Dispatch from Jordan: Improving care for war-wounded Syrian refugee youth

Syrian refugee camp in Amman, Jordan

Why should I listen to you, an American, Harvard psychologist? What do you know about war and hunger? Why should I trust that you’re here to help? What makes you different than all the other researchers who come to Jordan just to collect data and leave?

All good questions; hard ones, yes, but critical to answer if I wanted to be of any support to Jordanian healthcare systems in improving quality of care for Syrian refugee youth and families seeking refuge in the region.

Since beginning my doctoral studies in clinical psychology ten years ago, I have had a passion for global mental health. Over the past 3 years, I have been involved in a health system strengthening project in Amman, Jordan that is focused on integrating mental health and psychosocial support services into physical rehabilitation centers serving war-wounded, Syrian refugee youth.

The Syrian refugee crisis

Approximately 40 percent of Syrian refugees are under the age of 12. These youth have experienced horrific atrocities of war and are at high risk for a range of mental health issues, such as depression and post-traumatic stress.

Many Syrian refugees have been forcibly displaced to Jordan; indeed, one in 10 Jordanian residents is a Syrian refugee. Despite high rates of trauma and clear psychosocial needs, there is limited access in Jordan to experienced mental health providers who are able to treat these children effectively. Furthermore, there are widespread concerns about the effectiveness of outreach efforts and the quality of available care.

Filling the gap: The transfer of expertise

In high conflict, low resource settings, the demand for treatment often exceeds supply. The rehabilitation centers in Amman grappled with a similar reality. Numerous children were struggling with both physical and emotional wounds, and it was often hard for staff to determine which patients had the highest needs and with what frequency care should be delivered. 

Evaluation that allows practitioners to differentiate between acute and subacute needs is critical to determine patient priority and to execute appropriate interventions. Without this, children with less severe symptomology were mistakenly prioritized over those who required more urgent care.

The goal of this project, therefore, was two-fold:

  • Provide general education for paraprofessionals on psychological trauma and on the unique experiences of youth who have experienced wartime violence, displacement and limb loss.
  • Enhance our understanding of the mental health and psychosocial needs of trauma-exposed, war wounded Syrian refugee youth through data collection.

However, before any training or research could begin, the fundamental issue of trust had to be addressed.

Trust has to come first

As a clinical psychologist working at the Refugee Trauma & Resilience Center at Boston Children’s Hospital, I arrived in Amman, Jordan feeling confident in my knowledge of the refugee experience and of clinical intervention for trauma exposed youth and families. Yet, I quickly realized that I had grown so accustomed to working in the United States that I had overlooked a foundational element of health system strengthening, particularly when working cross-culturally: trust has to come first. 

As an American psychologist, establishing trusting relationships in the Middle East can be challenging for multiple reasons. Decades of geopolitical conflict between the West and the Middle East has had unfortunate implications for global partnerships. Furthermore, historical trauma has been woven into the fabric of the region due to centuries of tension between various warring countries in the Middle East.

In order to build trusting partnerships with members of communities that have endured historical trauma and exploitation, it’s critical for researchers and practitioners alike to demonstrate tangible signs of safety and care. I employed various strategies to signal to my partners that I could be trusted and that I was invested in true collaboration. Those that proved to be the most effective were:

  1. Learning and showing respect for cultural norms, values, and practices
  2. Engaging local, community partners in all aspects of the work
  3. Having respect for the systems that are in place
  4. Encouraging and participating in open, honest communication
  5. Listening to local perspectives on both the problems and the solutions
  6. Acknowledging the wisdom, resilience, and aptitude of the local community—partners and patients included
  7. Validating legacies of historical trauma and exploitation
  8. Taking accountability

All of these strategies and more have been invaluable to establishing a global partnership that is not only long-term, but also equitable. From there, sustainable solutions have followed, including the training of paraprofessionals in techniques for identifying and responding to symptoms of posttraumatic stress, educating rehabilitative staff in ethical procedures for human subject research, the creation of a curriculum to guide the facilitation of an expressive arts therapy group, and the development of an intake process to triage patients with greater mental health needs. 

Applying learnings at home

Prioritizing trust building, however, is critical to quality of care in the United States as well. As a scientist-practitioner committed to strengthening health systems to better meet the needs of trauma exposed children and families, fostering safety, trust, collaboration, and self-efficacy are foundational to both my research and clinical practice at Boston Children’s.

This project in Jordan has not only improved my capacity to provide meaningful services internationally, but also here at home.

Learn more about Boston Children’s Global Health Program.

About the blogger: Emma Cardeli, Ph.D. is a research associate at the Refugee Trauma and Resilience Center (RTRC) at Boston Children’s Hospital, an instructor in psychology at Harvard Medical School and a licensed clinical psychologist with years of experience working with traumatized children and families from culturally diverse backgrounds.