A replica of the Clock Tower in Homs, which became the city’s most famous gathering point during anti-regime demonstrations in 2011. It was built by the Syrian residents of the Katsikas refugee camp, in Greece’s Epirus region. The clock is set to the time they entered the camp and a caption underneath it reads: “Time stopped when we came here” – September 2016 (Andres Barkil-Oteo/SyriaUntold)[This article is the outcome of a partnership between
SyriaUntold and openDemocracy].

Five years in, with almost 5 million refugees
outside Syria, 6.5 million internally displaced, and 450,000 deaths,
the Syrian war is a humanitarian disaster of extraordinary
proportions. In this current grim reality, why think about mental
health services? Is it advisable to treat the severely ill first (the
clinical approach), or to prioritize the strengthening of community
ties (the population health approach)? In this essay a model based on
opposition-linked self-organizing councils will be discussed as
potential primary partner in fortifying mental health resiliency in
the affected communities.

Holistic Approach

When planning mental health services, treating PTSD is what
usually comes to mind; i.e., clinical approaches to clinical
problems. However, this is a very narrow and limited vision, that
many times leads to the over-pathologizing of social suffering.

To counter these problems and to embrace a more holistic approach
to the mental health issues of societies, the World Health
Organization (WHO) sponsored the Inter-Agency Standing Committee
(IASC) Guidelines
for Mental Health and Psychosocial Support in Emergency Settings.
These guidelines revolutionize the way we look at mental health
services, expanding them to include psychosocial issues like
providing safe shelter, food, and connections with family members,
and broad community support.

It
is widely recognized that, in a situation of war, family and
community networks are disrupted

Examples of what constitutes basic services and security include
the establishment of security, adequate governance, and the provision
of services addressing basic physical needs. A mental health position
on these issues is to advocate that these services be put in place
and delivered in a way that maintains dignity and promotes mental
health wellbeing.

The issue of family and community support are second in
importance, immediately following the attainment of basic needs. It
is widely recognized that, in a situation of war, family and
community networks are disrupted, so it is beneficial to restore them
through initiatives like communication improvement efforts, family
tracing and reunification, and assistance in mourning and communal
ceremonies.

The Role of Local Councils

Who is going to deliver these services? Usually this framework is
implemented by local and international NGOs in post-disaster
settings. However, in the current Syrian context, this can be very
challenging. In addition, given that we are looking at a protracted
conflict that could last for years, it is preferable to look for
sustainable solutions.

Finally, whatever solutions are proposed, it is important to
suggest models that have been implemented previously, and which are
not something foreign to the societal context.

In the last few years, many examples of self-governance
“councils” spontaneously emerged in many opposition-held
cities in Syria. These emerged when communities became free of the
state and its services, as well as its overbearing impositions.

These social orders were created not by a top-down government
mandate but through voluntary cooperation, and creative innovation.
These came into existence mainly as a practical and non-ideological
solution to immediate problems they were encountering, including
living under missiles and barrel bombs, and unreliable or
non-existing sources of potable water, fuel and electricity.

The way these councils
developed — through democratic elections, finding consensus with
armed forces, or with representation based on families or local power
circles — depended on the location and local actors.

These social orders were created not by a top-down government
mandate but through voluntary cooperation, and creative innovation.

The late Omar
Aziz, a Damascene intellectual and political activist, was one of
the first people to write about local council models that aim to help
people to “manage their own lives independent of institutions and
state agencies, and to create a space for collective expression that
supports the collaboration of individuals”. Aziz stood
for a complete break with the existing state, the achievement of
collective liberation without waiting for regime change, or for one
ruling power to replace another. He believed that communities are
capable of producing their own freedoms regardless of political
vicissitudes.

Some of the essential
roles of the councils include helping people secure shelter, food
and safe space; assisting families to connect with their loved ones;
providing emotional and legal support for detainees and their
families, along with information about their situation; and
coordinating medical services, media coverage, and educational
initiatives.

A Syrian artwork from the Katsikas refugee camp in Greece’s Epirus region – September 2016 (Andres Barkil-Oteo/SyriaUntold)

Fostering Agency to Counter Learned Helplessness

What is the relation between the local councils and the future of
the population’s mental health? For years, generations have become
habituated to what in psychology is known as “learned
helplessness”.  Learned helplessness is the total
acceptance of a given condition: when someone is repeatedly exposed
to shocks, with no ability to resist or escape, they become docile
and accepting. Should an exit from the shocks subsequently be
provided, the opportunity to escape will not be taken.

