Psychological Disorders

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Chapter 7

Trauma, Coping, and Resiliency among Syrian Refugees in Lebanon and Beyond A Profile of the Syrian Nation at War

Naji Abi-Hashem

INTRODUCTION

How are the Syrian refugees coping and surviving? And how are they handling the many losses, displacements, traumas, psycho-emotional struggles and sociocultural obstacles? What motivates them to keep facing hardships and to thrive in the face of adversities in constructive ways? This chapter will attempt to highlight the abilities of many deeply affected Syrians to transform their tragedy and misery into a trajectory of purpose, a mission of survival, and a path toward resiliency. They are willing to work extremely hard, live in tight places or on tiny budgets, and keep a grateful attitude in order to preserve their dignity, basic survival, and safety of their loved ones. Syrian refugees are proving to be quite industrious and able to utilize any available resource, opportunity, facility, and support to their benefit and family welfare. All the while they carry with them many scars of war, torn memories, and strong longings for home, from where they were suddenly uprooted and unwillingly left behind. In spite of all their misfortunes, they seem to keep the hope alive.

As the author of this chapter, and a Lebanese-American clinical and cultural psychologist, I have been living and functioning in two geographic regions, the United States in North America and the Middle East, almost dividing my time between the two. In both places, I am involved in teaching, counseling, training, lecturing, networking, writing, and cross cultural service. While in Lebanon, I normally spend time consulting with health care providers, counselors, educators, pastors, and community leaders. One of my passions is to care for the caregivers, especially those who are working under stress, serving underprivileged populations, or operating in danger and on the front lines. Often I am called upon to conduct training seminars or debriefing sessions for those teachers, caregivers, and volunteers who are helping some of the multitude of refugees in their area. Therefore, I have observed firsthand the related struggles, stress, agonies, and persisting symptoms. Also, I had the opportunity to work with hundreds of Syrians from all walks of life and social backgrounds, formally and informally, as we see them and interact with them on a daily basis everywhere we go in town.

Personally, I grew up in a mountain town in Lebanon called Aley, went to a Catholic school there, and initially pursued technical college in Beirut for training in Electronics. My first job was at the American University Hospital. So, I lived in Beirut in late 1970s and early 1980s, during what known as the civil armed conflicts and other people’s wars on our land. While enduring the long bloody troubles and trying to help others through their dark times, I continued my education in the general area of liberal arts, covering

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social and cultural studies, psychology, pastoral care, philosophy, counseling, and theology. At age 30, I traveled to the United States in 1984, to focus more on graduate studies in pastoral counseling and clinical psychology, respectively earning an MDiv, an MA, and a PhD in these fields. Then, I became fully licensed as a psychologist in the State of Washington in 1995. While in the States I served as a consultant to a number of agencies that deal with Arab Americans and with Middle Eastern congregations. So, I have had a long educational journey and community service heritage both in Lebanon and the United States. In terms of my spiritual practice and religious preference, although it is within the Protestant tradition, I really consider myself as interdenominational, relating to all churches and faith traditions. I have been involved in many interfaith conferences and been part of several ongoing in-depth Christian-Muslim dialogues, especially in Beirut, Lebanon.

Therefore, my academic background and outlook on human service are varied, broad, intercultural, and interdisciplinary in nature. Often, I am invited to speak in public, teach an intense course, or present at conventions on subjects related to the Middle East, cross-cultural counseling, migration and refugees, Arab Americans, the impact of globalization, psychology of religion and spirituality, fundamentalism and radicalism, tragic loss and grief, and war stress and coping. Now, that personal background overview will lead us to explore the topics and themes of this particular chapter.

As of today, it is estimated that the Syrian crisis is one of the worst humanitarian disasters in our modern times. The armed conflicts in Syria are still raging, and it seems that there is no end in sight for its calamities. These intense wars and fighting have been going on nonstop since 2011, tearing apart the land and its people. The reality is that nobody knows exactly how many people have escaped, relocated, or been forced out; how many have been hurt and injured; and how many have totally disappeared or tragically lost their lives (Almoshmosh, 2015; James et al., 2014; Quosh, Eloul, & Ajlani, 2013).

Many political observers and social analysts are truly concerned about such a crisis of such a magnitude (Carpenter, 2013; Geha, 2016; Laub & Masters, 2013; OCHA, 2017). It has the potential to heavily burden and destabilize, not only neighboring countries, which is already happening, but also faraway societies, countries, and governments. It is affecting political establishments, geographical borders, the global economy, and world powers. Iraq came first and now Syria. The combined effects of both misfortunes are causing a substantial increase in negative discourses, hostile sentiments, religious fundamentalism, and political radicalism in the Near East and beyond.

Since 2011, it is estimated that the death toll of Syrian people has reached about 500,000 of all ages and backgrounds. Some reports predicted that about 400,000 victims died as a direct result of the bombing and fighting, and about 100,000 died as a result of the military sieges, lack of basic living necessities and care, and break down of the infrastructure. In addition, five to six million have become refugees outside Syria and

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six to seven million have been displaced within Syria. Between 50,000 and 100,000 are reported detainees or missing. Millions are injured, and thousands have been drafted, persecuted, starved, or tortured. Presently, between 13 and 14 million are in need of essential humanitarian aid and improved basic living conditions (Boghani, 2016; Mercy Corps, 2017; OCHA, 2017; UNICEF, n.d.; World Vision, 2017).

Background and National Profile The country of Syria is located on the eastern side of the Mediterranean Sea in southwestern Asia, with a population of approximately 22 million. It is surrounded by Iraq to the east, Lebanon and seashore to the west, Turkey to the north, and Jordan to the south. In addition, Syria has a small section border with Israel/Palestine, mainly the Golan Heights, which is located in the southwest. Syria is about 71,500 square miles and most of it is positioned at the western end of a rich farmland, called the Fertile Crescent.

