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The pain of exile

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Science  19 May 2017:
Vol. 356, Issue 6339, pp. 682-685
DOI: 10.1126/science.356.6339.682

Long-persecuted Yezidis unite to cope with the mental stress of forced migration.

PHOTO: © EMRAH YORULMAZ/ANADOLU AGENCY/GETTY IMAGES

Hazim Shingali and his family had no time to gather their belongings on 3 August 2014, when they heard that hundreds of armed Islamic State (IS) group fighters were storming toward their town of Sinjar in Iraqi Kurdistan. The 22-year-old college student, his parents, and his five younger sisters fled on foot to an arid mountain near the Syrian border, along with about 50,000 other Yezidis, members of a religious minority.

“We did not have enough water and food. We all ate the leaves of trees,” Shingali says. Members of the IS group massacred 3100 Yezidis who stayed behind, according to a study published this month. The group also abducted some 6800 women and children, many of whom they tortured, raped, and forced to convert to Islam. Shingali's family hid on the mountain for 10 days before escaping in a 3-day march to Syria and later to a refugee camp in Turkey. “Many women and children died of thirst or hunger,” he says.

Half of his family sought asylum in Germany, but they didn't have enough money for everyone to go. Shingali and his sisters, then 10 and 14 years old, stayed in Turkey for a year and then made it to Greece. But by March 2016, Germany had tightened its borders, stranding the siblings and more than 3000 other Yezidis in Greece.

Four years after the attack, Shingali and his family have escaped grave bodily harm. But like thousands of other exiled Yezidis, they are still dealing with the psychological aftermath of a forced migration that tore families apart. When political or religious violence drives people from their homes, “there's confusion, loss, a rupturing of all sorts of bonds,” says cultural psychiatrist Laurence Kirmayer of McGill University in Montreal, Canada.

Two weeks after the Islamic State group attacked her hometown of Sinjar in 2014, a Yezidi woman takes shelter with her baby outside Dohuk, Iraq, unsure of her family's future.

PHOTO: © AHMAD AL-RUBAYE/AFP/GETTY IMAGES

According to Kirmayer, Yezidis serve as an extreme case study of the psychological challenges that refugees face at every stage of forced migration, from the initial trauma of violent upheaval to the stress of uncertain asylum status and eventual resettlement. In a 2016 study of Iraqi Yezidi adults in a Turkish refugee camp, nearly 30% showed symptoms of both posttraumatic stress disorder (PTSD) and major depression.

Yet psychologists and psychiatrists working with Yezidis today also note their remarkable resilience. This stems in part from their tight-knit communities and the rituals and storytelling traditions that have helped them weather centuries of persecution, says Jan Kizilhan, a German psychologist of Yezidi descent at Baden-Württemberg Cooperative State University in Villingen-Schwenningen, Germany. “Yezidis know what it means to survive genocide,” he says. “It's in our music, our narratives, our behavior.” By studying how Yezidi refugees are coping, he and others hope to learn how to better support the mental health of the more than 60 million people worldwide who have been forced to leave their homes.

Because they are targeted for their religion, Yezidis suffer not just as individuals, but as a group, says Andres Barkil-Oteo, a psychiatrist with Yale School of Medicine and Doctors Without Borders who has worked with Yezidis in Greece. So the traditional Western model of one-on-one, individualized psychological treatment is not always adequate, he says. “The problem is collective—how do you treat a community?”

YEZIDI RITUALS MAY TRACE BACK to nature-worshiping traditions of ancient Mesopotamia, although their monotheistic religion contains elements of Islam and other faiths. In addition to one God, Yezidis worship seven divine beings, including a peacock angel called Tawûsî Melek. Yezidis believe that souls are reborn until they achieve perfection, says Khanna Omarkhali, a scholar of Yezidi religion at the University of Göttingen in Germany. One can only be born a Yezidi; no conversions are allowed. Directed by a spiritual leader named Baba Sheikh, Yezidism is mostly an oral tradition, with few, if any, texts.

That lack of texts has left Yezidism vulnerable to misinterpretation, including the accusations of devil worship that the IS group used to justify slaughter and rape and that have fueled persecution of Yezidis for centuries. Yezidis consider the 2014 attacks the 74th genocide in a series dating back to the Ottoman Empire.

Today, about 420,000 Yezidis remain in Iraqi Kurdistan, with 350,000 displaced in formal and informal camps. About 300,000 are scattered throughout about a dozen countries worldwide, with the largest population in Germany, says Murad Ismael, executive director of the Yezidi advocacy group YAZDA in Houston, Texas (see graphic, p. below). He fears that the genocide may sever Yezidis from their sacred sites in the Middle East forever.

