The need for trauma-based services in the Middle East
Between 2013 and 2016, Trauma Aid UK (TAUK) organised three consecutive eye movement desensitisation and reprocessing (EMDR) basic trainings (parts I, II and III) in Turkey for 95 mental health professionals. All participants were invited to complete the Arabic translation of the Need for Trauma-Based Services Questionnaire (NTBSQ) (Abdul-Hamid, et al., 2016). This was developed to elicit the opinions of mental health professionals about the trauma suffered in their countries and how they are currently dealing with it. Additionally, it asks for their suggestions for meeting the need for trauma services in this traumatised region. It uses both quantitative and qualitative inquiry to provide data from the therapists, all of whom were involved in treating and caring for individuals with trauma-related problems.
The participants were asked to list what they considered to be the three most prevalent mental health problems in their country. The results, as expected from recent events in the Middle East, showed that 51% of the respondents listed post-traumatic stress disorder (PTSD) as the most common presenting problem, followed by depressive disorders (25%) and anxiety disorders (9%), psychotic problems (4%), childhood psychiatric problems (3%) and lastly substance abuse (2%). These results were the same when participants were asked about mental health presentations in their local clinical practice – PTSD 43%, depressive disorders 31% and anxiety disorders 13%. Participants reported that they were seeing between one to 35 cases of trauma-related problems per week, with a mean of 10 ± 7.5 cases per day.
The real significance of our survey is the demonstration of unmet clinical need.
Participants considered that they were only able to address the needs of around a third (35%) of their clients who presented with trauma symptoms. This means that around two thirds of their clients remain untreated due to a lack of resources and trained clinicians.
It was also reported that most (75%) of the mental health professionals attending the EMDR training had not received any prior trauma psychotherapy training and as a group they were almost totally naïve to EMDR. In terms of the interventions they were able to offer their traumatised clients (prior to EMDR training) only 55% of the practitioners mentioned that they used cognitive behavioural therapy (CBT), but this was not trauma-focused CBT. The remainder used medication (9%) and a variety of different forms of therapy not approved for PTSD such as psychoanalysis, art therapy, counselling, family therapy, solution-focused therapy and religious therapy (using the Quran and Islamic teachings).
The practitioners indicated that they would most like to provide effective psychotherapy but that occupational therapy and social work (which are understandable in the context of working with refugees) also need to be available.
Participants were asked to suggest ways of improving mental health services provided to their clients. The most important and frequent themes were the training and supervision of qualified mental health staff in conjunction with the creation of dedicated trauma services. Teaching trauma first-aid programmes in Arabic was considered important as was providing psychological services for refugee camps and the provision of group and online therapy. These were mentioned in the context of making psychotherapy accessible in countries where transport and security are problems for clients.
The need for EMDR psychotherapy in the Middle East is clear. The responses in our survey demonstrated extreme themes (“the loss of relatives after explosions or assassinations”, the presence of “terrorism and kidnapping”) of trauma that people in the Middle East are experiencing. The internal and external displacement of refugees has also added to the mental health problems of these people and when therapists try to help refugees, they have great difficulty in finding an appropriate place to hold psychotherapy sessions in the refugee camps.
This demanding situation is made worse by the fact that, while there is an increased number of mental health problems, there is an associated and corresponding reduction of the professionals and facilities that could help trauma patients because of the emigration of qualified medical and psychological staff due to the security situation. For example, one participant wrote that the number of “psychologists in the whole of [my country] is less than 10.” Many of the remaining mental health staff are unqualified with lack of both pharmacological and psychotherapeutic treatments. Specialist mental health teams, centres or mental health assessment tools are practically non-existent.
There is an increasingly desperate situation in the Middle East not only in relation to the degree of exposure to trauma and the resulting trauma-related problems but also the lack of resources to meet the needs of traumatised populations.
Most participants agreed that the immediate need is “to train more psychotherapists who can help trauma victims.” The participants, even those who spoke good English, appreciated a chance to learn EMDR in Arabic. They were grateful to be able to master an effective trauma therapy that could enable them to offer immediate help to their compatriots.
It is important to highlight some possible methodological biases that might have affected our results. This is a cross-sectional survey, so the results do not reflect the exact population rates of prevalence. The numbers provided are best estimates by the health care professionals. In addition, the selection of participants for the EMDR training favoured those from countries and regions suffering from higher levels of trauma which might have biased the results further. Therefore, answers to the question of the perceived prevalence of problems in the professional’s country should be taken as the participants’ own impression.
Before the start of the Trauma Aid UK EMDR training in the Middle East, there were a few attempts to train professionals in EMDR in the Middle East. Unfortunately, these attempts did not include the follow-up and supervision that ensured the completion of the training and meeting the needs of the trainees and their clients. From the beginning and learning from Trauma Aid and Humanitarian Assistance Program’s (HAP) past experiences in other countries, we decided to establish a comprehensive programme that will ensure the long-term establishment of EMDR in the Middle East and eventually lead to self-sufficiency in providing professional EMDR training.