The nation is officially known as “The Syrian Arab Republic” or “The Arab Republic of Syria” (In Arabic, Al-Jamhooriyyah el-Arabia Assouriyah). Its landscape consists of many fertile plains, a few mountain ranges, and widespread deserts. Its borders do not match with Ancient Syria and Damascus Land (Souriyyah al-Koubra wa bilaad el- Shaam). The country has been the home to many diverse ethnic, sociocultural, and religious populations. Lifestyles are mixed, reflecting the urban, complex, and modern styles and the rural, simple, and traditional styles. The majority population is Arab Muslim of the Sunni branch. Other minority groups include the Kurds, the Armenians, the Assyrians, the Alawites, the Shiites, the Arab Christians, and the Arab Druze (cf. Abi-Hashem, 2003, 2008a; Hourani et al., 2016; Lawson, 1992; Nation Master, 2013).

Syria is an extremely ancient country, and has a rich cultural heritage. Many old civilizations have passed through, invaded, and ruled the whole area, leaving clear and deep marks. Once, Greater Syria was the hub for the ethnic Arab Kingdoms, long before the Arab-Muslims came to the scene. Later, Greater Syria became a center for the Islamic Empire. Thus, it has a history of being the guardian of Arab Nationalism and, at some point, of the Muslim heritage, thought, and culture.

In 1946, Syria became a fully independent nation, ceding from the French Mandate. Prior to that, it was part of the Ottoman Empire, similar to the fate of many nearby countries. Since then, Syria has been a member of the Arab League, the United Nations, and the Organization of the Islamic Conference (OIC), as well as many other global organizations. Modern Syria has also a history of political unrest and coups. One of these coups brought Havez el-Assad to power, the father of the current president, Bashar el-Assad. Since then, Syria has been a very stable and cohesive society, because Assad established a one-party rule, a secular ideology (with a thin cover of religion), and an authoritarian regime in the style of a police state. The 1973 constitution gave the president major executive powers, including the commander in chief of the

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armed forces and the secretary general of the ruling party, which is known as El-Baath Party (Hourani, et al., 2016).

Along with other concentration areas of cultures in the Near East, like Mesopotamia, Egypt, and Phoenicia, Ancient Syria was also part of the cradle of civilizations, where some of the greatest human achievements were established. Language, philosophy, astronomy, religious thought, human trade, systems of agriculture, governing models, cultural exchanges and other fields of inquiry had their roots there. Damascus has been the longtime capital and is the largest city in Syria. Damascus, along with Aleppo and Hama, pride themselves on being among the oldest continuously inhabited cities in the world (Abi-Hashem, 2003, 2008a; Abul-Fadil, 1998; Haddad, 1994).

Rural Syria is extremely traditional. Nomadic and seminomadic tribes are still roaming the countryside. There are also several racial-ethnic people-groups who settled there through the generations, and some of them are integrated within their region. Historically, the location of villages was usually determined by the availability of water, fertile land, and safe fortification. Community living is in very close proximity, and streets are very narrow. A mosque, a shrine, or a church normally stands in the middle of the community, or built on higher grounds nearby, so that it can be seen from afar and provide a landmark for the surroundings. Even within cities, several families (usually related) live in one large dwelling place, around an enclosed major entrance, with a garden and a water fountain inside the compound. The families often gather there daily to eat, visit, stay abreast of current events, and discuss important social affairs. However, this type of high-density living proved to have both advantages and disadvantages on the structure of Syrian marriages, families, and communities. Life is normally characterized by a strong sense of collectivism and social bonding, but leaves little space for personal maneuver and privacy (Hourani, et al., 2016; Mulaika, 1979; Sfeir, 2000).

Because work is seasonal and opportunities are very limited in rural-desert areas, many families and younger generations have been migrating to larger towns and cities, thus facing extra challenges for mental and sociocultural adjustments and placing extra demands and pressures on the limited social institutions. The country’s rich natural resources and agriculture supplies have been subject to internal feuds and commercial exploitations. The industrialization of many areas has caused pollution of already- overstretched water resources. Inefficient irrigation methods and misuse of fertilizers have compounded this phenomenon creating further competition and wider gaps between the haves and the have nots. Many observers see these trends as the genesis of the current unrest and popular uprising, which has triggered civil turmoil, and therefore dragging the country into localized fighting, open borders, and multiple battles and leading it into deeper divisions and widespread wars.

Syrians, like other Middle Easterners, are a very hospitable people and easily welcome friends and strangers into their homes. Aleppo is the second largest city and

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the economic-industrial center of the country. It is also the home of the Armenian population, about 400,000 people, who became well integrated and prosperous in that region. The Arabic language is strongly emphasized in Syria, at the expense of other foreign languages. All school and university curricula are transliterated and taught in Arabic. Syria has prided itself as the protector of Arabism.

The following facts reflect some vital statistics about the country (cf. Hourani, et al. 2016; Lawson, 1992; Nation Master, 2013; UN Data, 2017; UNHCR, 2015a, 2015b): The gender distribution in Syria is 51.3 percent for males and 48.7 percent for females. The distribution of population is 54 percent urban and 46 percent rural. The literacy rate in Syria for those 15 years of age and over in 1995 was 75 percent as the government requires six years of compulsory primary education for all. The average life expectancy in 2012 was 75 years. The annual growth rate was 6.2 in 2005, 3.4 in 2010, and 0.4 in 2014. The ethnicity of Syria is composed of: Arabs, 75 percent; Bedouins Arab, 7.5 percent; Kurds, 7.3 percent; Palestinians, 4 percent; Armenians, 2.8 percent; and Others 3.4 percent. The distribution of religious affiliations as of 1992 was: Muslim Sunni, 74 percent; Alawites and Shiites, 11 percent; Christians, 10 percent; Druze, 3.0 percent; and Others (like Yezidis), 2.0 percent. Before the current extended conflict, Syria hosted a number of refugees and asylum seekers from Iraq, Sudan, Somalia, and Afghanistan in addition to the Palestinian refugees settlers, who have been in Syria since 1948. Many of those had to flee and relocate multiple times in recent years, both inside and outside Syria. Trauma Through Cultural Lenses What is considered tragic or traumatic in one place is not exactly considered the same everywhere. The concept of trauma is very broad and has many layers and dimensions. There is a variety of terminology to describe any traumatic event, like tragedy, disaster, adversity, calamity, destruction, catastrophe, terrifying event, severe crisis, devastating loss, threatening danger, horrific violence, etc. Although there are some technical differences among some of these terms, they have often been used interchangeably in the literature as well as in the mass media, due to their perceived similarities and impact on human nature. There are many aspects to the notion and experience of trauma; among them are the mental-emotional, interpersonal-behavioral, physical-physiological, tribal-communal, religious-spiritual, social-national, existential-philosophical, and traditional-cultural.

