Break the Stigma: Let’s Talk about Mental Health in Lebanon

The crises in Lebanon fractured a system that was already cracked and perpetuated mental health stigma at the structural level.

For more than 20 years, Shayma1 struggled to find help for her depression. Shayma lives in Saida, a commercial port city in southern Lebanon and home to a large portion of less affluent neighborhoods. Her community has been shaken by the unrelenting socio-economic crises that hit the country beginning in 2019 and have since worsened. While primary healthcare centers (PHCCs) are available, she felt the care they provided overlooked who she was as a person and was limited to purely physical health needs. The needs “of our psychological wellbeing weren’t addressed,” says Shayma. “We didn’t even know that mental health services were accessible to us.”

Choosing to consult

Shayma, a 38-year-old Lebanese mother of four children, grew up at her grandparents’ after being abandoned by her parents soon after birth. She decided to seek care for her mental health when she realised that her condition arrived to a point where it started to affect her relationship with her children, as well as their mental health and wellbeing. She recalls feelings of emptiness and sorrow throughout her upbringing and sought an escape route when she married at 18 years old.  

“I was under strict control. I didn’t feel comfortable talking about my feelings then and I didn’t feel supported at all,” says Shayma, fighting back tears, as she describes her living circumstances with her conservative grandparents, “I begged for some affection; I still feel this emptiness in me.”  

Group therapy session with a psychologist from Première Urgence Internationale in Saida. January 2023.

In her community, Shayma said the common routine when one suffers from feelings of emotional distress is to go to a Cheikh, a religious authority who is known to recite verses for the purpose of emotional relief. “We later heard about psychological support sessions, but I faced so much stigma which held me back—until I reached a point where I had to seek therapy.”  

Other people’s opinions: a barrier to taking the first step

In 2013, she experienced an emotional breakdown after childbirth; that is when she decided to seek psychological support and was prescribed anti-depressant medications. “I only rejected mental health care at first because of society’s backlash; everyone would think I had a serious illness or that I was crazy,” says Shayma. “But after years of struggle I realized my mental health was more important than what people say.”  

In its quest to integrate mental health and psychosocial support (MHPSS) services into primary healthcare settings, Premiere Urgence Internationale takes a leading role in providing comprehensive and integrated MHPSS services through a stepped care model. A multidisciplinary MHPSS team comprised of social workers, psychologists, psychiatrists and team managers support PHCCs to provide MHPSS services with various intensity of care for the individuals with lived experiences of mental health conditions or those who present any other MHPSS-related symptoms, with ongoing assistance and free referrals to additional services based on their needs.  

In addition to existing services at the individual level, Première Urgence Internationale‘s MHPSS Team, specifically its psychologists and social workers, provide psychosocial and psychological support group activities as well as awareness-raising sessions at the community level. Such activities aim to spread knowledge about MHPSS-related topics and to equip individuals with the resources they need to cope well with daily challenges and to protect their resilience while supporting others in their community. 

Shayma has been participating in therapy sessions for about six months with Premiere Urgence Internationale’s psychologist in a Première Urgence Internationale-supported PHCC in Saida.  

Raising public awareness

“I believe there should be more awareness about the importance of mental health care. If mental health is not maintained, physical health will suffer in turn. I used to feel my heart racing and pain in my extremities, but I am now 70% better after seeking therapy. I wouldn’t talk about it openly because society wouldn’t leave me alone, but I would recommend psychological therapy to anyone who is suffering,” she says. “The best thing I’ve learned here is the beauty of sharing individual milestones and struggles in group therapy sessions. I have formed connections and friendships that I now cherish. I used to cry and get angry all the time. I avoided contact with people, behaved aggressively with my children. I now feel happy and secure, and this is what I wish to transfer to my children.” 

Activity during a group therapy session. Saida, 2023

According to the report published by the Lebanon Inter Agency Coordination with a particular focus on MHPSS in 2022, these increasing mental health concerns are resulting in deteriorated physical health, inability to focus on daily tasks, weakening relationships within households, inability to properly care for family members and oneself and increased reports of self-harm, suicide attempts and suicides.  

Growing needs but difficult access to health care

In addition to an increasing need for MHPSS services, challenges and barriers that limit people’s ability to access health care, particularly MHPSS services, are additional factors. These issues include: deteriorating supply chains, brain drain and a shortage of MH specialists, reprioritization of less urgent health issues, lack of knowledge about the services that are available, stigma surrounding MH-related topics and complaints, and financial limitations that prevent people from making an effort to seek mental health care.  

