‘The phoenix that always rises from the ashes’: an exploratory qualitative study of the experiences of an initiative informed by principles of psychological first aid following the Beirut blast

ABSTRACT

Background: On 4 August 2020, an explosion occurred in Beirut, Lebanon. Hundreds of people were killed, thousands injured and displaced. An initiative was rapidly initiated to provide remote support informed by psychological first aid for the mental health of Lebanese young adults affected by the blast. However, little is known about recipients’ experiences of such initiatives.

Objective: This study aimed to qualitatively explore the experiences of supporters and recipients in the community-led initiative following the blast.

Method: We recruited a diverse sample of four supporters and four Lebanese recipients who took part in the Beirut initiative. Semi-structured interviews were conducted with participants. Reflexive thematic analysis was used to analyse the qualitative data.

Results: We developed five themes from the qualitative interviews, which highlighted ideas around accessibility, alienation, the relationship, elements of the safe space created by the initiative, and unmet needs and areas for improvement. Recipients described the detrimental impact of the blast on their mental health within the Lebanese context and beyond. Recipients and supporters elucidated complex experiences of the support and its impact.

Conclusions: Our findings suggest remote support has the potential to be acceptable for young adults in Lebanon. Further research into support informed by psychological first aid after similar crisis events is warranted.

HIGHLIGHTS

• Following the Beirut blast on 4 August 2020, an initiative was implemented to provide remote mental health support to Lebanese young adults.

• Reflexive thematic analysis was used to analyse qualitative data from interviews with supporters and recipients after support sessions were completed to identify themes across diverse experiences and views.

• Participants described a feeling of alienation after the blast, the development of a meaningful relationship between supporter and recipients, and gratitude for having a safe space to process and share difficult feelings. Possible avenues for improvement and implementation were suggested.

Antecedentes: El 4 de agosto del 2020, una explosión ocurrió en Beirut, Líbano. Cientos de personas fueron asesinadas, miles lesionadas y desplazadas. Una iniciativa fue rápidamente iniciada para promover el apoyo remoto informado por la primera ayuda psicológica para la salud mental de los adultos jóvenes libaneses afectados por la explosión. Sin embargo, poco se conoce sobre las experiencias de los destinatarios de dichas iniciativas.

Objetivo: Este estudio buscó explorar cualitativamente las experiencias de las personas que apoyaron y recibieron primera ayuda psicológica en una iniciativa liderada por la comunidad luego de la explosión.

Método: Reclutamos una muestra diversa de cuatro tipos de personas que apoyaron y cuatro destinatarios de apoyo que participaron en la iniciativa de Beirut. Se llevaron a cabo las entrevistas semiestructuradas con los participantes. Un análisis temático reflexivo fue usado para analizar los datos cualitativos.

Resultados: Desarrollamos cinco temas a partir de las entrevistas cualitativas, los cuales subrayaron ideas en torno a la accesibilidad, la alienación, la relación, los elementos del espacio seguro creado por la iniciativa, y las necesidades no satisfechas y las áreas de mejora. Los destinatarios describieron el impacto perjudicial de la explosión en su salud mental dentro y fuera del contexto libanés. Los destinatarios y quienes apoyaron compartieron experiencias complejas de apoyo y su impacto.

Conclusión: Nuestros hallazgos sugieren que el apoyo remoto tiene el potencial de ser aceptable para los adultos jóvenes en el Líbano. Se garantizan futuras investigaciones sobre el apoyo informado en la primera ayuda psicológica luego de una crisis similar.

背景：2020年8月4日，黎巴嫩贝鲁特发生爆炸。数百人死亡，数千人受伤并流离失所。迅速启动了一项举措，通过心理急救为受爆炸影响的黎巴嫩年轻人的心理健康提供远程支持。然而，对此类举措的接受者的体验知之甚少。

目的：本研究旨在定性探讨爆炸后社区开展举措中支持者和接受者的经历。

方法：我们招募了四名支持者和四名参与贝鲁特倡议的黎巴嫩受助者的多样化样本。对参与者进行了半结构化访谈 使用反思性主题分析来分析定性数据。

结果：我们从定性访谈中制定了五个主题，强调了有关可及性、梳离、关系、倡议所创造的安全空间要素以及未满足的需求和需要改进的领域的想法。接收者描述了爆炸对黎巴嫩境内外的心理健康造成的不利影响。接受者和支持者阐明了支持及其影响的复杂经历。

结论：我们的研究结果表明远程支持有可能被黎巴嫩的年轻人接受。有必要对类似危机事件后心理急救提供的支持进行进一步研究。

KEYWORDS:

• Beirut blast
• remote support
• psychological first aid
• qualitative
• trauma

PALABRAS CLAVE:

