We integrated findings from the interviews and the causal loop models and presented these in relation to three main themes: 1) perceptions of mental health problems, 2) causes of mental health issues including relevant gender differences, and 3) health seeking behaviors and practices to maintain wellbeing.
Perceptions of Mental Health Problems
Overall, participants from different settings and nationalities agreed that individuals with mental health issues are severely stigmatized. When asked about how people with mental health issues, like depression, are viewed by others, participants noted that mental health is not viewed or accepted as a disease that needs treatment but rather as a failure on the individual’s part to function normally or fit in.
“In today’s society, if someone is struggling with mental health, people point fingers and say he is crazy.” A Lebanese man living in Beirut
“They don’t view them positively. They would consider them crazy and as if they are less than human.” A Syrian woman residing in Beirut
Participants acknowledged that stigma is largely fueled by a lack of knowledge and information among communities.
”There is no awareness. Some people think it’s because a person is not religious. They don’t take it like it’s a disease that needs treatment.” A Lebanese woman living in Beqaa
However, most of the participants mentioned that in principle they disagree with social stigma and discriminatory behavior. Similarly, participants emphasized that empathy plays a major role in making the life of people struggling with psychological issues easier. Moreover, many of them discussed the importance of seeking help from a therapist and normalized it. Only a minority of participants mentioned that the community is now accepting mental health issues and that they are becoming less of a taboo.
“It used to be a taboo issue and an embarrassing one. Now, people deal with it and accept it.” A Syrian woman residing in Beirut
Causes of Mental Health Issues (Fig. 1)
We proceeded to discuss findings corresponding to causes of mental health issues via reference to the causal loop model elicited via group model building sessions (FIGURE 1). We distinguished four main categories of risk factors as identified by participants and will discuss these via reference to the causal loop diagram in Fig. 1.
Long term effects of exposure to war and violence (Blue zone in Fig. 1)
The elaborated graphs and rich pictures (see Appendix 3) identified that the Lebanese civil war as well as the Syrian crisis have both resulted in long-term effects on the mental health wellbeing of both communities. Participants talked about the loss of loved ones, families and homes as well as their exposure to violence. These events have led to constant worry over their own safety and that of loved ones, which is a main contributor to stress and mental health issues. Interview findings support these accounts:
“When someone dear dies, this could also lead to mental illness.” A Lebanese woman from Beirut
Participants also discussed the presence of interpersonal violence within families (upper right end of the blue zone), though such discussions were more prevalent among Lebanese residing in the Beqaa area and among Syrian refugees in both contexts. Participants in these groups mentioned that the culture and environment shaped men to be aggressive and violent within their families and larger community. Female participants echoed this and spoke about episodic exposure to violence both against women and children. Consequently, both male and female participants from the Syrian communities and the Lebanese living in the Beqaa noted that children fall in the cycle of intergenerational trauma and repeat patterns of aggressive behaviors. Participants described that violence in the household and family, as well as sexual harassment towards women (noted in violet in the model), are major contributors to stress and mental health issues.
The political and social effects of war (Orange Zone in Fig. 1)
When asked to discuss the trends and precipitating factors driving the mental health burden over time, participants talked about the impact of wars and conflict on political stability and the socioeconomic situation of the population in Lebanon. Participants identified the Lebanese civil war as well as the Syrian crisis as key events that kept the Lebanese political system vulnerable to corruption and over time precipitated the erosion of confidence in current governance (orange zone, upper left section of Fig. 1).
Lebanese participants described the influx of Syrian refugees to Lebanon as considerable and attributed the aggravation of the already existing local challenges in governance and the economy to this influx (see next section for how these challenges affect socio-economic fabric of Lebanon). Relatedly, participants from both communities mentioned that the displacement had led to integration challenges and this in turn exacerbated social tension in the country. One frequently mentioned example included discriminatory practices in schooling. Separate schooling times for Syrian and Lebanese children are necessary to manage demands given the scarce national resources, however this means children mix rarely and teachers are overworked and thus resort to discriminatory practices towards Syrian children.