How people perceive, label, experience, or express trauma, or any other event, concept, notion, or feeling for that matter, is quite different. All depends on many vital aspects and wide influences. These include ethnic, social, emotional, religious, cultural, psychological, and existential factors. Experiences of acute stress and tragic occurrences affect people regardless of age, location, mentality, or status, yet each in their own way. Traumatic experiences can have equally deep influences on both the

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personal-individual and the collective-communal levels. Cultural background, emotional capital, life wisdom, psychological awareness, communal cohesiveness, mental outlook, social support, and religious faith all are essential dynamics in responding to crises and tragedies. Interestingly, communities, societies, and nations tend to react, process, struggle, and cope with adversities and disasters in a similar way to an individual person or a private self (Abi-Hashem, 2011a, 2012, 2014b, in press; Ellis & Abdi, 2017; Kleber, Figley, & Gersons, 1995; Mitschke et al., 2017; UNHCR, 2015a, 2015b).

In contrast to most Western views and models, life experiences, in general, and traumatic stressors, in particular, extend beyond the individual person or one human soul. They reach a broader level and scope to the large social context. People’s understanding and reactions to life’s events are significantly informed by their worldview, subcultures, and values, and are guided by their collective bonds and family sustenance, which typically are provided generously within their group, tribe, or community. In most poor, low-income, and developing countries, people expect hardships in life and seem to have a higher tolerance to pain. According to Kleber, Figley, and Gersons (1995), trauma does not occur to us in a vacuum; rather, it is shaped and approved by our surroundings, our value system, and our cultural heritage. Societal and cultural dimensions of traumatic stress are organic and fundamental. Thus, trauma is not only an individual matter but also a collective and communal matter, and that fact should necessitate a careful approach to all labeling and clinical diagnosing, like the posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and related Diagnostic and Statistical Manual of Mental Disorders (DSM) classifications. Many international educators and clinical caregivers believe that mental health criteria cannot be applied everywhere in the world equally or blindly. In addition, some of these experts observed that certain diagnoses, like the PTSD, have been overly used and mechanically applied, not only in the general West, but also elsewhere across the world (Abi-Hashem, 2008b, 2014a, 2015, 2016a; Arkowitz & Lilienfeld, 2009; Kleber, Figley, & Gersons, 1995; Marsella, 1982).

For typical Syrian evacuees and refugees, losing their sense of stability, basic life functions, rootedness in the land, most of their physical possessions, and sense of national pride are considered major and significant losses. Moreover, experiencing suddenly and for the first time intense fighting, the outbreak of war, and severe destruction, accompanied with blood, death, horrific images, and disabling fear were too tragic and traumatic for them to bear. Most Syrians have expressed that after growing up in an extremely safe, secure, and controlled environment (as in a police state) along with plenty of almost free services, like education and medical care, (provided by the government), now trying to settle in a totally new location, learn new ways of life, and dealing with a new set of rules and authorities made them go through a serious mental shock and stressful reorientation process (adjustment disorders), some of which have been traumatic in nature, since many relocated from rural areas into dense urban

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settings. Although they stated that they were not easily shaken by mini-traumas and regular hardships of life, at the same time they described the tearing apart of their tightknit families and community bonds, the total disappearance of close friends and relatives, and the disturbing sounds and smells of heavy fighting hitting home as a real tragedy (ma’saat) and a deep trauma (fajiaah) (Abi-Hashem, 1999a; Almoshmosh, 2015; Arkowitz & Lilienfeld, 2009; Clinic Psychology, 2016; Hassan et al., 2016; James et al., 2014; Mitschke et al., 2017; Quosh, Eloul, & Ajlani, 2013).

The Syrian Crisis Syria was once a very stable country and its people were nicely settled in their communities, rooted in their land, embedded in their routines, and tranquil in their generational living. Suddenly, they were caught up in a devastating war, totally unprepared and terribly unequipped to face such a calamity of such magnitude. Like the Iraqis before them, Syrians quickly became destabilized, traumatized, and victimized, with no time to process their disorientation, bind their wounds, sort their options, or say goodbye to their homes, community, and way of life. Many had to flee with minimum belongings (if any) and with no sense of awareness or direction as where to go or what to do next. They were caught off guard, were ill prepared, and quickly began to manage serious disillusionments and endure multiple losses, injuries, and huge uncertainties. Some decided to stay “home” regardless of the dire situation, choosing the known for the unknown.

In the Middle East, home is precious, and symbolic of a family’s heritage. Also, such decisions depend on the circumstances of the violence, on the windows of cease-fire, and on the mental-physical ability of the survivors. Not everyone could pack a few things and run. So, many anxious people stayed behind not knowing what would happen to them or their neighborhood. Those who remained soon came under siege of brutal militias or military, enduring heavy bombardment and trying to survive among the rubble. In other developed countries, immediately following any major accident, tragedy, crime, mass shooting, or natural disaster, scores of first responders, counselors, social workers, pastors, volunteers, etc., hurry to the scene to offer their therapeutic attention and service. Then, the survivors would continue to receive guidance, treatment, and supportive care. In contrast, Syrian victims have been largely left alone to help each other and, at times, to suffer in silence and obscurity. They lean on and uplift each other. When one falls or collapses emotionally, the others rally around him or her to support and encourage. They take turn in containing the pressures, intervening when needs are urgent, and morally elevating each other in dark times. Obviously, the most difficult aspect of any crisis or tragedy is its consistency and unpredictability. In times of war, when the agony keeps unfolding, the uncertainty is prolonged, the stress becomes chronic with no end in sight, and the ability to survive and the tolerance to endure all

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drop down significantly (Abi-Hashem, 2006, 2011a, 2014b; Hobfoll et al., 1991; OCHA, 2017; Wong & Wong, 2006).