• Explosión de Beirut
• primera ayuda psicológica
• cualitativo
• trauma
• apoyo remoto

关键词:

• 贝鲁特爆炸
• 心理急救
• 定性的
• 创伤
• 远程支持

1. Introduction

On August 4th, 2020 in Beirut, Lebanon, 2,750 tons of ammonium nitrate exploded, causing destruction within 20 km of the blast site. More than 217 people were killed, over 7,000 injured, and 300,000 displaced (Amnesty, 2021). The Beirut blast exacerbated the sociopolitical unrest in Lebanon, including increased rates of unemployment and poverty, essential resource shortages (United Nations Office for the Coordination of Humanitarian Affairs, 2021), and an economic collapse (World Bank, 2021).

Cross-sectional data suggests a complex and deteriorating mental health landscape in Lebanon after the blast. A survey of 903 adults found that 10 days post-blast, 83% reported depressive symptoms, 78% reported anxiety symptoms, and 84% reported post-traumatic stress symptoms (Embrace, 2020). Another survey found post-traumatic stress disorder (PTSD) rates of 26% in a sample of Lebanese young adults after the blast (Zouki et al., 2022). The blast may have exacerbated existing mental health difficulties of Lebanese people, including depression, anxiety, and stress, which have also increased due to factors such as the coronavirus pandemic (COVID-19) and the collapsing economy (e.g. El Othman et al., 2021; Salameh et al., 2020). As a result, the already fragmented mental health systems with inadequate resources to provide integrated services in Lebanon may find it increasingly challenging to respond to the mental health burden that may be caused by its unique sociopolitical stressors (Noubani et al., 2021). Even with the combined efforts of government services and community-based organisations, innovative ways of supporting the mental health of Lebanese people are urgently needed.

Providing remote and scalable support may address the resource shortages and restricted mobility of Lebanese people, reducing the burden on mental health systems and non-government organisations (Naal et al., 2021). One option is the delivery of support informed by psychological first aid (PFA), an evidence-informed model which aims to equip practitioners with a framework to provide humane and practical support to people experiencing serious crisis events and mass trauma (World Health Organisation, 2011). Laypeople and volunteers can be trained to deliver support as preliminary care.

Although the evidence around PFA’s effectiveness is limited, it has been used within contexts of disaster and humanitarian crises to support people psychologically, increase local capacity, and strengthen public mental health systems (Dieltjens et al., 2014; Fox et al., 2012; Sijbrandij et al., 2020). In Lebanon, PFA has previously been used in the context of supporting Syrian refugees, with research suggesting improved readiness and knowledge of field workers (Akoury-Dirani et al., 2015). Indeed, PFA may be used in the context of mental health problems during COVID-19 (Minihan et al., 2020) and organisations used remote-delivered PFA to support people after the Blast in Lebanon (Embrace, 2020; International Medical Corps, 2021). Despite the need for wider-scale implementation of support in such crisis’ events, there is a dearth of research on PFA and similar interventions’ impact on those who are being offered support in Lebanon or internationally.

This study aimed to qualitatively explore the experiences of supporters and recipients in a community-led initiative that was developed to contribute to the rapid response to support the mental health of Lebanese young adults following the blast.

2. Methods

2.1. Beirut initiative

The initiative was advertised on one of the authors’ (AB) Instagram story a week after the blast. This included a call for volunteers to provide informal support and an invitation for those struggling from the aftermath of the blast who wanted to seek remote brief informal support to contact the founder on the social media platform. A small number of the founder’s contacts also shared the post on their accounts to maximise outreach. Interested individuals were invited to contact the founder and were emailed information about the support sessions.

Seven individuals volunteered to be supporters (BCFC, NAS, RAH, AC, AR, ASC, and JSH), all of whom had at least an undergraduate degree in Psychology and varying prior experiences of providing clinical support (such as psychological assessments, guided self-help, and group interventions) to people with mental health difficulties in various settings (for up to four years). BCFC, AB, NAS, RAH, GLB, AC, AR, ASC, and JSH were all completing their master's studies in clinical mental health sciences and related courses. Volunteers were invited to a remote meeting to clarify the initiative’s objectives, format, and delivery. As the initiative was led and delivered by non-clinicians to rapidly address the psychological needs from the blast, an informal support format was proposed. Supporters were emailed the freely accessible PFA guide for field workers supporting disaster survivors (World Health Organisation, 2011) and a brief which explained the context of the blast and outlined their responsibilities in the support sessions. A remote one-session (1 h) training session was delivered by JB, a consultant clinical psychologist and associate professor with specialist expertise in trauma and mental health, which covered the core principles of PFA to complement the PFA guide and brief. The planning, delivery and evaluation process was supervised by JB. Any difficulties in sessions were discussed confidentially with JB as needed.

