Cognitive Behaviour Therapy Design For Syrian Women: A Group Project Proposal Literature Reviews Example
Introduction and Rational
How it started
The Arab Spring began in Tunisia following the dramatic suicide of a young poor street peddler named Mohammed Bouazizi in December 2010. The young street vendor was trying to save some money in order to pay tuition for community college. A local police officer, however, killed the dream of the young peddler. When the police officer asked Bouazizi to move away from the street, he continued working since he had no other way to make a living. As the police officer asked him again, he took his cart and slapped him in the face. Bouazizi could not handle that situation and ended up committing suicide in the middle of traffic (Asharq Al-Awsat, 2011). This incident resulted in the Tunisian President to step down and fled from the country.
The dramatic and rapid changes in Tunisia inspired many young people in Middle Eastern countries such as Egypt, Yemen, Libya, and Syria. The protestors took to the streets to push their leaders onto reforms or out of power and they succeeded to an extent. However, there are some countries that still face violence from their regimes. Syria is one such country that is still under repressive rule and attacks of the Asaad regime, in particular since 2011. According to a report from the United Nations High Commissioner for Refugees, one in every eight Syrians has fled the war-torn nation, raising the number of people fleeing the country to about three million over three years of the civil war (2013). Currently, there are over 3 million people taking refuge in neighbouring countries of Turkey, Lebanon, Jordan and Saudi Arabia. In addition, there are more than 35,000 refugees awaiting registration and estimates of several hundred thousand more are not included in the official figures (UNHCR).
The physical and psychological impact of war on refugees has been widely studied for years. Carlson & Rosser-Hogan (1991) found higher numbers of psychological disorders such as PTSD and MDD among refugee populations. One meta-analysis of 56 studies examined the impact of refugee experiences and found a high rate of PTSD and other major depressive disorders (Fazel, Wheeler, & Danesh, 2010). Researchers also found that 1 in 10 women and 1 in 20 men develop PTSD after surviving a war (Ozer &Weiss, 2004). More specifically, a recent study conducted in Saudi Arabia among Syrian refugees showed that 19% of women between the ages of 35 and 50 developed symptoms of major depressive disorders and PTSD after three month of moving from Syria (Alhadi, Algahtani & Salem, 2014). These research studies illustrate the need and the potential benefits of group interventions treating major depressive disorders and PTSD among female Syrian refugees.
Major Depressive Disorders and PTSD
According to the Wold Health Organization, major depressive disorder (MDD) is one of the most common psychological disorders (2002). It is characterized by a loss of interest in family, friends, work, and other personal pleasures (Myers, 2003). In Canada, about 3.5 million met the criteria for a mood disorder during their lifetime with major depressive disorders accounting for the majority of cases of mood disorders, 3.2 out of 3.5 million (Pearson, Janz & Ali, 2013). In U.S. population, major depressive disorder affects around 14.8 million, which is about 6.7 percent of the U.S. population. And women are 70% more likely than men to develop MDD during their lifetime (CDC, 2012). In Middle East, there are no clear data that show numbers of MDD in each country, and this because:
Political issues: In some countries, health care institutions are shut down or neglected due to political issues or crises. For example, in Iraq, many community mental health care units closed in Al Anbar, Nineveh, and Kirkuk after being controlled by The Islamic State of Iraq and Sham (ISIS; Al-Arabia, 2014).
Economical issues: The countries of Arab Spring are facing major challenges. For example, Egypt is going through an economic crisis in all sectors (El-Haj, 2014).
Cultural issues: Shame and guilt are important emotions that can affect people seeking help for psychological problems, particularly in many Arabic countries (Naeem, 2012).
Researchers, however, showed that the Middle East and North Africa do have the highest depression rates (Alize, et al., 2013). They found that the highest level depression rates countries are Afghanistan and some North African countries, and the political conflicts and the low quality of health services increase the rate of MDD (Alize, et al., 2013). Another study conducted in Morocco among depressed Moroccan women showed that MDD is significantly associated with stressful life events, children health problems, relationship issues, and pregnancy complications (Agoup, Moussaoui, Battas, 2005). In Iran, a systematic review of 24 articles found that the rate of MDD among Iranian population was 4.1%, which is higher than the result of the national study 1.8%. Women in this study were affected at 2.1% which seems a reasonable rate as women are twice more likely than men to experience MDD (Sadeghirad, et al., 2010).