In 2011, what appeared to be a regular uprising and police confrontation, in one small corner of Syria, developed quickly into a widespread armed conflict that engulfed various regions. The Syrian crisis became so complex that no analyst is able to understand it completely. It grew rather fast, shifted numerous times, ignited so many fronts, involved many inner and outer players, penetrated into all the sociopolitical layers, and put the nation on a serious downhill spiral. What used to be a very stable land, ruled by a strict regime with heavy security apparatus, quickly slipped into major disorder and dangerous turmoil. Mini wars and social chaos became the norms. Cities were divided and militias ruled the streets. Black markets, arms dealing, and trafficking youngsters flourished overnight. “Green lines” (a term used to describe the dividing line or limit between two warring factions in urban civil wars) were formed on the ground, and many cities and towns were transformed into mini battlefields. Fierce fighting raged heavily with the use of conventional weapons and war machines to inflict unbelievable physical destruction and mental-emotional pain and horror.

Of course, there are some regions and city areas that are still intact within Syria and life is going on naturally there. Other areas are restricted and require passes and maneuvers to go around (with plenty of check points). But there are way too many other areas and places that are highly dangerous, utterly devastated, and completely destroyed. Even seasoned caregivers and reporters, at times, don’t have words to describe the scenes they are observing. A reporter described a town, which was once a hub of activities and livelihood, as a ghost city (Masters & Kourdi, 2016). Another, a veteran of war coverage, shares her intense eerie feeling, when walking through some of the neighborhoods in Aleppo and sensing the deafening silence and the dark shadows of death. Another said, “This is Hell!” Others declared that there would be no real winners in these compound wars, only and certainly losers (Ward, 2016). Although the news media still relay powerful images, five years into the troubles, unfortunately most of the viewers around the world have become numb to the realities of war, distancing themselves from that agony, to protect themselves consciously or unconsciously, or justifying their passive attitude by considering the tragedy as a Syrian problem and part of the Middle East’s chronic troubles. However, scores of volunteers, caregivers, and humanitarian aid workers are still working tirelessly on the ground in refugee centers, neighborhoods, and camps. They are bringing much needed help, hope, and healing and a new zest for life to the desperate and destitute (Abi-Hashem, 2004, 2016a, in press; Boghani, 2016; Ko-Din, 2017; Uechi, 2016; Ward, 2016; World Vision, 2017).

War Migrants and Sociocultural Adaptation

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Since the beginning of the armed conflict and bloody war, the Syrian society has plunged into dark living conditions and communal disasters. According to a number of sources and statistics (cf. Mercy Corps, 2017; Norton, 2014; SCPR, 2015; UNHCR, 2015a, 2015b; WHO, 2017), almost half of the existing population in Syria (about 11 million) has shifted or relocated to another place or region, at least once; two-thirds of the population is now considered living in low socioeconomic conditions, in tangible scarcity, or in extreme poverty; life expectancy has decreased from 75.8 in 2010 to 55.6 years in 2014 and it continues to drop lower due to the significant impacts of the war; the destruction has endangered all resources and infrastructures in the country affecting family life, individual well-being, and social welfare; the unemployment rate has increased from 15 percent in 2010 to 28 percent in 2014, and is expected to reach about 50 percent at the end of this year; half of Syria’s children have dropped out of school or never had any academic training at all, due to the collapse of the schools and educational systems; 60 out of 90 public hospitals are damaged or malfunctioning and about 40 hospitals are completely out of service; most people remaining inside Syria are forced to live under some kind of security siege, social alienation, internal subordination, or terrible estrangement; 90 percent of the displaced and refugees actually remain in the Middle East (Lebanon, Turkey, Jordan, Iraq, Egypt, Iran, Gulf area, etc.), and 10 percent only are trying to migrate to other continents, mostly Western Europe. Finally, Syrians now constitute the single largest migrant, displaced, or transplant population and humanitarian crisis in the world. More than half of these refugees are children and teenagers. Mental-Emotional Agonies Among Syrians today, few have escaped the effects of the tragic events or war insecurities. Symptoms of acute stress and psychological disturbances are elevated among survivors of all groups and ages, each one exhibiting psycho-emotional troubles in their own way (Alpak et al., 2015; Hassan et al., 2016; James et al., 2014; Quosh, Eloul, & Ajlani, 2013).

Unfortunately, the most difficult type of stress is the one that is inherently prolonged in nature. Many sociopolitical observers predict that the Syrian armed conflict and multiple- militia fighting will continue to drag on in the country for a long time (Carpenter, 2013; Laub & Masters, 2013). Sadly, there is no global or regional political will to end the disaster… and even if there is a clear resolve, there is no simple solution available at the moment for this enormous crisis (Abi-Hashem, 2006, 2016a; Hobfoll et al., 1991; WHO, 2017).

Besides the major disorientation and disillusionment many people experienced, those who were directly exposed to war atrocities were affected the most. The more severe the traumas, the more serious were the symptoms, at least at first. Thus, the degree of

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impact depended on the degree of exposure. Most people neither had words to describe their agonies nor were aware of their serious psychological conditions. Right after evacuation, most individuals and families began to display symptoms and shared their internal suffering. Here is a sample of such cases and statements (James et al., 2014; News, 2016; Personal communication, 2016; UNHCR, 2015a, 2015b; Ward, 2016; WHO, 2017): a young girl looking weak and pale, keeps hiding, barely talking or smiling, and is regularly withdrawn; a mother, exhausted and depressed, easily cries with anguish every time there is a mention of her previous life and present refugee status; an elderly man cannot stop thinking of his home, garden, and neighborhood, memories that plunge him into unspeakable sadness; a boy, acting out during the day and wetting his tiny mat at night; a teenage girl cannot sleep more than two hours without waking up afraid, at times screaming from nightmares; another young lady cannot hide the hurt and shame of being sexually assaulted and raped during a militia invasion, yet she tries to help a boy whose body is full of shrapnel after a nearby explosion; a young man cannot erase bloody images of his best friend and cousin who went into pieces in front of his eyes, due to a shell bomb hitting their small street; an older man refuses to eat much, or mix with others, after witnessing his own building collapse and kill all his family members; a young woman, who was a schoolteacher, now shares a tent with relatives, and deeply grieves the loss of many family members and students as she saw her own school hit repeatedly, destroyed, and burned with fire; a child, when still under siege and bombardment, kept seeing a dream of a fountain running of fresh water and a basket of fresh fruits; and an older lady kept wondering whether she would ever again see and smell a fresh rose, before she dies.

