health professionals”, such as psychiatrists, to work in the refugee health facilities.
- Providing mental health medications as part of the medications’ donations.
- Engaging non- mental health specialists after providing them with the needed training, to enable them to perform first aid psychosocial support, and help improve mental health conditions of refugees
(UNHCR 2019).
Both MSF (Medicines San Frontiers) and IOM (the International Organization for Migration, are important humanitarian actors who implement aid in an emergency, including mental health support in crisis and displacement. Some international organizations have developed their own “guidelines”, “manuals” and “minimum standards” of mental health support in emergencies. For example, the UNHCR has produced an ‘Operational Guidance on Mental Health & Psychosocial Support: Programming for Refugee Operations’ (UNHCR 2012); where they provide specific guiding steps to mental health response in refugee settings; taking into consideration the right- based approach, equal rights to receive services, vulnerabilities, as well as training their field staff and service providers on these guidelines. IOM is one of the international organizations that provide mental health and psychosocial support “directly” to migrants, displaced people, and
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refugees; and is working on building capacities of humanitarian service providers in MHPSS (IOM 2015). IOM has focused on psycho-social support and developed a training manual on “community-based mental health and psychosocial support in emergencies and displacement”. In addition to that, MSF (one of the leading humanitarian agencies that provide health and mental health support in emergencies) (IOM 2015). MSF also was one of the earliest organizations to produce their manual on “psychosocial and mental health interventions in areas of mass violence” based on a “ community-based approach” in 2005, which was printed in a second edition in 2011(De Jong 2011). The manual involved, psychiatric treatment, counseling, and psychosocial approaches to mental health. The Inter-Agency Standing Committee IASC has also produced in 2019, a “guidance note” on “community-based approaches to mental health and psychosocial support programs”. These programs aim to support community resilience and collective healing, by supporting and encouraging refugees to participate in social and community activities; through their programs and activities. This approach also allows people to heal from within and be an active part in their own mental and emotional healing process, instead of “passively” receiving treatment, or avoiding it may be due to stigma (IASC 2019).
Regarding the services provided for the treatment of mental health, WHO (2009) highlighted the importance of community-based mental health services. Psychosocial interventions not only that it has changed the “quality of life” for beneficiaries and their families, but have also increased people’s levels of “satisfaction”, compared to usual medical interventions; that are usually provided through special mental illnesses hospitals and medical centers. In Europe WHO has criticized the total absence of community- based mental health interventions in 25% of EU countries. While in 50% of EU countries, people with mental health disorders or illnesses are being treated in large in “psychiatric hospitals”; spending more than 85% of money devoted to mental health services to large mental health institutions, instead of providing trained staff in the primary medical care and first-line service providers. Another reason for the gap in mental health services is that the most important medical drugs for the treatment of mental health disorders are usually not available in primary mental health care centers and have no policies to use these drugs in
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at least 2% of EU countries. One of the most important issues in the EU countries is the huge shortage of mental health service providers as a “workforce”. According to WHO (2009), the percentages of jobs related to psychiatrists, psychiatric nurses, and psychologists range between 0.1 – 100 per 100,000 population. Where psychiatrists percentage is around (1.8- 25) per 100,000 population, psychiatric nurse professions range from 3 – 104 per 100,000 population, and psychologists make around 0.1 – 96 per 100,000 population (WHO 2009).