These results confirm that there is an immediate need now to establish a local framework and structures for EMDR training to meet the increasing need for trauma psychotherapy. Guided by the successful trauma capacity building of both Palestine and Bosnia, we think that one of the primary goals is to establish national EMDR associations that could, with time and continued support from Trauma Aid organisations, establish an Arabic language training cadre and curriculum in EMDR.
We have been informed on many occasions by participants in online supervision that there is a developing crisis following on from the economic crisis in Europe and the Gulf Arab states. Many of the charities that work with refugees have closed their mental health facilities. This is leaving a sizeable number of the professionals trained by Trauma Aid UK, unemployed and unable to help the traumatised refugees. Moreover, a recent survey of mental health professionals working in Syria’s neighbouring countries have suggested that Syrian refugees need trauma mental health services (Abdul-Hamid, et al. 2018).
One of the ways that might contribute to better meeting the psychological treatment needs of the vast number of refugees in the region could be to replicate the Mekong Project in Southeast Asia which not only trains therapists but also employs them (Mattheß, & Sodemann, 2014). Such a project might be called the Euphrates Project or similar.
Unfortunately, in my opinion, many countries in Europe that have the money to fund such a project are influenced by far-right populist politics in Europe that clearly would not want to do anything that helps Arab refugees. They are also impeding the progress of forming an EMDR association for the Arab countries by refusing to help in the accreditation of Arab EMDR trainers.
I would like to acknowledge the contribution of my late friend and colleague, Sian Morgan, who not only played a pivotal role in conducting the research reported above but was also instrumental in supporting EMDR training in two war-affected regions: Bosnia and the Middle East. The first TAUK EMDR training was held in Bosnia and Herzegovina in 2009 and continued with many further trainings that helped build up a significant trauma treatment capacity, leading to the establishment of the Association of EMDR therapists in Bosnia and Herzegovina in 2014.
Since the Iraq War and the so-called Arab Spring, The Middle East has experienced devastating conflicts, terrorism, death and destruction, most recently the terrible earthquake in Syria and Turkey. The need for trained trauma therapists is as great as ever. Sian and I started talking about training EMDR therapists in Arab countries through TAUK when we first met in 2012. Since then, TAUK has trained over 150 mental health professionals. Many of these professionals now work with refugees in the region (Abdul-Hamid, et al. 2018).
A few months before her death, Sian completed training 30 Iraqi mental health professionals. They all completed the three-part basic EMDR training with supervision between the trainings. This was the first such training conducted online in a centre linked to the University of Baghdad in the Iraqi capital.
Sian’s dream for the Middle East was not only to create a regional EMDR Association but also to create a project parallel to the Mekong Project in Southeast Asia which I mentioned earlier. The Middle East project is yet to be realised but may gain some impetus now that the results of the survey (which was written with Sian and Prof Jamie Hacker Hughes) have highlighted the requirements that, if fulfilled, could meet the vast trauma need in the Middle east.
I am full of hope that the new president of TAUK, Shiraz Farrand, will work further to achieve Sian’s hopes and dreams for the Middle East. Shiraz was born in the Middle East and has been a trustee and close associate of Sian and, like her, participated actively to promote Middle East EMDR training over many years.
Walid Abdul-Hamid, MRCPsych, PhD EMDR Europe Consultant/ Supervisor and Trainer in training, Trustee and Middle East Coordinator at Trauma Aid UK, Senior Consultant Psychiatrist, Central Team, Combat Stress, Tyrwhitt House, Oaklawn Road, Leatherhead, Surrey, KT22 0BX.
Sian Morgan (deceased) BACP and BABCP Accredited Psychotherapist, EMDR Europe Trainer, past President of Trauma Aid UK.
Jamie Hacker Hughes (PsychD, FAcSS, FBPsS, FRSM) Consultant Clinical Psychologist, and Visiting Professor at University of Hertfordshire.
Abdul-Hamid, W., Hacker Hughes, J., Morgan, S. (2016). The need for trauma-based services in the Middle East; A pilot study. Jacobs Journal of Psychiatry and Behavioral Science, 2(2), 015.
Abdul-Hamid, W., Hacker Hughes, J, Morgan, S. (2018) The Syrian refugees’ need for trauma-based services, a survey of mental health professionals. Psychiatria Danubina, 30,(5), 249-252.
Mattheß, Helga & Sodemann, Ute, (2014) Trauma-Aid, Humanitarian Assistance Program Germany. Journal of EMDR Practice and Research, 8(4): 225-232.