Psychosocial Effect and Adjustment

In the aftermath of any natural disaster, major tragedy, or war violence, survivors

often experience a wide range of mental-emotional disturbances. Besides the horror of wars, people carry the scars of loss and grief, memories of shattered communities, and the lack of stability and security. The pressures of uprooting and escaping, and then squeezing everybody in tiny living places so as to share the quarters with other families (e.g., kitchenette, one entrance, small bathroom, a drinking tab), have created tremendous mental stressors and relational tensions among the people involved. Six years of intense wars have torn the country apart. Young families, along with children and elderly, have borne the weight and disastrous consequences of this conflict. Helpers from humanitarian, media, religious, and volunteer organizations working in Aleppo, reported that the situation there was the direst ever seen, and the victims of that urban war have endured hardships that would last for several lifetimes (Ward, 2017; World Vision, 2017). Those who were less exposed to war traumas and atrocities still suffer from significant anxieties, apprehensions, mourning, and existential questioning.

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Many Syrians feel they have lost their social identity, life savings, sense of belonging, communal lifestyle, unique heritage, and national pride. When everything seems collapsing, people are forced to redefine their lives and outlook on existence. Some find new meaning and purpose, others fall into despair and apathy, yet others mobilize their spare energy and passion to help those less fortunate, and with that they help themselves in return. That is the resilient art of meaning making (cf. Wong, 2013). Unlike medical and humanitarian aid, psychological caregiving and mental health services are not as prominent, available, or urgent as the physical and medical needs. Limited psycho-emotional care started very late in the process, well after the war events unfolded and intensified. Assessment and therapeutic interventions were scarcely offered or even accessible to Syrians, both inside and outside Syria. There is still a major shortage of trained personnel, social workers, and therapy counselors. Some serious mental health problems were actually discovered by default or chance, while other health care providers and volunteers attended to pressing needs of the affected and displaced. In the last couple of years, psychiatric/psychological caregiving and trauma counseling have been more available to some of the needy, who have responded very well. They show enthusiasm and gratitude to any therapeutic activities, clinical intervention, educational programs, or pastoral care, especially among the children and young generation (cf. Abi-Hashem, in press; Mercy Corps, 2016, 2017; News, 2016). The multiple concerns and agonies of Syrians include their ongoing grief over the collapse of their country along with excessive worry over their safety and means of survival. The unknown destiny of their properties and fate of family members, the uncertainties of having enough income, and a lack of information about their own future all add to their marked disorientation and acute anxiety. They are constantly facing challenges, like adapting to new environments and tight living surroundings, receiving mixed messages from the hosting societies, trying to manage their cultural shock, and binding their wounds while relearning to survive again (UNHCR, 2015a, 2015b). Intercultural adjustment and cross-cultural adaptation place extra pressure on any displaced people or refugees. In a new setting, some remain isolated and aloof (alienation), others mingle and melt within the setting (fusion), while others assimilate well and achieve a healthy adaptation (integration). Therefore, acculturation stress can be a significant burden for those vulnerable, drained, distressed, and demoralized (Abi- Hashem & Brown, 2013; Chan, Young, & Sharif, 2016; Mitschke et al., 2017; Wong & Wong, 2006). Mutual Impact on the Countries of Lebanon and Syria Lebanon has the largest refugee population in the world compared to its size and population (Caryl, 2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013; Sobelman, 2015). It is roughly the size of Rhode Island in the United States or the Island of Cyprus in the Mediterranean Sea. Although Lebanon was caught by surprise

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with the magnitude of the Syrian turmoil and displacement, it has done great favors to host far more Syrians per capita than any other country in the world. There are no sanctioned camps or refugee concentrations in Lebanon (except a few with loose security apparatus), unlike in Jordan and Turkey, where guards closely check the camp entrances and activities. At first, the Lebanese accommodated the Syrians realizing this may be just for a short time before they return home, once the troubles subside. Instead, the Syrian troubles escalated further and spread wider, making Lebanon one of the easiest and best choices for escape and resettlement. In the last couple of years the Lebanese authorities woke up to the fact that this may be a long and chronic crisis and began to put requirements and restrictions on Syrians in order to regulate their influx and intense presence (e.g., criteria for entrance into the country, need to have a Lebanese sponsor in order to work, and short but renewable residence).

Evidently, the majority of Syrians coming to Lebanon have experienced immense hardships, yet they are decent, hard-working, law abiding, and god-fearing people. They qualify to be labeled as refugees. Those able to work are quite willing to provide cheap labor, which eventually helps the Lebanese economy. However, other Syrian civilians, not directly affected by the war and who do not consider themselves as refugees, are also drawn to Lebanon due to its open policy, safety, and opportunities for livelihood. These come in and go out as they wish (no visa required, just minimal paper work), get benefits similar to the refugees, compete with the Lebanese for jobs, and take the money back home, yet are only considered regular workers or visitors. This has been confusing as to “who is who?” A tiny Syrian elite came to Beirut from Damascus and Aleppo early on, and brought their wealth; but a vast majority of Syrian evacuees are now extremely poor and depending on Lebanese welfare, menial jobs, and private donations. The sudden migration from Syria and constant influx through the wide borders into Lebanon has absolutely overwhelmed this tiny country’s infrastructure and limited resources.

Due to previous friendly agreements between the two countries, people could move easily between them. Therefore, it is difficult to know exactly how many Syrians are in Lebanon as they have literally infiltrated almost every street, corner, and town in Lebanon, from up the mountains to the seashores. Many Lebanese are apprehensive about such migrant density and even begin to feel as strangers in their own land (Geha, 2016; Marsi, 2015; Refaat & Mohanna, 2013).