On the levels of community-based and focused non- specialized intervention for mental illnesses resulting from traumatic experiences, there has been significant attention recently given to the effects of cultural physical practices, on physical and mental health. Ancient eastern societies have developed many local practices for healing body and mind, one of these practices is Yoga, which became very popular and is being used universally to overcome stress and maintain body-mind health (Kessler et al. 2017). During the research interviews, it was noticed that participants have mentioned some approaches to psychosocial support and mental health. However, as many of them mentioned yoga and mindfulness for reducing stress; through group activity. The researcher thought to introduce the link between yoga and MHPSS as an example of successful psychosocial interventions. Yoga nowadays is very widespread activity around the world, and famous for being an affordable and very beneficial treatment choice (Varambally et al. 2012). It was found to be particularly appealing for individuals who do not prefer psychotherapy due to stigma (Kessler et al. 2017). Researchers noticed the emphasis of yoga on mindfulness and have built some theories on yoga effect on cognitions, by decreasing negative thoughts and promoting adaptive thinking. Besides, many researchers argued that the physical postures and breathing techniques can help address many mental health problems. Researchers also argued that yoga might help in treating trauma-related illnesses and symptoms by promoting positive psychological changes that might be beneficial, due to the alteration effect on neurotransmitters (Sharma & Haider 2013). (Khalsa 2013) Van der Kolk (2014) described many ways yoga can affect the brain of trauma-exposed individuals by activating areas that process qualities such as trust, control, pleasure, and engagement that are
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usually affected by trauma, besides enhancing sleep, regulating the physical response to stress, promoting well- being and increase self- efficacy”. The most commonly practiced yoga around the world and Europe is called, Hatha yoga. It emphasizes postures “asanas” and breathing exercises “pranayama”. Some of the major styles of hatha yoga are Iyengar, Ashtanga, Vini, Kundalini, and Bikram yoga”. (Macy et al, 2018).
Finally, by focusing on non- professional psychosocial programs, humanitarian actors in mental health aim to address mental health severe issues such as “acute stress reactions, bereavement, depression, psychosis, PTSD behavioral and developmental disorders, alcohol and drug-related problems, and psychosomatic complaint, and guidance on talk therapies”. Producing guidance manuals on psychosocial interventions by big organizations (WHO, UNHCR, IOM, MSF, IASC) is an indicator that psychosocial interventions are very important and can help to bridge the gaps in mental health services (WHO 2013). Such references also have mentioned the importance of “minimum requirements for training, supervision, skills, attitudes, and need for follow-up. They also discuss additional safety and security concerns for intervening on psychological and social issues in remote or insecure settings”. Most of the guidelines and training manuals on MHPSS have recommended focusing on psychosocial interventions including social engagement and community-based activities while ensuring the referral of “severe cases” to professional treatment. Finally, the researcher has noticed while reviewing these training manuals and guidelines, that they might lack guidance on MHPSS for humanitarian workers in the field. Unfortunately, none of the manuals have mentioned the importance of mental health and psychosocial support for workers and volunteers in the humanitarian work, but some manuals such as WHO (2013) has focused on the importance of training, supervision, care, and follow up with workers in the humanitarian field.
Chapter 3: Greece and response to the ‘refugee crisis’ 3.1 A glimpse on the ‘crisis’
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The issue of migration has become very sensitive to the European Union after the flooding of migrants and refugees to Europe in 2015; especially the ones who enter the EU through Greece (Alpes et. Al 2017). Thus, the EU has decided to establish “an agreement” with Turkey in March 2016; the agreement involved “procedures” for dealing with refugees and migrants entering Greece from Turkey. However, the “EU- Turkey statement” involved implementation of an “action plan” that both parties (the European Union and Turkey) have accorded in November 2015, to solve the “refugee crisis”. The “action plan” evolved from the agreement have ensured that Turkey allows Syrian refugees to work in Turkey (which is not granted for refugees in turkey), those refugees must be considered under “temporary protection”. The decision was taken to reduce the number of refugees who try to reach Europe for work. Moreover, the “EU- Turkey statement” has determined “new visa requirements” for refugees and migrants (Syrians and some other nationalities) coming from Turkey; while increasing the “presence” of security coastal guards and police on the shores of turkey were refugees come, and coordination with Turkey in terms of securing the borders and “sharing of information” (Alpes et. Al 2017), (Adam 2016). According to the UNHCR, refugee situation report (2015); the number of arrivals to Greece from migrants and refugees has reached more than 861,630 persons in 2015, compared to 43,318 in 2014. Numbers of arrivals were the highest in the year 2015, and 2016 (177, 234 arrivals in 2016) respectively UNHCR (2016). The number of arrivals decreased