Nazli Sinem Koytak Michael Bronner

The number of Syrian refugees passed the 1 million mark in March and continues to climb as the civil war grinds on. As of this writing, the United Nations High Commission for Refugees cites 1,245,437 registered Syrian refugees, with more than 200 thousand awaiting registration. The actual numbers of Syrians fleeing into Jordan, Lebanon, Egypt, Iraq and Turkey are much higher, as some 7,000 to 8,000 Syrians seek sanctuary and shelter across the borders every day, many going unregistered (the number of internally displaced Syrians is thought to be about 2 million – some ten percent of the population). 

Nearly 300 thousand of Syria's registered refugees are in Turkey, accommodated in 17 tent- and container camps over eight provinces. Resources are severely stretched. In just a recent 24 hour period, 304 fleeing Syrians were admitted at the Turkish border, with 226 others agreeing to return to Syria voluntarily. 

Physical shelter and security are critical, but myriad and more complicated battles continue in the minds refugees once they're out. Nearly all have suffered trauma of one kind or another because of the war or have family members still very much at risk inside Syria. The reality is that the prospects for any future peace – and, if it is to be a lasting one, reconciliation – depend as much upon the outlook of the refugees as it does the daily shifts on the battlefield at home. 

Six months ago, thirty-four-year-old Nazli Sinem Koytak, a clinical psychologist from Istanbul, answered an ad for therapists to work with Médecins Sans Frontières/ Doctors Without Borders on the Syrian border. She is now part of the MSF team living and working in Kilis, the Turkish border town closest to Syria’s ancient and now war-torn second city, Aleppo. She was interviewed via telephone and Skype by Warscapes editor Michael Bronner earlier this week:

Michael Bronner: Tell me a little bit about your background and training…

Nazli Sinem Koytak: I studied psychology as an undergraduate in Istanbul, then clinical psychology for my masters. I worked for five years in hospital-based psychiatry clinics with different populations, but mainly with children and adolescents. In my masters thesis research, I worked with children studying how they conceptualize death and cope with it. This was in Istanbul, with a normal population of children between 7- and 11 years old. 

MB: What were some of your key findings?

NSK: The main finding, which is also very important for my clinical practice, is that when adults try to shelter children from anything associated with death, which is of course a very common practice, it makes them much more anxious and terrified than if they were allowed access to this integral part of life. I think children are very much aware of what death is, whether they can put it into words or not. They can handle it if we give them the chance to handle it. Death is part of life, like the falling of leaves or the passing of older people, and if grown-ups could handle death more easily, in a psychologically healthy way, children would as well. Grown-ups contaminate children’s concept of death by making it much more fraught with anxiety. 

MB: Your research dealt with death generally, rather than a traumatic context.

NSK: Exactly. 

MB: And then war breaks out in Syria…

NSK: And then war breaks out -- 

MB: What gave you the idea to apply for the MSF job? 

NSK: For the last three years, in addition to my other research, I have been deeply interested in conflict resolution. Now I’m in the middle of everything I’ve studied theoretically in books. I was very interested in the political climate and the social movements emerging as the Syrian conflict began.

To tell you the truth, I was very enthusiastic, but also very hesitant at first about the idea of working with refugees. I’d previously worked with refugees, in my fourth year at university, when I volunteered organizing psychosocial activities with Chechen refugee children. But I saw the MSF advertisement online, had a face-to-face interview and a couple of Skype follow-up interviews with MSF staff in the field. They told me I got the job, and I packed my bag. 

MB: Tell me about your work, and some of your impressions of the border and the refugees you’re working with?

NSK: I’m working with MSF as a clinical psychologist. I do individual and group psychotherapy and psychosocial activities. Here, because of scarce human resources, we deal with all age groups...I have never been to this part of Turkey before. I’m told by my MSF colleagues that this is one of the least difficult assignments in terms of living conditions for the staff (laughs). We have electricity. We have Internet. We have hot water. For the refugees, this is not the case, for sure. For someone like me coming from Istanbul, this is like living in a desert. We can hear the bombing all night. 

Sinem Koytak provides psychological support for Salwah Mekrsh, 18, who was shot by a sniper in Aleppo and is now a refugee in Kilis.