According to several analyses and reports (Aljazeera, 2017; Geha, 2016; UNHCR, 2015a, 2015b), Lebanon has been drained and devastated for paying such a high price and is currently at risk. The refugees’ presence has created a number of social dilemmas, including housing shortages, serious competition for jobs, an educational and medical crisis, an unprecedented street children problem, major safety and security concerns, higher unemployment, and ethno-demographic shift. There are plenty of mixed marriages and unwanted out-of-wedlock children. The childbirth rate among the

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Syrians in Lebanon is double that of the Lebanese themselves (Aljazeera, 2017; Geha, 2016; Marsi, 2015; Refaat & Mohanna, 2013; UNHCR, 2015a, 2015b).

In addition, there has been an increase in using or abusing public services and private donations, drug dealing, money laundering, prostitution, child exploitation and trafficking, gang and crime activity, secret arms selling, and black market activities. Lebanese observers fear that some fighters, criminals, and radical militants, freely roaming in Syria, may have already infiltrated the border into Lebanon and may create dangerous cells and draw followers. The Lebanese security forces are strong and alert but the task of keeping up security is enormous and is stretching their capabilities. Thus, there are some serious threats to the cohesiveness, survival, and integrity of the Lebanese themselves. Such negative consequences and social disorders normally follow any major armed conflict, population displacement, and forced migration.

In spite of all the disadvantages and tangible or existential threats, Lebanon has so far shown extreme resiliency, containment, and adaptability as a tiny nation, which already has its share of problems. Lebanon continues to mobilize its limited resources and highly motivated service personnel to help and accommodate the huge social demands of Syrian refugees, visitors, and migrants. The market place, housing, schools, factories, shops, labor forces, construction sites, homes, etc., still are welcoming Syrians openly. This was unexpected, due to the negative way the Syrian regime and its army treated the Lebanese in the past, when they ruled Lebanon with an iron fist for almost 20 years (Akoury-Dirani et al., 2015; Aljazeera, 2017; Geha, 2016; UNHCR, 2015a, 2015b).

According to Karam (2015), Lebanon has been the recipient of more than a million Syrian evacuees and migrants (those registered back then prior to 2015), even without having a major say in the matter. Although struggling and overwhelmed, Lebanon as a hosting country is surviving and helping the Syrians to survive as well. With that, it is setting an example for the international community, especially Europe, that accommodating refugees is possible and doable, of course with a price but also with an advantage of having industrious people on its land—very hard working and highly family-community oriented (see also Caryl, 2015; Sobelman, 2015).

A few hundred thousand Syrians used Lebanon temporarily as a stepping-stone to apply, via the local United Nations offices, for political asylum or full immigration to a Western nation of their choice. The rest have settled in and built their lives locally, until further notice. Some of them express a strong desire to return home to their beloved country. Others seem very happy in Lebanon and have no intention of leaving again (Caryl, 2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013; Sobelman, 2015).

The very fact that Lebanon does not require that Syrian refugees and war victims be grouped in reservation camps, is by itself an empowering fact that offers a major psychological boost to their morale. Syrians love Lebanon due to its open policy and freedom of moving, working, living, mingling, and enjoying its diversity, leisure, and beauty (with no need to learn a new language). These aspects and ample commodities and the availability of social services are greatly contributing to the Syrian refugees’

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sense of personal dignity, restoration of some stability, emotional recovery, and general empowerment. However, as with every sudden population influx and relocation, such huge numbers coming from Syria, a neighboring and sister country, has created serious implications on this hosting society of Lebanon. Therefore, anxiety, fear, and resentment are rising among locals and nationals. The Lebanese government, social institutions, and private sectors were never ready for this demographic flooding, so they became at loss what to do and how to handle this unplanned migration. After a year or so, when it became evident that there was no solution in sight, and the flood of Syrians into Lebanon continued, reports of discrimination cases, refusal of service, and tightening of privileges and freedoms increased. Still, the Lebanese in general are accommodating, employing, facilitating life, and providing for the Syrians, young and old, with generous hospitality, trust, and solidarity. Thus, what was a Syrian struggle for survival and recovery has now become a duel Lebanese-Syrian struggle for survival, recovery, and resiliency (Akoury-Dirani et al., 2015; Carta, Moro, & Bass, 2015; Caryl, 2016; Karam, 2015; Marsi, 2015; Refaat & Mohanna, 2013; Sobelman, 2015).

Thus, in many ways, the country of Lebanon and its people can be presently considered as co-partners in the coping process of the Syrian crisis and as co-survivors alongside the Syrian people in enduring and thriving toward better tenacity, mastery, and resiliency, all in the face of an unprecedented communal, national, and regional war disaster and adversity of such magnitude.

Healthy and Unhealthy Coping Styles As in any major crisis and disaster, people, often labeled as victims or survivors, try to find ways to soothe the pain and cope with the anxieties and acute stresses. They usually develop coping strategies that range from the healthy-constructive to the unhealthy-destructive ones.

Some of the unhealthy, risky, and damaging modes of coping include withdrawing, isolating, becoming cynical, falling into apathy and pessimism, perpetually moving and relocating, acting out behaviors, resorting to aggression and domestic violence, engaging in addictions, resorting to occult/black magic practices, gambling and overspending, using/abusing drugs and alcohol, overworking, oversexualizing, etc. However, in terms of healthy coping strategies, the following are a sample of those that survivors usually employ during and after tragedies. Syrians are displaying many of these skills and others as well, reflecting their unique ways and subcultures in handling stress and striving toward restoration (cf. Abi-Hashem, 2006, 2008b, 2011b, 2013, 2014b, 2016a; Chan, Young, & Sharif, 2016; Clinic Psychology, 2016; Hassan et al., 2016; Mercy Corps, 2016, 2017; Mitschke et al., 2017): Syrians are bonding and adopting each other as friends and relatives, especially those who lost family members. They are becoming creative in finding innovative ways to work and survive financially.

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Even young children and teenagers are becoming little entrepreneurs and market smart (unfortunately at times in black markets) as many are cleaning cars, working as bag boys in grocery stores, trading in vegetables, collecting any good items for recycling from stores, garbage, or trash, are willing to work in anything and with any capacity, even selling items on the streets and among cars or begging there for long hours, just to raise small funds to help mother or grandmother or siblings with food and rent and the basics. They are bravely enduring the hardships of street life—the hot sun, dust, dirt, and harassment by others, young and old, even competition among themselves, just to make enough at the end of day, if at all possible.