significantly in 2017 and 2018 (up to 30,000- 32,000) and increased again in 2019 to 74,613. The huge drop in numbers of arrivals happened after the EU- Turkey deal in March 2016 (Kousoulis et al. 2016). According to their last situation snapshot, UNHCR (2020), had reported that the number of refugees and migrants arrived in Greece from the beginning of 2020, from both the sea and land did not exceed 10,705, by July 2020. Most arrivals to Greece were from Syria (50- 54%), then from Afghanistan, Iraq, Iran, and Africa. However, the sudden influx of refugees seemed overwhelming for the Greek government and for the NGOs to operate. Gkionakis (2016) have reported that there was not enough space and shelter for the big crowds of refugees and that it was very hard to establish in no time the proper “identification” and “referral mechanisms”. According to Kousoulis et al. (2016), most arrivals to Greece were
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very quick to travel to other European countries (before 2016’s EU- Turkey deal), and this was obvious from the national data, as many of them are not interested to apply to asylum in Greece. Arrival by the sea (the most common way to reach Greece), can be very dangerous; and going through this experience is most probably traumatic (Kousoulis et al. 2016). Many people have died in the sea trying to reach Greece; horrible stories were shared in the media for people who lost their family members on the way to Greece by the sea in rubber boats after paying huge amounts of money to “smugglers” (Ben Farhat et al. 2018). In 2015, according to the UNHCR’s “situation snapshot” (UNHCR 2014), around 799 migrants have died in the sea on their way to Greece, and in the years 2014- 2019, the number was 1948 people who have died in the sea. (UNHCR 2020). Gkionakis (2016) suggested that there must be psychosocial training (like psychosocial first aid) to police, workers, volunteer, and guards in the islands to able to deal with survivors from “wreck ships” (usually results in trauma for survivors and maybe the loss of family members), and most aid workers in the islands don’t have such training. According to Kousoulis et al. (2016), most of the emergency cases in Lesvos island were “trauma and hypothermia” also some were “trauma injuries”. MSF has documented and reported over more than one year and a half, many screening failures to screening and selecting vulnerabilities to be moved to the mainland, made by Greek authorities on the islands (MSF 2017).
To elaborate more on the migration conditions in Greece, Gkionakis (2016) highlighted that most refugees seeking asylum must usually spend long periods in camps; with very limited standards of living, while many of them need first aid psychosocial support. According to Gkionakis (2016), many refugees are vulnerable to trauma either during crises or during /after their journey to seek asylum. The health facilities and services were very severely insufficient including especially mental health services. Mental health emergency response, translation, and cultural mediation was so much needed in the hotspots and camps. The living conditions inside the camps and huge numbers of arrivals were so overwhelming. But also, it was reported by Gkionakis (2016), that the Greek guards were pushing people to the sea again instead of giving help. Violence rates from the coast guards and some civilians were high, especially after March 2016 (where EU- Turkey deal
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took place) and this was adding a lot to the extremely dangerous conditions the refugee went already through. (Kousoulis et al. 2016), Gkionakis (2016). MSF field report (MSF 2017) indicated that more than 80% of refugee mental health patients in Samos have experienced violence, 25% have been tortured, and 19% have experienced “violence”. However, the experience with violence and trauma have been also present during migration, especially on the Turkish borders and also on the Greek Islands, where many incidents of violence from police and coastal guards have been reported highly after the EU-Turkey agreement (compared to before March 2016), (MSF 2017, P: 4-6).
3.2 Availability of Mental health services for refugees in Greece
To have a look at the availability of mental health and psychological support for refugees in Greece; Gkionakis (2016) give an insight into that. According to his article, mental and psychological services were severely lacking in the islands were refugees first arrive; and although some NGOs that have carried training for volunteers and staff on psychosocial first aid and mental health support, these organizations were very few at the beginning of the crisis. Nonetheless, most of the organizations that provide psychosocial interventions (such as Babel day center) have moved to the mainland after the situation in the islands has been controlled. According to Gkionakis (2016), most of the arriving refugees seek to reach other European country destinations through Greece where they can find employment opportunities and better living conditions. Some refugees would come to live in Greece but soon they would discover that there is no way to be able to find work in this country that suffers from the financial crisis, in addition to the cultural, language, and other barriers to social and economic integration. The psychological wellbeing of refugees arriving in Greece might have mostly been affected by the hardship of migration, ethnic and cultural differences, and a traumatic experience that caused disorders. But according to Gkionakis (2016), the strong point for refugees was psychological treatment try to focus on, is the refugees’ resilience which is their strong point.