Yet throughout their ordeal, Yezidis have maintained a common core of belief and culture. At a refugee camp called Faneromeni in northern Greece last December, Shingali, his sisters, and 20 other Yezidi families were preparing for a holy day in a crumbling two-story building surrounded by industrial lots and dormant potato fields. Women chopped parsley and tomatoes for the holiday meal while men shared cigarettes outside and stoked fires. Everyone wore bracelets of twisted red and white thread, which Shingali said symbolize peace and love.

Driven from their homes because of their religion, Yezidi refugees in Syria celebrate the liberation of Sinjar in Iraq.

CREDIT: © JOHN MOORE/GETTY IMAGES

Few in the camp felt festive, however. One of Shingali's sisters, now 17, sat on the floor in the room the siblings shared, fiddling with the bracelet on her wrist. When she tried to speak, her words stopped in her throat in a series of violent hiccups. A psychologist who visited weekly attributed the worsening speech impediment to stress, Shingali said.

The strain of becoming a refugee can exacerbate existing problems and eventually develop into mental illness. According to a 2016 survey of 38 Yezidi children in a refugee camp in Turkey, all had symptoms of at least one psychiatric illness, with sleep disturbance and depression the most common. In a second 2016 survey of 238 Iraqi Yezidi adults who had recently fled to a camp in Turkey, 40% had symptoms that fit a diagnosis of depression or PTSD.

Diagnosing mental illness in refugees is difficult, Barkil-Oteo says. People's normal reactions to poor living conditions and uncertain status are hard to disentangle from symptoms of an anxiety disorder or depression. At the same time, signs of distress are easy to miss because people vary in how they express suffering. The terms that many Yezidis use to describe their psychological burden—“heavy heart” or “burning liver”—don't appear in the Diagnostic and Statistical Manual of Mental Disorders.

CREDIT: G. GRULLÓN/SCIENCE

Yet researchers studying refugee mental health have made great strides over the past 20 years, says physician Richard Mollica, director of the Harvard Program in Refugee Trauma in Cambridge, Massachusetts. In the 1980s, “we had no idea how to provide treatment” for people fleeing violence, he says. Now, tools such as a checklist of traumatic experiences and symptoms that can be adapted to most cultures have helped identify mental health needs shared by many refugees, he says.

Maggie Schauer, a psychologist at the University of Konstanz in Germany, is helping treat more than 1000 Yezidi women who escaped from the IS group. Kizilhan helped bring the women to a small town in Germany's Black Forest for psychological treatment. Although classic PTSD focuses on the aftermath of previous events, Schauer says these women still experience fresh trauma when they hear of assaults on relatives and friends still captive in Iraq.

For example, one woman recently learned that her two young sisters are missing. She feels guilty for not being there to protect them, Schauer reports. “She says, ‘I can't sleep, because I know what [the IS group] will do to them at night.’” When such news arrives via WhatsApp and Facebook, the women often experience depression, nightmares, flashbacks, and hypervigilance—an ongoing sense of threat.

The woman's experience shows how Yezidis experience trauma collectively. When someone is attacked simply for being Yezidi, their compatriots suffer even if they don't know the person, Kizilhan says. For example, in February, the community saw a video that showed two Yezidi boys apparently forced to convert to Islam and then carry out a suicide bombing. “Every Yezidi felt that,” he says.

The IS group's attacks are so traumatic in part because they violate the strictest laws of Yezidi society—taboos against conversion and sexual relations outside the community—and so isolate victims from their own people. “Traditionally, in Yezidism if a person has accepted another religion even once, they are not able to come back,” Omarkhali says. Women raped by outsiders have faced similar ostracism. “When we take Yezidi girls from Iraq to Germany, they can be very confused,” Kizilhan says. “Are they Yezidis, are they Muslims?”

AT FANEROMENI, a man named Falah who was once a barber in Iraq invites a guest into the room that he shares with his family. Everyone drinks tea and smokes cigarettes, and Falah brings out a stringed instrument called the tembûr. He plays a song about the sadness of leaving Iraq while his two toddler boys bob up and down, kicking their feet to the music. Next, Falah plays a second song about his hope for relocation to “anywhere that's good for life,” he says.

Yezidis often prefer to talk about ferman—their history of genocide and forced migration—than about their own traumatic experiences, Kizilhan says. For Western psychologists trained to focus on the individual, “it can be frustrating when someone begins their own story by talking about their great-great-grandparents,” he says. But those collective, historical stories can be helpful. “Talking can bring more clarity about what happened before, during, and after a trauma, which then opens the door to begin talking about a brighter future,” he says.