MB: What are you’re finding clinically…

NSK: In the case of an earthquake or some sort of event with a beginning and end, you have a trauma and then a period of healing. But in our context, my Syrian patients are living through a past trauma and an ongoing trauma every day. Many of the women here have relatives still inside Syria. They have brothers, husbands or relatives who died or are missing in Syria. There is little or no contact with those across the border. They just wait for bad news. This is something incredibly paralyzing for people here in terms of their psychological wellbeing. It is very complicated. You cannot work through grief from past events while the war is ongoing. A healthy process of mourning is impossible, and the problem is exacerbated by the conditions in the camps. The future is extremely uncertain, and this creates anxiety – you can sense it in everybody, whether they are clinical or not. Depression is common, all anxiety disorders, and PTSD. 

As a general approach, this traumatic context can lead to any kind of psychological disturbances. It’s much harder for children because they cannot express themselves eloquently. Their mothers are depressed and anxious, which can limit attention to their children’s symptoms. It is understandable that the grown-ups are overwhelmed by their own issues of life and death, but the children are also really struggling. 

MB: How are the children’s reactions different?

NSK: Children don’t express themselves verbally a lot, or they are not able to so developmentally, so I work with them via play therapy or through art, mainly drawings. The drawings can provide a window into what they are thinking. The drawings typically deal with war – with guns and bombing. They are experiencing real terror. And all their games are related to the war. Every stick turns into a gun. Over and over they play these war games, to make some meaning out of it – that’s my interpretation. 

MB: Does playing war games help, then?

NSK: In my perspective, if not therapeutic, it is a way of acting out the reality they are in. Even in therapy sessions, they might play war games. It’s useless to tell them not to play these games. It’s a way to get them to take what’s inside and act it out – in a peaceful way. I think, when they play these games, voluntarily or not they give us a clue as to what they’re thinking and feeling. Also, I have clients – children – who just lay down. They are physically normal, but they are too depressed to do anything, even to play. These are much harder to reach than the others, because even if it’s painful to see the war reflected in play - fighting, dying, killing again and again - at least those that are active are expressing what is inside themselves. This is how they digest the reality. 

MB: Is there an equivalent for adults?

NSK: Aggressiveness and explosive anger is very common. There are many unique psychological symptoms for each client, but anger is very common. Relationships between husbands and wives – family relations – are very conflicted these days [among the refugees]. Family members are fighting a lot – sometimes even physically. There is underlying nervousness and anxiety. In some cases, family members prefer isolation rather than being together. There is a lot of crying. 

As you’ve probably inferred, I don’t have very many male clients. Most of the men are still in Syria.  The men that do come for treatment present with a range of social, physical and psychological problems…They are also very angry, and aggressiveness is a common symptom. Isolation and withdrawal is much more common among males. Also, people feel very insecure…Especially in the case of teenage girls and unmarried women, parents are very protective and/or conservative – probably more so than in previous life. This adds rigidity to their lives as refugees and makes life harder, even if it is for the purpose of trying to protect the weaker or more vulnerable members of the family.

MB: Is there also political anger?

NSK: It’s mostly personal anger – anger shown between family members – but there is also a higher social consciousness full of anger. For example, I had a client who lost three of her daughters in a bombing. She didn’t know or understand very much about the conflict between the government and the rebellion beforehand. I met her ten days after the bombing. She was still in deep shock. During one of her first outbursts she was swearing, and you could feel, really, how hot this rage was. It makes me very concerned. How will this kind of anger and rage be channeled? Generally, is there a way to heal when there are such intense emotions - and in some cases a desire for revenge - and turn these into something more constructive or more peaceful? It is very legitimate emotionally, but very worrisome.

MB: Well, is there a way to channel the rage?

NSK: There should be. There are some examples - in Rwanda, South Africa and other places. There are precedents for reconciliation. This is, of course, not MSF's field of work, but as I said, personally, I have been very interested in conflict resolution. There have hardly ever been clinical psychologists involved in these processes. But I am very much in the field, and when the war is over I am hoping to be part of developing strategies for healing after civil war without the residual hatreds morphing into new civil wars.