The implementation of the EU/Turkey-deal in the 18th of March 2016  resulted in a dramatic reduction of migrant flows but with a very high cost on migrant’s MH. MH care needs have therefore increased and became more complex. Yet, MH service provisions have not adapted to this, and remain inadequate due to lack of resources and the difficulty to offer this more complex MH care appropriate for the diversity of migrant populations. In addition, independently of MH service provision, current traumatic stressors were reported by most migrants, which led to a prolonged suffering. To our knowledge this was the first qualitative study that was conducted among migrants being stranded in a contained space of a country perceived by most as a transit destination in Europe, and what factors influenced their mental health.
In our findings three main themes were generated: institutional abuse, CTS and lack or inefficiency of MH service provision, which merit attention.
Research on institutional abuse and the variety of settings in which it is taking place is still ongoing with different approaches towards its definition . In our research, the term institution refers to the setting where psychological abuse can be expressed and analyzed in the context where, “the abuser holds a position of trust and authority over the abused one” . This definition would include the camps on Lesbos Island. From our findings, the main camp authorities, who are responsible for the provision of accurate information on asylum procedures, security and proper living conditions did not fulfill their protective role. On the contrary, as was repeatedly expressed by most of the participants their behavior was more of an abusive kind.
Chetail and Brauenlich suggest that stranded migrants, independent of nationality are commonly subjected to a wide range of psychological abuses and violations committed by a range of actors and institutions . Literature on institutional abuse frequently includes groups of people that are in need of care like those within a psychiatric institution  or within institutional care for the elderly . It is commonly characterized “by the systemic destruction of a person’s self-esteem through psychologically abusive tactics” . Although psychological abuse inside psychiatric institutions or institutions for the elderly cannot fully account for the devastating life conditions of the refugee camp, the vast majority of migrants expressed the dependency on governmental and camp authorities.
Migrants reported being left with no reference point to provide answers regarding their prolonged stay and the daily struggle in inhumane living conditions. Camp authorities are unable to provide sufficient answers or solutions regarding the absence of proper protection, their future options, the humiliation of waiting in lines for basic services like water and food provision and the constant fear of deportation. We therefore consider that under the EU/Turkey-deal abusive relationships are formed, where the perpetrators are the camp authorities like EASO, GAS and police. On the other hand, the victims, who are the migrants, are obliged to spend a prolonged period of time in a camp environment that systemically destroys their self-esteem.
Continuous traumatic stress (CTS)
It is argued that the effects of victimization through psychological abuse and the presence of continuous stress can lead to severe trauma . Displaced populations by persecution or warfare find themselves living in contexts where the traumatic stressors are continuous , and/or in a state of permanent emergency. A study that was conducted in Serbia among migrants travelling along the Balkan route, showed that out of 992 migrants who attended MH consultations, 383 had experienced at least one but even up to three traumatic events during their journey since leaving their country of origin . Continuous fears of being deported to Turkey or the country of origin, continuous pursuit of a vulnerability status, continuous threats on the personal sense of safety are some of the examples migrants experience on Lesbos Island. These ongoing and realistic threats demonstrate a consistent focus on present and future stress.
In the literature there are different opinions whether CTS can actually lead to more serious psychopathological symptoms, like post traumatic stress disorder (PTSD), major depression or anxiety disorders . A study from Israel connects CTS with the development of PTSD, complex PTSD or acute stress disorder . Another study by Bleich et al. in a general population in Israel found a moderate psychological reaction under repeated traumatic experiences. They suggest that prolonged exposure to traumatic events may increase the level of severity of other types of psychopathology more than it increases the risk for PTSD .
In our study setting, the participants demonstrated a variety of symptoms under prolonged traumatic stress: self harm, substance abuse, suicide attempts, cognitive impairments, and isolation. It is unclear whether these symptoms are directly connected with CTS. Recent research has mainly focused on examining psychopathological reactions under continuous traumatic stress comparing factors such as type and duration of exposure, geographical context and ethnical identity [38, 39]. Further research is needed in order to demonstrate whether individual perceptions, specificities of the camp living condition, characteristics of traumatic stress and cultural perspectives are connected with the above symptoms.