With PTSD, researchers highlighted that there is a lack of clarity regarding the prevalence of PTSD (Kaylor, King, 1987). In Canada, however, researchers used a sample of 2991, aged 18 and above, examining the prevalence rate of PTSD in Canada to around 9.2%, with a rate of current month of PTSD of 2.4. The same study showed that the most common traumatic events causing PTSD are unexpected death of a loved person, sexual abuse, and seeing injured or killed person (Van Ameringen, Mancinic, Paterson, & Boyle, 2008). As Canada is accepting high number of refugees every year, the rate of PTSD may increase. In US, according to U.S Department of Veterans Affairs, around 7-8% of the population will have PTSD at some point in their lives, and women are twice more likely than men to have PTSD.
In Middle East, many countries faced or are still facing war and different type of violence. The past examples include the Egyptian-Libyan War in 1974, the Lebanon Civil War in 1976 to 1982, the Iran- Iraq war in 1980 to 1988, the Gulf War in 1990, recently, the civil wars in Syria, Libya, Yemen, and Iraq. All of these wars and violence have put millions of people at high risk for PTSD. Karam and his colleagues found that around 3.4% of people who experienced the civil war in Lebanon showed some symptoms of PTSD (2008). A study conducted in the city of Al Mosul in Iraq, with sample of children and adolescents (n = 3097) aged 6 to15, found that 10.5% reported symptoms of PTSD (Al-Jawadi & Abdul-Rhman, 2007). Among the conflict between Arabs and Jews, Hobfoll and colleagues in a study after the second war (Intifadah), found that around 18% of Arabs (n = 394), and 6.6% of Jews significantly met the criteria of PTSD (2008). The prevalence rate highly increased among Arab citizens who were living in Gaza. Researchers reported that 68.9% of children and adolescents (n=229) met the criteria of PTSD (Elbadour, et al., 2007). Within the same period of time, another study showed that 10.2% of Jewish citizens had PTSD (Gelkopf, Solomon, Berger, & Bleich, 2007).
More specifically among refugee populations, Shrestha and colleagues (1998) examined the psychological impact of torture among Bhutanese refugees in Nepal. They used two groups, a random sample of 526 tortured refugees and a control sample of 526 non-tortured, and found that torture among refugees plays a significant role in the development of major depressive disorders, anxiety and PTSD. In another study conducted in Norway among refugees, the researchers examined the development of psychological disorders among refugees in South-Eastern Norway. Sixty-three patients participated, with a majority of 53% being Arabs. The researchers found high level of symptoms of PTSD, MDD, and anxiety disorders after exposure to multiple traumatic events (Teodorescu, et al, 2012). Schweitzer and colleagues (2006) also examined the psychological impacts of Sudanese refugees in Australia. They found less than 5% met the criteria of PTSD. However, 25% reported clinically high levels of psychological distress including sadness and anxiety. More specifically among Syrian refugees, Farhood and Dimassi examined the prevalence and predictors of psychiatrist disorders among six villages in south Lebanon. All the villages in the study are in south Lebanon where the population is mixed Lebanese and Syrian. There were 625 participants in the study. They found that the disorder rate was higher than the international rate. There were 33.3% who met the criteria of PTSD and 19.7% had high level in the depression scale, and women were significantly greater in number and rate than men (Farhood & Dimassi, 2012). In another study among Syrian refugees, researchers examined the levels of depression and PTSD in Syrian refugees in Lebanon. They used the Beck Depression Inventory and PTSD Checklist, and found that the majority of the refugees were depressed and had high level of PTSD symptoms (Amoun, Debal & Raidy, 2013).
Therapy approaches for MDD and PTSD
There are many different therapy approaches and designs to deal with MDD and PTSD. In this part, I will briefly go over some therapy approaches that have been used with MDD and PTSD. Eye Movement Desensitization and Reprocessing (EMDR) combines cognations of traumas with directed eye movement (Prochaska & Norcross, 2010). A review of the studies of PTSD shows that it is the most effective EMDR approach for treating adult and children with PTSD. Ahmed, Larsson and Sundelin-Wahlsten (2007) applied the EMDR individual intervention on 33 children diagnosed with PTSD in a randomized control trial study. Results showed a significant improvement in children that were treated with EMDR compared to other groups. With other cultures, a study done in Argentina supported the efficacy of using group EMDR with clients after natural disasters. The result showed that among 124 children aged 7 to 17, EMDR had significant efficacy, decreasing PTSD in a short time (Aduriz, bluthgen, and Knopfler, 2009).