Socioeconomic constraints (Green Zone in Fig. 1)
As noted above, participants described political instability and governance challenges in the country as major factors impairing economic growth. Participants from both communities and residing in the two contexts talked about issues of unemployment and expensive livelihoods (Green zone, lower left part of the model in Fig. 1). The inability to secure employment impeded the improvement of an individual’s economic status and rendered them unable to afford daily life needs for their families and children as well as access to affordable healthcare in case of illness.
Syrian refugees noted that the loss of their properties/households and displacement to Lebanon has led to their struggle with harsh financial situations. The rules and regulations followed by the Lebanese government, starting with the legal restrictions on employment and the lack of appropriate aid and resources, have added to the stress of this vulnerable group and worsened their financial situation. Consequently, many Syrians were looking for informal jobs but were facing discrimination regarding their salaries.
“If you go looking for a job, they barely pay you 200 or 250 ($). You work so hard, and you barely earn anything. You feel your efforts are in vain. All this affects how you feel. Yet, I hope we remain healthy and capable of working.” A Syrian man living in Beirut
On the other hand, most of the Lebanese participants mentioned that they are competing with Syrian refugees in the labor market, which is resulting in the host communities’ decreased ability to secure employment. Lebanese participants stated that Lebanese employers prefer Syrian refugees over locals because of their acceptance of lower salaries; while official employment of Syrians is highly regulated, regulation relating to salary scales of Syrians is lacking.
Gendered expectations driving onset of mental health issues (Yellow Zone in Fig. 1)
We noted gender differences for the drivers of stress and mental health issues within the family. Men considered financial obstacles as major drivers to stress and mental health issues (demonstrated by the blue arrows) because of their failure to secure employment, improve their family’s economic situation and meet aspirations for a better life.
“There are many causes. I feel men worry more about financial matters, if he is unable to make his family happy. Men feel that money is the most important thing that they can offer to make their family happy. Mothers worry about taking care of their children, if they are not in a good mental state, if they have marital problems, or if they can’t meet their children’s demands. This causes stress. Children need to be well educated.” A Syrian woman living in Beirut
“First, poverty can lead to a mental illness. When someone has no money and is unable to make ends meet or provide for his children, this greatly affects a person’s mental state. Just imagine not being able to secure the needs of your children, such as education, food, cloths. This has a major effect on parents’ mental state. This also affects children who would have nothing.” A Lebanese man living in Beqaa
Women from both communities described their worries in a different way (purple arrows). They highlighted the challenges of social inequality and the patriarchal social system whereby men predominate in roles within the job market or within the households. Women described their tasks of child rearing and household responsibilities as overwhelming and stressful. Syrian woman, in specific, talked about their constant worry about their children who face lots of discrimination and bullying at schools in Lebanon.
Health seeking behaviors and practices to maintain wellbeing (Fig. 2)
Participants of both communities and areas reflected on a consistent set of health seeking behaviors. We elaborate further on the factors affecting the rate of health seeking, the diverse routes for health seeking and drivers and barriers for seeking support from the health system (variables highlighted in green).
The level of confidentiality expected from different sources of help, as well as the stigma around mental health issues, were the main factors shaping the rate of seeking support as mentioned by participants from both genders and communities (violet colored arrows).
Determinants of health seeking (green pathways of Fig. 2)
Health seeking behaviors were determined by the social connectedness of the persons experiencing mental health issues. Participants considered their families, friends or partners as the frontlines for support, which is due to the ability of the latter to listen and provide support confidentially. However, gender differences were apparent. Women noted they were more likely to open up to family and friends as they are the main source of support for people suffering from mental health issues. Women explained that one seeks support from the people who can be trusted, who are able to listen actively and to provide support for the individual. However, men explained that they are less likely to talk about their issues and would keep them to themselves. Men further expressed a preference towards waiting before seeking support; this was noted in line with their adherence to religious doctrines where they considered that God is testing their patience when passing through life hardships and struggles.
A minority group of both genders mentioned that they will not disclose to anyone because they do not want to burden their loved ones. These participants in particular noted they would engage in self-management and diverse coping mechanisms in order to find solace and break the cycle of suffering. Different coping mechanisms were mentioned by women and men, such that women tend to engage in self-care and changes in dietary habits (violet/ purple arrows); men mentioned that a person would resort to harmful habits and behaviors such as smoking, alcohol and in dire circumstances even resorted to committing crimes (blue arrows).