Agency is a dangerous thing, and authoritarian regimes, to rule
and survive, depend on the erosion
of agency, and the inculcation of learned helplessness.  If
there is no way out, then the best response is to adapt
to the system.

People in this mentality lose the desire to grow and prosper, and
they concentrate
on preventing things from becoming worse (especially when they don’t
believe they can improve their situation). Fear of the system, and
dependence on the system, creates a toxic mixture that slowly erodes
agency.

One cure for learned helplessness is to foster “agency.”
Agency is the capacity, condition, or state of acting or exerting
power. An act of agency is one that has an outcome that the
individual has, in whole or part, foreseen.

In the psychological literature, agency is comprised of three
steps: foresight,
choice and self-initiated action. “Foresight” refers to the
planning phase of engaging in a novel activity, before the initiation
of the act itself. The experience of choice is the selection of a
specific behavior by an individual. When one is coerced to do
something, the set of brain mechanisms engaged is entirely different
from those activated when someone choses the same behavior. Thus,
learned helplessness eliminates the experience of choice.

Self-initiated action is an action carried out through one’s own
effort. In the case of learned helplessness described above, if the
shocks were stopped without any input on the part of the victims, the
latter would not experience agency, because they had not played any
part in the cessation. While the victim experiences relief, the
learned helplessness remains. Thus, even doing good things for people
may not be the best way to improve their functioning; agency and
empowerment only come because of effort by individuals.

Evidence shows that people who have experienced trauma are at risk
of losing their sense of competency

A widely-held maxim in psychology is that having a sense of
control over events is one of the main sources of feeling safe. One
of the primary traumatic symptoms in those suffering with PTSD is a
sense of helplessness, a lack of the basic senses of trust,
predictability and safety.

The concept of self-efficacy,
or personal agency, is found whenever individuals believe that their
actions will likely lead to positive outcomes. This concept can be
expanded to collective efficacy, which denotes the condition of
groups that believe that they are likely to produce good outcomes.

Evidence shows that people who have experienced trauma are at risk
of losing their sense of competency, and the skills required to deal
with problems they encounter, so successful interventions seek to
empower social groups to overcome hardships. Since it is somewhat
unrealistic in war-like environments to expect individuals to create
this sense of competency on their own, communities need to come
together to solve collectively the problems that affect them.

The WHO recognizes the capacity of self-efficacy as essential for
recovery, so it emphasizes the promotion of self-sufficiency and
self-government among war-affected populations.

Activities that are conceptualized and implemented by the
community itself may contribute to a sense of communal efficacy.
Among the major mental health interventions following the tsunami in
Asia, for example, were community
efforts to support the rebuilding of fishing boats, allowing
fishermen to resume their livelihoods.

Similarly, for children and adolescents, the restoration of the
school community is recognized by the WHO and the United Nations
Children’s Fund (UNICEF) as an essential step in reestablishing a
sense of self-efficacy among children.

In the absence of local public health systems, supporting a form
of self-governing councils could be the building block for providing
a population mental health approach. This could be especially
important in the case of internally displaced or refugees who were
uprooted from their cities, and away from their local formal and
informal systems of governance.

Research showed that people’s recovery from the psychological
effect of political violence is highly dependent on individuals’
perceptions of community resilience. The bond between individuals and
their communities promote
agency and resilience through friendships, shared meaning of their
suffering and collective vision for their future.

In summary, there is strong evidence from studies done in other
countries with mass exposure to trauma and protracted conflict, that
community based programs do have positive impact on increasing
people’s resilience and promoting adaptive coping strategies.
Empowering communities’ sense of agency and control increases
their collective efficacy and their social capital. These are the
building blocks for community recovery after mass trauma events in
protracted conflict settings.

This approach tends to be largely ignored in favor of a focus on
individual clinical cases; but to heal the individual, we need to
help the community to heal itself, escape from learned helplessness,
and foster agency and action. This will then serve as a foundation to
build clinical programs that deals with individual clinical problems,
and not the other way around.

You can read this article on SyriaUntold here