Supporting Refugees’ Mental Health: ‘Often an Afterthought’

The Russian attack on Ukraine has resulted in more than 6 million Ukrainians fleeing their country, creating the largest movement of refugees that Europe has witnessed since the end of World War II. Nongovernmental organizations and multinational firms have responded emphatically to the developing humanitarian crisis with urgent necessities, such as food, pet food, hygiene products, clothing, short-term housing, transportation, SIM cards, medical assistance, and free gynecological services. As Russian military might continues to besiege the country, world leaders have denounced the invasion while a campaign launched by EU Commission President Ursula von der Leyen and Canadian Prime Minister Justin Trudeau, in partnership with Global Citizen, has called on world leaders to pledge humanitarian aid to refugees, not just from Ukraine, but from around the world.

Zarlasht Halaimzai is the founder of Amna, an international organization that specializes in supporting the psychosocial well-being (mental health and social needs) of refugees and other displaced people by providing them with trauma-informed care. From Amna’s office in London, she explains that mental health for refugees is “often an afterthought,” the neglect of which “can cause lifelong problems that then affects all the other things that governments and agencies care about, such as employability, integration, health.”

Halaimzai traveled recently to the Polish-Ukrainian border to assess the needs of Ukrainian refugees, the majority of whom are women and children, and the front-line workers who are there to help. She understands that trauma doesn’t end when one crosses a border into safer territory — and she has infused this knowledge into Amna’s programs. Its activities arose as safe spaces to meet the unmet needs of refugees enduring the emotional effects of leaving everything behind — their home, their belongings, friends, and family — while facing an uncertain future.

Halaimzai, who is finishing a master’s degree from Oxford in mindfulness-based cognitive therapy, is intimately familiar with the subjects of war, displacement, and trauma. At the age of 11, she became a war refugee when her family fled Kabul. It was 1992, following Soviet troop withdrawal from Afghanistan, and after the United States agreed to end armed support for Afghan anti-Soviet factions. Without the presence of American troops, militias were left to fight for power, and life in the country became increasingly unstable. Halaimzai’s family first fled to Uzbekistan and lived in exile for four years before applying for asylum in the U.K. In her 2021 TED talk, entitled What’s It Like to Be a War Refugee, she speaks of her experience living in limbo, as a displaced person, saying: “War is dislocating. It gets inside your body and makes you into a thing, a corpse. It can dislodge empathy, hope, and joy and replace them with fear.”

Halaimzai founded Amna in 2016 after returning from the Turkish Syrian border, where she was advising international NGOs on education and child well-being, to help refugees dealing with the emotional effects of violence and displacement. The organization first launched its programs from a tent on the Greek-North Macedonian border as restrictions tightened on refugees fleeing Syria and other countries, such as Afghanistan and Iraq. It now has a core staff of 14, including a program team and a youth team, plus a network of therapists who are based in Greece, Albania, the U.K., and Canada. Since the onset of the global COVID-19 pandemic, Amna has started offering services online, which enables the programs to help people in a greater variety of locations.

Amna’s activities are carefully designed to help counter toxic stress and trauma and to nurture playfulness, joy, and belonging. This can give people a sense of reprieve from the challenges of life in camps and shelters and offer the safety of community as they face extreme uncertainty. Through play, and arts and crafts, refugees are helped to reconnect and socialize with others; through movement, they are helped to reconnect with their bodies and to feel present; through mindfulness and relaxation, they develop awareness of what they are feeling and are provided with tools to help them regulate their emotions; and through storytelling, they are assisted in taking mastery of their own narrative and provided with the space needed to tell their stories about their traumatic experiences.

Sarah Klaus, an adjunct assistant professor at Georgetown University Center for Child and Human Development, praises Amna’s attention to the individual needs of refugees, pointing out that Amna’s work has “evolved into an evidence-based approach — one of the first — providing trauma-informed care and activities to support the youngest displaced children and families in the communities and camps where they are living.”

Informed by an understanding of a refugees’ culture, Amna’s programs harness rituals and practices that already exist in refugee communities. Attention is paid to people’s internal sense of safety and to validating their experiences of trauma and conflict. Group therapists may ask parents what kinds of books or toys they’d like the space to have, or what kinds of games they play with their children. They may also invite parents to take the lead in some sessions by telling stories, which may be tales they grew up with.

Halaimzai recalls a women’s knitting group in Greece comprised of Syrian and Afghan refugees that met in 2017–2018. “This is our way of providing something that creates a respite for women to come and do something with their hands. It’s therapeutic — they love it. We made sure we bought the kind of wool and colors they wanted, and over these knitting circles people shared quite personal, often horrific stories, and you could really feel the support in the room but also how much that went to unburden the women that were talking about themselves.”