Traditionally, Syrians tend to socialize with each other closely and celebrate all social events and feasts together, with hosting families or communities around them. Often that includes having music and singing and, at times, folk dancing. This proves to be therapeutic in many ways, which provides beautiful communal strength and restoration. Often, they gather in small circles, ladies for morning coffee, and older men in the afternoon for playing cards or table games, smoking water pipes, and discussing current worries, events, and politics. Children are found playing ball in the tiny corner of their street or shelter building. All of these have become very healing activities. When gathering around food, which is an engrained habit in the Middle East psyche since ancient times, normally people have a great opportunity to nurture and support each other, bond closer, and show solidarity with each other. Many Syrians are becoming spiritually more active and finding strength in faith. Although the majority of people in the Middle East are religious by affiliation, if not by practice (religious affiliation/celebrations are part of social identity and culture), many are now seeking genuine faith and new spiritual experiences for deeper meaning, comfort, commitment, camaraderie, and contentment.

Others are volunteering to help fellow refugees and evacuees who are less fortunate than themselves, both in Lebanon and back home in Syria. Many are cultivating passions and future inspirations even among children who are begging on the streets of Beirut. I usually stop and talk with many of them. They gather around me eagerly and love the attention. I get to meet them by name and inquire about their lives. Where do they come from? Are they alone or with any family members? How long have they been begging on the streets? When did they eat last? Were they ever at any school in their lifetime? In response, I hear sad stories. But when asking what would they like to become when growing up and why, without hesitation, and with a spark in their eyes, they answer: nurse, to help treat my sick family and all victims of this ugly war; teacher, to educate children so they will not miss school like us; farmer, to help my aging father work in our good land; etc. Unfortunately, many children have lost their childhood and have not played, studied, or laughed much, yet they have not lost their ability to dream and set worthy and bright goals for the future.

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Promoting Further Resiliency and Strength Resiliency refers to the human individual potential and the collective communal spirit to effectively and positively face adversity, tolerate ambiguity, handle pressure, cope with crises, and recover from disaster or tragedy (Abi-Hashem, 2011a, 2016b; Ungar, 2008, 2013). Nevertheless, surviving usually comes with a price tag. People normally bounce back but not without a scar, a stress, a residual, or a heaviness.

Resiliency focuses on the hopeful side of life and mobilizes the positive strength in human nature. Other words are used to describe resiliency: Flexibility, hardiness, elasticity, resourcefulness, tenacity, robustness, and mastery. There are several psychological dynamics, cultural mediators, and spiritual factors at work in every aspect of surviving, coping, and thriving. However, enduring suffering constructively somehow adds to the emotional maturity and spiritual depth of people. For the sake of our discussion, resiliencythen is more than an isolated individual construct. It can be best described as a cultural competency in action and as a fluid concept that is a function of the emotional resources, social identity, religious values, and cultural capitals of the group or the community (Abi-Hashem, 2011a, 2016b; Chan, Young, & Sharif, 2016; Ungar, 2008, 2013).

Syrians Respond Well to Lebanese Outreach Government agencies, NGOs, community groups, schools, churches, mosques, and other local societies and organizations are doing all they can to help, accommodate, and empower the refugees of all walks and ages, especially the women and children. Foreign agencies often work with national Lebanese teams in joint efforts. Together, they are providing health care, social work, and medical clinics, in fixed or mobile locations. Most hospitals treat Syrians free or with minimal fees. The ministry of education established after-school tracks across Lebanon for refugee children, as the Syrian curriculum is somehow different and less rigorous than the Lebanese (still many cannot enroll because they have to work). Also, women are being trained in basic reading, writing, and entrepreneurial skills to help them start small businesses or sell products. In addition, services provide for emotional recovery, personal training, pastoral ministry, and spiritual care to help the displaced find more healing, solace, restoration, and existential hope. Sociocultural coaching helps those feeling intimidated and lost in transition.

Syrian refugees are responding amazingly well to all these initiatives and services and are asking for more. Although the majority of Lebanese caregivers are exhausted and depleted, they keep on giving enthusiastically, realizing the rewarding outcomes and sense of fulfillment. Countless Syrians are bouncing back, flourishing, and doing much better under unfavorable circumstances. They are deeply grateful to all the attention,

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help, and care. Many have lost almost everything to the ugly war, but maintain their imagination, resolve, affection, and hopefulness (Clinic Psychology, 2016; Geha, 2016; Mercy Corps, 2016; UNHCR, 2015a, 2015b). Implications for Mental Health Care and Counseling The following are hints for intervention, and practical guidelines for health care providers and mental health professionals, including key questions to ask the survivors during almost any therapeutic encounter and counseling service (cf. Abi-Hashem, 1999b, 2008b, 2011b, 2013, 2014a, 2014b, in press; Almoshmosh, 2015; Chan, Young, & Sharif, 2016; Clinic Psychology, 2016; Hassan et al., 2016; James et al., 2014; Lee, 2010; Mitschke et al., 2017; News, 2016; UNHCR, 2015a, 2015b; WHO, 2017):

• Establish a welcoming atmosphere and a warm relationship for the distressed people, so they would feel comfortable and safe (could be on a walk or over a meal).

• Gently ask about general details of what happened to them without pressing them with questions. Avoid sounding like you are interrogating them.

• Show basic empathy and provide much needed comforting statements. • Educate the sufferers about the nature of common emotional disturbances that

usually follow tragedies. • Insure the safety and survival of each person with whom you are working by

providing solidarity, reassurance, and physical provision (if needed and possible). • In case of multiple traumas and victimizations, start with the most urgent one and

gradually move to the others. • Teach people basic ways how to reduce their anxiety, stress, and interpersonal

tension. • Help people discover the unhealthy reactions they use to protect themselves, their

loved ones, or their fragile emotions. • Introduce desensitization and encourage them to reverse any unhealthy coping

modes in a gentle, yet effective manner. • For those struggling with acute traumatic stress, teach them to reframe their thinking

and responses, so their fears and calamities will not become exaggerated. • Be careful when uncovering tragic memories, because some aspects of any

recollection could expand unconsciously to become vague, and the real becomes mixed with the unreal.