Through a technique called narrative exposure therapy (NET), Schauer uses storytelling to help the Yezidi women in Germany heal. Together, therapist and survivor create a narrative of the survivor's life from birth to the present, putting the most disturbing events, discussed in detail, in a broader context. In more than a dozen controlled trials across cultures, the approach has reduced symptoms of PTSD, says Schauer, who helped pioneer the method. Unlike therapies that focus on a single event, NET accounts for the importance of cumulative trauma. The approach reflects robust, growing scientific evidence that the number of traumatic events a person has experienced is the most important predictor of PTSD and depression, Schauer says.

NET also incorporates ritual. Survivors use flowers and stones to lay out good and bad life experiences. In working with Cambodian refugees, psychiatrist Devon Hinton of Harvard Medical School in Boston encouraged patients to make customary offerings to the dead. Doing so can help assuage recurrent nightmares involving visits from deceased relatives. For Muslims, practices such as ritually washing the face, arms, and feet—signifying spiritual purification—can help refugees recover a positive self-image.

The ability to reconstitute community of some kind is one of the most potent protective factors for refugee mental health, Kirmayer says. For Yezidis, Kizilhan and others pushed for a collective response to the rapes and forced conversions: a change in religious laws to allow women and forced converts to again become official Yezidis.

Baba Sheikh and other religious leaders agreed. They developed a new, collective ritual in which a sheikh declares that Yezidis who were raped or forced to convert are once again true Yezidis. The ritual “blesses these women as Yezidis,” Omarkhali says. If boys and men manage to escape captivity, “they are accepted back into the community,” she says. The ritual works, Schauer says: “The women strongly believe that this blessing makes them part of the group again.”

Yezidis stand out for the communities they forge in refugee camps, which they often set up on their own, separate from Muslims and other groups. That the Faneromeni camp contained only Yezidi refugees “was no accident,” Barkil-Oteo says. It formed when dozens of Yezidis, saying that people from other groups had insulted them, together walked out of a larger camp and demanded their own location.

With an established leader and defined roles for community members, Yezidis at Faneromeni seemed to have an easier time than other groups solving challenges in camp, Barkil-Oteo says. When one of his patients had to be hospitalized, for example, the group designated two people to always stay with the patient—an impressive display of social support, he says. In Germany, the women Kizilhan works with “are like sisters; they take care of each other,” he says.

Despite their penchant for sticking together, the current exodus is testing Yezidi unity, Kizilhan says, as Yezidis from different regions and perhaps different religious practices resettle in new host countries. Without a safe haven in their ancestral homeland, “I'm not sure what will happen” to the community in coming decades, he says.

A Yezidi woman receiving psychological treatment in Germany ritually represents her life story, using stones to mark traumatic events and flowers to show happy events, as part of Narrative Exposure Therapy.

PHOTO: © INKA REITER

IN THE LONG TERM, the traumas Yezidis experienced in Iraq are unlikely to be the only important factors in their mental health. What happens to them in their new homes also is crucial, Kirmayer says.

Discrimination and social isolation in a new country can boost rates of mental illness, says Morton Beiser, a psychiatrist and epidemiologist at Ryerson University in Toronto, Canada. In a June 2016 study in The Journal of Nervous and Mental Disease, Beiser found that refugee children had higher rates of depression, anxiety, and other ills than other migrant children from the same countries. Some people might assume that past traumas explain the elevated rates. But Beiser's team found that the differences among children were best explained by what happened after arriving in Canada. Refugee children experienced more discrimination: Peers more often called them names, hit them, or swore at them, and some teachers treated them unfairly.

Today, some countries are working to reduce such discrimination (see p. 686), although some strategies, such as splitting refugees into smaller groups, may test Yezidis' bonds with each other. In recent years, Germany has provided a tolerant environment, says Sebastian Maisel, a professor of Middle Eastern studies at Grand Valley State University in Allendale, Michigan. In the 1990s the country opened its borders to all Turkish Yezidis after reports of human rights abuses. Roughly 20,000 Yezidis came, leading to a generation of well-integrated German Yezidi professionals, including Kizilhan, who immigrated to Germany as a boy. “It was a model of success,” Maisel says.

Shingali says he hopes his family will repeat that history. Throughout the winter, the girls still were not sleeping, and their psychological state deteriorated. Then, in March, he and his sisters were approved to go to southern Germany, where the family will be reunited. On the cusp of yet another journey, Shingali voices the wish of refugees everywhere: “I hope the future will be better.”

  • * This reporting was made possible by a Rosalynn Carter Fellowship for Mental Health Journalism.

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