Referencing Amna’s early childhood care and development program called Baytna (“Our Home” in Arabic), Halaimzai recalls: “I remember one particular little girl, Lala, that came into one of my groups. She would literally not touch a toy — that’s how frightened and withdrawn she was. We’d offer her all kinds of things, and she wouldn’t even pick up a crayon at the beginning — she just didn’t leave her mother’s side. She was about 4 or 5, and I just spent time with her and the group over a few weeks and months, and every time she did a little thing it was just such a big moment. When she sat, not in a play group, but on the periphery watching, that was a big day. It was a celebration when she reached and picked something up or when she played. In a few months she was just like a normal little girl, just playing and laughing, and I will just never forget this because you could see, when she came in … she was just petrified.”

With the goal of facilitating integration into a refugee’s host community, Halaimzai explains how Amna gauges success: “What is being measured is joy and belonging and playfulness as a way of seeing if we’ve had an impact. We really try to create places that are joyful because joy is a way of building resilience. This is important because, otherwise, where do you pull that capacity to get out and stand in line for hours to get a meal? We don’t really talk about the importance of joy and kindness and the community connection, how important this is. Even in the context of things that are really, really dark, I think it’s even more important.”

Halaimzai explains that Amna’s programs take a nonclinical approach that is based on the “belief that the emotional responses that refugees are having are normal human reactions to what they’ve gone through.” She adds: “We don’t want to diagnose people with trauma or pathologize their feelings, and evidence shows that light-touch, nonclinical interventions to people going through these experiences can go a long way in supporting mental health and preventing long-term psychological disorders that might otherwise require clinical interventions.”

Since its inception, Amna has provided help for more than 10,000 refugees. The group now partners with like-minded organizations around the world to reach as many refugees as possible, providing trauma-informed care to refugees in Greece, Albania, Kosovo, Italy, and Pakistan who have arrived from dozens of countries including Syria, Afghanistan, Nigeria and Bangladesh, It is currently expanding its network by co-creating hubs and implementing Amna’s programs with organizations in Poland, Romania, Moldova, Ukraine, and Afghanistan. Halaimzai points out: “We follow a very specific methodology where we select organizations that are very embedded in their community — they’re not large NGOs — and we build a trusting relationship with them.”

Halaimzai is well aware that most refugees do not experience the kind of welcome and outpouring of resources that have been given to those from Ukraine. She points out that in situations in which political leaders and media in a host country express animus toward refugees, it intensifies their trauma. When refugees are vilified publicly, they “arrive to more suffering, to even more hostility, and this can compound trauma even more.” Considering that she has worked in several humanitarian crises, from the Turkish/Syrian border to Calais and Greece and now on the Polish border, Halaimzai was asked by the news television network French 24 if she sees a disparity in how different communities of refugees are treated. While commending the international support for Ukrainians, she said, “Absolutely — there is clearly a difference. There’s a recognition these people [Ukrainians] have been through really quite difficult and traumatic experiences, and as they come out, there’s support available to help them to recover and to help prevent additional suffering as they come to another country. This is something not happening for a lot of refugees coming out of Syria or Afghanistan.”

A similar opinion was recently shared by United Nations High Commissioner for Refugees Filippo Grandi. In a statement marking the International Day for the Elimination of Racial Discrimination, he acknowledged: “We also bore witness to the ugly reality, that some Black and Brown people fleeing Ukraine — and other wars and conflicts around the world — have not received the same treatment as Ukrainian refugees.” According to Amnesty International, there are over 84 million forcibly displaced people worldwide, 26 million of them refugees, more than half of whom are women and children.

The therapeutic approach Amna takes with its groups, particularly those for youth, is both significant and profound in the context of an international bias in humanitarian response and media coverage. Halaimzai explains: “Their self-worth develops because they are in a safe space, they’re working with other young people who share their experiences, and they can begin to imagine a future that is different than what is being reflected back at them when they go onto social media or watch the news. That really affects people when the only image that you see is a negative one. And you can see a different type of future that develops in their imagination, and they can begin to see themselves free of fear, free of pain; with a sense of agency and self-worth about their life.”

In addition to providing services directly to refugees, Amna offers training to workers and volunteers who are themselves helping refugees, offering support and the tools required to strengthen their own well-being and emotional regulation. By training those who receive refugees — humanitarian aid workers, nurses, teachers — Amna provides care to prevent trauma and burnout on the front lines. “It sucks to hear, day after day, the darkness and cruelty that we’re capable of,” Halaimzai explains. In collaboration with the Ukraine Association of Psychologists for Grief and Bereavement and Compass Pathways, Amna is also providing well-being support to Ukrainian psychologists to support their work with children and families caught in war.

Liana Gent, executive director of Netherlands-based ISSA (International Step by Step Association, one of Amna’s partner organizations, calls Amna “a group of dedicated, compassioned professionals with the ability to combine a high level of knowledge and skills with personal experiences with violent conflicts. … They believe in the strengths and capacities of communities affected by conflicts and forced displacements and support them on the journey of recovery.”

Halaimzai’s essential message resonates for people bearing witness to Ukrainian women and children fleeing their besieged country. “One of the reasons I do this work is because I’ve seen it work,” she says. “If you hold people in a way that acknowledges their suffering and pain and you support them and you care for them, it does make a huge difference.”