• Ask them what they miss most about their previous lives before becoming refugees. Help them process and treasure good memories.

• Remember that the experience of grief, loss, trauma, and tragedy is not separate from people’s mentality, worldview, culture, and spirituality. These always interact and overlap.

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• Make sure to conduct grief counseling simultaneously with trauma therapy in order to facilitate the mourning process of complicated bereavement and the mastery of traumatic reactions.

• Refer severe cases to medical and psychiatric evaluation/treatment as needed. • Investigate the challenges of social adjustment and cultural integration they are

facing. “What are the most difficult aspects of you being a refugee right now?” • Acknowledge the hardship and possible discrimination they may be facing. • Commend them on any positive step and degree of strength they are utilizing,

gaining, and demonstrating. • Help them to constantly shift their mental focus from being victims to being survivors. • Network with other caregivers to find out what supportive resources are available in

nearby cultural centers, communities of faith, and society at large. • Introduce experiential activities alongside talk therapy. Give them homework to do,

even simple activities, and discuss the next steps of recovery to avoid any future lapses.

• Guide them to establish new relationships, set new goals, develop realistic expectations, and discover new inner potentials and aspirations.

• Inspire them to possibly get involved in helping other people who are struggling with similar agonies, so by helping others they will eventually help themselves.

• Encourage them to cultivate healthy soul care and spiritual vitality. To do that, first find out whether faith has become a part of the solution or the problem in their lives. “How can your faith and religious values inspire you at this time of life?”

• “Are there any elders, mentors, or sages in your life circle that you can seek to guide and nurture you?”

• “How would your grandparents handle and cope with a similar situation? What common sense, insight, and generational wisdom from your heritage can you use and employ?”

• “If you are a role model, what can others, young or old, see and observe in you? And learn from you?”

• Encourage them to use resources from the new environment and also make contributions into it.

• Help them navigate the challenges of adjustment and integrate well in the hosting society, without losing much of their social identity or cultural heritage, yet without isolating and becoming socially rigid, in order to blend well and function best.

• Encourage them to practice basic meditation and mindfulness. • Promote resiliency and survival. Hopefully, these people will begin to transfer their

pain into purpose, their crippling into creativity, their misery into mission, and their tragedies into treasures.

• Finally, remain available for continual support, guidance, accountability, nurture, and encouragement.

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CONCLUSION

In this chapter we have discussed the agony and perseverance of the Syrian people who have been directly affected by the ongoing armed conflict and large-scale war since 2011. We have described the background of their ordeal and focused on the dynamics of their coping skills and survival abilities. We have presented an overview of the circumstances preceding the massive troubles and tribulations that hit most of their homeland along with a general profile of the country and its population, subcultures, social norms, and religious faiths, so to help us better understand the scope and seriousness of the current situation and put its acute humanitarian crisis in the right social framework and psychological perspective.

As the armed conflict and fighting continue and, at times, spread or switch from one regional area to another, scores of Syrians continue to suffer greatly. Besides their tangible losses, actual military sieges of their communities, and destruction of their homes and neighborhoods, they had to endure severe emotional horrors, multiple physical displacements, bodily injuries, and often death of a family member or loved one, and obviously accumulated levels of traumatic stress.

Some of them became refugees in their own country. Others became refugees in a nearby country across the border, like Jordan, Lebanon, Turkey, and Iraq. A few of them, relatively speaking to the millions displaced, made their way to North Africa, the Gulf region, or to the European continent. However, the majority of them settled in residential communities or large established camps near the Syrian border, indefinitely waiting and desperately hoping to return home perhaps someday.

We have found that, under the right circumstances, and with the intentional help, care, and hospitality of the hosting country or community, even the most traumatized and victimized Syrian refugees have been able to slowly (but surely) readjust, gain strength, persevere, recover, and build a new life in exile. Those who were able to return to their relatively safe towns and villages have started cleaning, repairing, and reestablishing their neighborhood again. Survival and resiliency are manifested by their ability to utilize well the resources available to them, respond well to the coaching and training provided to them, engage in the guidance and counseling given to them, and be indigenous and creative in finding solutions and new innovative ways around the many obstacles facing their restoration.

We have also seen that the welfare and survival of Syrian refugees has not been without negative consequences on the hosting communities, societies, or countries. In this chapter, I have included a Lebanese perspective about that difficult aspect and how, since the very beginning of the Syrian war, the tiny nation of Lebanon has been extremely strained, and still, as a full resolution of the crisis appears unattainable. Lebanon is now considered having the largest refugee population in the world per capita. However, and in spite of this sobering reality, the Lebanese government and

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people, regardless of their socioeconomic background, political persuasion, religion, or education rally behind accommodating Syrian evacuees and migrants in all areas and on all levels. Thus, the Lebanese have become partners with the Syrians in enduring their crisis and paying the heavy price of their displacement. The Lebanese people also have shown tremendous resiliency, practiced great absorption, and exhibited remarkable solidarity. And together they have displayed a great model of containing the aftermath of an ugly war and a catastrophic tragedy, which have caused a national misery, an unbelievable regional dilemma, and an unprecedented humanitarian crisis.

As the author of this chapter, I have shared many personal insights, observations, and conclusions based on my social interactions, clinical interventions, private interviews, in- depth readings, and cross-cultural works. A glimpse of what the helpers, providers, and volunteers, who are working with Syrian refugees, are facing and experiencing is also included. This perspective is to complete the psychosocial picture and provide a global view of the impact of such a war disaster on both the caregivers and care-receivers alike.

In conclusion, the whole account may serve as a testimony to the resilient human spirit which, on one hand, can endure adversities, experience various traumas, and be moved deeply by multiple calamities and, yet, on the other hand, can begin to restore the many losses, heal the profound emotional wounds, recover from the painful agonies, and chart a new path toward a future filled with hope, confidence, patience, striving, and survival.