Brief psychological therapies also are widely used with mood disorders. One meta-analysis study examining 34 studies that used brief cognitive behaviour therapy and problem solving therapy found that brief CBT and PST are effective treatments in primary care units treating anxiety, depressive disorder and PTSD (Cape, Whittington, Buszewicz, Wallace & Underwood, 2010). Some studies also showed that brief cognitive behaviour therapy as either effective or possibly more effective than some medications in managing depression (Gloaguen, Corttraux, Cucherat & Blackburn, 1998; Wampold, Minami, Baskin, Callen, 2002). In non-western societies, for example in Bangladesh, several research projects found a high level of effectiveness of CBT for people with psychological problems such as depressive disorders, anxiety and OCD (Mozumder, 2007; Shahid & Begum, 2007). In addition, in Egypt, Habib and Seif El Din (2007) evaluated the effectiveness of using cognitive behaviour therapy in children and adolescents with MDD. The sample was 198 boys and 136 girls from Alexandria, and they found that using CBT for short-term decreased the level of depressive symptoms. In Jordan, researchers used CBT among university students with some mood disorders for three months, and found a significant improvement in their grades. The students also had lower depressive symptoms and less use of avoidance and negative coping strategies (Hamdan-Mansour, Puskar, Bandak, 2009).
Therapeutic intervention among groups
The idea of group therapy in general has many benefits:
Group therapy can be more cost effective than individual therapy
Group therapy can be an educational process where clients can learn from others in some coping strategies and getting some feedback
You are not alone with group therapy settings where clients can improve the trusting relationships to share their issues (Lindsay, Paohus & Nairne, 2008)
Group therapy has been wildly used with psychological problems and also with the psychological impact of physical issues. Classen and colleagues used supportive-expressive group therapy with 125 women with breast cancer and found group supportive-expressive therapy can reduce distress in patients with breast cancer (Classen C, et al., 2001). Brunner, et al (2013), conducted a systematic review, which included eight randomly-controlled trials, to conclude that Cognitive Behavioural Therapy is a promising treatment approach for influencing psychological factors in lower back pain.
Many group therapy models have been used with some psychotic disorders. Research has shown that CBT to be effective in increasing insight and association among a group of patients with schizophrenia (Rathod, Kingdon, Smith & Turkington, 2005).
More specifically with MDD and PTSD, a study among 19 sexual assault survivors showed that using CBT had significantly decreased the symptoms both on PTSD and depression measures (Resick & Schnicke, 1992). Chen and colleagues (2006) evaluated the impact of CBT group therapy on MDD and self-esteem. They found cognitive a significant improvement on depression relief and improvement of self-esteem.
Therapeutic intervention among refugees cross-culture
Many refugees in the world go to countries that are somehow different from their home countries and culture differences can impact the therapeutic intervention. Because most counselling approaches were developed by White males from America or Europe, it is possible that they may conflict with cultural values and beliefs of third world or minority individuals (Scorzelli, 1994). Marwan Dwairy found from his experiences as therapist who got his degree from the west and practicing in Eastern society that it is totally different. He highlighted that “clients seems to be different from those described in the context of psychological theories. Clients react differently to his diagnostic and therapeutic intervention” (Dwairy, 2006). There are still culture issues, gender issues, and social issues that mental health professionals face in Middle East (Al-Ruwaitea, 2008). Del Carmen Rodriguez (2004) mentioned the importance of getting to know clients’ world view, and that can help counsellors to adapt therapeutic strategies in a way that will resonate with clients’ culture. Summerfield (2000) showed that every culture has some psychological knowledge where in it is important for professionals to recognize and integrate traditional healing strategies into counselling. Hoskins (2003) came with what she called “culture listening”, and how that can be a cornerstone of understanding someone’s pain. She states:
What is really needed is the ability to sit and just witness the pain of years of oppression, to honestly admit that there is really no way of rectifying the kind of injustices that have been levied towards one culture for the benefit of another, and to listen so carefully to the contours of person’s experience that one’s own perspective shifts considerably just through the act of listening. This for me is what it means to be culturally attuned. (p.331)
One great example of creating cultural bridge between Western group counselling and traditional healing practices is the study of Loewy and Williams (2002). They integrated the traditional East African coffee ceremony and group counselling with Ethiopian and Eritrean women refugees. By getting in deep and understanding the East African culture, Loewy and Williams (2002) found that the East African ceremony, which is also known as the Buna ceremony, plays very strong role, spiritually and psychologically, and that has been part of East African culture for over 3,000 years.
As has been detailed above, as most of the refugees populations come from collective cultures, healing commonly takes place within groups. This shows the potential benefits of integrating some traditional Arab coping and healing practices with Cognitive Behavioural Therapy as an intervention treating major depressive disorders and PTSD among female Syrian refugees.