When the social network and the coping mechanisms fail to secure the wellbeing of the affected person, seeking support from the health system is viable (highlighted in green). Participants mentioned that the substantial delay in accessing the health system is principally due to social stigma.
“I: What are the obstacles that stand in the way of people going to a therapist?
CM: They would think that they’d seem crazy.” A Syrian man living in Beqaa
“Our society views you as crazy if you see a therapist. So, society stands in your way when you want to seek therapy even if it is the only thing that would help you”. A Syrian man living in Beirut
Barriers to health seeking (variables highlighted in pink of Fig. 2)
Participants talked about the lack of trust in the ability of the health system to improve and maintain the condition of patients. Particularly, participants noted limited trust in the quality of services being delivered and in the ability of the specialists to treat MHPSS cases (pathways and influences highlighted in pink). All participants mentioned that patients doubt the ability of the healthcare provider to listen and support confidentially, and they lack the trust in the ability of the provider to treat and prescribe the appropriate medications. Lack of trust in both these processes, as well as the variable quality of such services, were noted to affect the rate of wellbeing maintenance and improvement (variables highlighted in pink, lower right end of the model).
“CM: Some people get scared. They tell you they don’t want to go because their condition might worsen. They want to solve their problems alone. If society is not helping, he can go to the doctor, but he does not want anyone to intervene.” A Syrian woman living in Beqaa
In interviews, some people explained that it is not only trust in the system that is compromised but also in the specific services provided.
“Why wouldn’t some people accept that?
CM: Some people don’t trust in therapy. They don’t think it is effective.” A Lebanese man living in Beqaa
The majority of participants mentioned that the level of awareness of mental health issues and the willingness to improve could play a major role for seeking health and therapy (lower right part of the model). Moreover, participants residing in Beqaa mentioned the lack of available services and the issue of commuting as a major barrier to seeking help from the system (lower right part of the model).
“Another factor is the area of residence, for example if I want to be treated by a good doctor but I live far from his clinic and I cannot always go to him. These are also minor obstacles.” A Lebanese woman living in Beqaa
“CM: Sometimes these services would not be available at a center nearby or if no one is supporting the person with a mental illness and encouraging him to get treatment.” A Lebanese man living in Beqaa
Financial barriers and the high costs of treatment were also mentioned as major challenges to healthcare access, particularly in the Beqaa.
“Sometimes it is expensive, so the cost stands in the way. Not everyone can afford it.” A Lebanese woman living in Beqaa
“Mostly Financial obstacles. Unless there is social security or insurance” A Lebanese man living in Beqaa
Points of fragility and suggested interventions
Participants were asked to reflect on the whole causal loop diagrams they developed and identify and vote for the top problem areas (so called points of fragility) affecting their mental well-being and health seeking journey; participants were then asked to identify interventions actively targeting these areas. (See tables in Appendix 4)
Participants across both settings and communities identified the precarious financial situation at the household level, as influenced by unemployment, as a major challenge to mental health and wellbeing. The Lebanese community in particular highlighted that the political instabilities and corruption in Lebanon were major reasons for poverty and were obstacles for development and prosperity.
At the individual level, women highlighted that family issues and the many expectations associated with raising children were factors that increased stress and precipitated the worsening of ones’ mental health problems. In contrast, men were mainly focused on employment and the socioeconomic situation in the country.
Towards the end of each workshop, participants were given the opportunity to suggest solutions and potential interventions to address the points of fragility in the system that had been highlighted. The solutions offered were focused on improving socioeconomic conditions, enhancing mental health awareness and service utilization as well as improving integration and acceptance of Syrian refugees in the host community. All participants noted the need for job opportunities with better salaries, which would enhance their financial situation and living conditions, thus improving their psychological well- being. Moreover, Lebanese participants highlighted that awareness campaigns and strategies to fight the widespread stigma around mental health issues and the need to reduce the costs of treatment in Lebanon is necessary. They clarified that campaigns should aim to increase the level of knowledge on mental health issues, educate people on mechanisms for coping and prevention, as well as inform the community about the availability of services. In contrast, Syrian community members emphasized solutions that tackle discrimination and integration challenges. They mentioned that awareness and educational strategies on fighting discrimination and integration challenges should be addressed in order to improve the relations and reduce the social tension among both.