To address these shortcomings, the National Mental Health Program (NMHP), under the leadership of the Lebanese Ministry of Public Health, announced a pilot integration strategy for MHPSS services to enable their provision at the primary health care level.  

All these findings and the recent actions taken by the NMHP indicate the pressing need to maintain support for primary health care services at the structural level, and for improved integration of MHPSS services into the existing health care settings. 

“People who suffer from neurological and mental health conditions have a long history of experiencing prejudice, stigmatization, and discrimination to varying degrees not just in Lebanon but around the world. This stigmatization happens at multiple levels and can take multiple forms like public stigma, self-stigma, and/or institutional stigma,” explains Irem Umuroglu, Première Urgence Internationale Lebanon’s MHPSS Coordinator. 

Noura, psychologue de Première Urgence Internationale

The daily struggle 

“Most cases we encounter at the PHCC are severely impacted by the economic crisis which in turn causes a spillover effect on their mental health, safety, productiveness, and sense of belonging,” highlights Noura Amkieh, a Première Urgence Internationale Psychologist in Saida. “Every day in Première Urgence Internationale-supported PHCCs, we perceive that the element of social life and family cohesion is one of the core areas that has been severely impacted by the economic crisis, which in turn has led to an exacerbation of mental health disorders, most commonly depression, anxiety, and adjustment disorder. The majority of assisted people report having these ‘core’ issues with their spouses/children and surroundings, significantly increase post-economic collapse.”  

Men’s stories are rarely heard when we talk about mental health. Issa has been struggling with anxiety and panic attacks for the past four years. He faces constant pressure as a father of three under harsh socio-economic conditions and a stressful working environment as a daily mechanical worker.  

“Only therapy helped me and taught me how to deal with my emotions,” says Issa. “I used to have panic attacks that I thought were caused by physical issues.” When Issa sought treatment at the PUI-supported PHCC in Saida for what he thought was a mere physical ailment, the physician there referred him to PUI’s social worker at the PHCC. He has been undergoing psychological therapy with Première Urgence Internationale’s psychologist for the past five months.  

As he recalls his journey leading up to mental health care, Issa cannot stress enough the importance of awareness about such emotional support being available and accessible. “I realize now how helpful it is to talk to someone whose only intention is to listen and help me relieve my pain. I am worried about my children; I want them to know how to deal with their emotions. I believe that teaching children about mental health issues is just as crucial as teaching them math and science,” adds Issa. 

With his increased knowledge about mental health care and its positive impact, Issa now deems himself capable and willing to talk to others about their struggles and to offer support. 

The Première Urgence Internationale MHPSS team reports that the impact is even greater for refugees who, in addition to the economic situation, are being constantly subjected to harassment, bullying and hate speech due to their status and the erroneous beliefs that people hold against them, such as the erroneous belief that they are unscathed by the crises in Lebanon, or that humanitarian aid programs are biased in their favor rather than vulnerable Lebanese.   

In everyday interactions in the field, the team can see how the economic crisis affected peoples’ sense safety and security. “We can see the devastating effect of grief and loss brought on by the pandemic and the sharp increase in immigration from Lebanon over the past year. We observe the signs of lack of social cohesion and belonging on both the national and refugee levels. All these factors along with others, exacerbated by the lack of mental health care awareness, are standing in the way of creating a more resilient and healthy sense of wellbeing,” adds Noura.

Issa, 37, during a consultation with a Première Urgence Internationale psychologist. Saida, 2023

The way forward

In its MHPSS programming, Première Urgence Internationale has been supporting the Lebanese Ministry of Public Health with the implementation of the ‘Mental Health Gap Program’, launched by the World Health Organization. As a clear acknowledgement of the value of mental health services and everyone’s right to receive them without restriction based on nationality or social standing, the program strives to integrate mental health services within general healthcare services. 

Première Urgence Internationale’s teams take part by teaching PHCC nurses and physicians how to provide psychological counseling in public health facilities while being supervised by psychologists and doctors. These trainings include identification and referral of persons with MHPSS conditions with the aim of offering patients with mental health conditions a prompt and comprehensive response. 

Moving forward with her therapy journey, Shayma wishes to start a forum of her own, similar in its setting to Première Urgence Internationale’s group therapy sessions. With her increased awareness about mental health, Shayma wants to inspire others to voice their inner emotional struggles and find relief in sharing them in a safe, supportive space.