MH service provision
Individualized MH provision is difficult due to the complexity and the lack of experience in similar settings were current traumatic stressors are always present. Since the setting of our research is relatively new, the adaptation of MH services for migrants needs is challenging and often blurred by the various cultural perceptions each nationality has.
People experiencing traumatic events often search for explanations and meanings of the context where such events are taking place. Cultural beliefs concerning misfortune or loss are shaping individual’s attributions. This often leads to a return to their cultural and traditional explanatory systems that dissociate from western conceptions . The complexity of providing such context-specific MH care can lead to prolonged untreated psychological problems which enhance the risk for the development of psychiatric symptoms. Lack of resources in the delivery of proper psychiatric care is often directing migrants to devastating alternatives such as self-harm, substance abuse or self- medication. The need for MH interventions for migrants and refugees has been stressed by studies in different contexts whilst also models for adaptation of MH services to migrant’s characteristics have been proposed .
The need for MH service provision for migrants, and their efforts to provide access to MH services in extremely harsh conditions, was described by the MSF medical team in Croatia . This was also characteristics by the high numbers of consultations in MSF Lesbos clinic and the reports of professionals. Despite the differences in context, the need for creating a safe space away from the daily living stressors is a common goal for service providers. Continuous stress is a characteristic of inadequate living conditions. However, when it is combined with social and physical impairments, the request for MH interventions is an important determinant for the MH of migrants. In order to provide standards for MH service provision, thresholds should be set for identifying those in need, taking into account the cultural norms through the participation of communities in the development of MH action plans .
The decision of the EU Commission and the Turkish and Greek governments to implement the EU/Turkey-deal in an effort to discourage migrant flows from Turkey to Europe has come with a very high price. Other such similar deals with Libya, Afghanistan and West Africa are likely to have similarly devastating effects on the life and health of migrants.
It has been well documented that, in some cases, “the symptoms of CTS, tend to diminish dramatically or completely resolve when they are no longer within harm’s way” .
Possible solutions to end CTS of the migrant population on Lesbos Island require an immediate stop of the institutional abuse, decongesting the islands by transferring people to the mainland, by improving the living conditions, and providing access to information and clear asylum procedures for everybody.
Strengths and limitations
Strengths of this study were that the verbatim transcripts of the KIs were re-evaluated by themselves prior to analysis. The study included participants from both camps as well as KIs which allowed triangulation of the data. The migrants were recruited by the HP-team who know the population well, and could guarantee that the inclusion criteria were maintained and an appropriate mix in terms of age and status were grouped. In addition, the CMs that were present during the FGDs and GIs are not only translators but familiar with the respective cultures of the interviewees. Hence, misinterpretations of the participants’ accounts were minimal. On the other hand, using CMs created a second layer of communication, and although post FGD debriefings took place, it is possible that some information was missed. However, quality assured as much as possible through the reevaluation of the translation by the same CM who translated during the FGD.
Other possible limitations include: results refer to the particular period in which the study was conducted due to the constantly changing context of migrant population. It was also not always possible to recruit a group of 6-12 participants .The PI, being Greek, was in some occasions associated with the Greek government, which provoked in some participants a hostile response, which potentially may have biased their perceptions.
The fact that the PI and co-investigator were identified as MSF staff may have created expectations amongst the participants, and consequently created a response bias. However, this was surpassed through the detailed explanation of their role and the objectives of the study, reinforcing the knowledge that no direct benefit could be obtained by their participation.
A serious security incidence in Moria, which occurred at the same time as the FGDs might have influenced participants’ responses. Lastly, one KI out of eight had less than one year of working experience with migrants in Greece.