Due to the initiative being a pilot and delivered by volunteers, capacity for outreach and delivery was limited. However, all six individuals interested in receiving support were offered the intervention. There were no exclusion criteria. Recipients were randomly matched to a supporter and emailed information outlining the parameters of the sessions and contacts to local services and organisations, including crisis hotlines and emergency services.

2.2. Intervention

The support comprised of six hours of contact that were remotely delivered in English across 6–8 sessions between August 2020 and January 2021. The intervention was informed by the WHO PFA model, which aims to equip practitioners with a framework to provide humane and practical support to people experiencing crisis events. Elements of PFA that the intervention contained in every session included promoting safety through assessing and supporting basic needs (including if recipients had access to food, water, and shelter, whether they were in a safe place, and facilitating active problem-solving if this was not the case), hope through active listening and emotional support (including praise for their efforts and validation of their experiences), connectedness, and self- and community efficacy through signposting to resources, services, and social support (Ruzek et al., 2007). The coverage of these elements in each session were integral to the intervention and explicitly laid out in the brief and single-session training provided by JB prior to the delivery of the intervention. Supporters were equipped with information about local services and organisations if necessary to refer recipients to more intensive support. Although the intervention did not strictly adhere to the WHO PFA protocol (2011), it addressed four essential elements common across all PFA models, except explicit calming/breathing techniques as recipients were not in extreme states of distress in sessions (Hobfoll et al., 2007).

The intervention used supporters who had not directly experienced the blast but shared similarities with recipients (i.e. age, life stage, student status). This is similar to other volunteer-led trauma interventions, such as Trauma Risk Management, which aims to use (non-trauma exposed) supporters to detect and support those at risk of developing mental health problems after potentially traumatic experiences (Creamer et al., 2012). To reduce risk for supporters, the intervention was also delivered remotely using Zoom, a secure video conferencing platform.

2.3. Ethics

All procedures were approved by the University College London Research Ethics Committee (Ref. 21101/001).

2.4. Participants and procedures

Adhering to the MRC process evaluations of complex interventions guidelines (Moore et al., 2015), we chose to use qualitative methodology to capture supporters’ and recipients’ experiences of the pilot initiative.

Convenience sampling was used where all seven supporters and six recipients were invited to take part in an optional interview. Those interested were asked to contact AB via email and were emailed the participant information sheet and consent form to complete. Semi-structured interviews were conducted by members of the initiative (AB, RAH, GB, and AR) by online video call with participants who provided written informed consent. The interview guide was drafted collaboratively by the team which consisted of mental health researchers, qualitative methodologists, and Lebanese people with lived experience of the impact of the blast. The interview guide covered the reason they chose to participate in the initiative, their experiences of previous support, their experiences of the Beirut initiative, and suggested areas for improvement (see Supplementary materials). Interviews were audio recorded and transcribed verbatim by the interviewer who conducted the interview. Potentially identifying information were removed from the interview transcripts and pseudonyms were used to protect participants’ anonymity.

2.5. Analysis

Reflexive thematic analysis (Braun & Clarke, 2006, 2022) was conducted by BCFC and AB as we wanted to take a naturalistic and phenomenological approach to understand participant experiences of the initiative. We sought immersion in the data by reading and re-reading the transcripts, writing reflective notes, and discussing potential themes. A sample of transcripts were independently coded and then potential codes combined into a coding frame that was applied to all transcripts. The coding frame was iteratively revised throughout as new concepts were identified. All coding was inductive, derived from the data, and not pre-determined by a priori hypotheses or theories. Themes were then developed from the coded data and refined with feedback from participants and the research team.

2.6. Quality

We adhered to the Standards for Reporting Qualitative Research Framework (O’Brien et al., 2014). To enhance the credibility of our results, we included multiple researchers in the processes of data collection, coding, and analysis, and presented our findings to the research team to discuss the validity of themes. One recipient who was interviewed reviewed the findings and provided feedback as a form of member checking. To increase the richness of our analyses, we have sought to be transparent about the research team, the perspectives we have taken throughout the study, and a lived experience account from the founder of the initiative. Quotes from participants are provided to evidence and substantiate analytic findings.

2.7. Reflexivity

The research team is a diverse group of researchers, representing a range of ethnic and cultural identities (including Arab, Asian, Lebanese, White European, White Irish, and White British). JB, who supervised the project, has more than 22 years of experience of working in specialist trauma and PTSD services and conducts research on trauma, mental health, resilience, and psychological interventions. In response to the Beirut blast, AB founded the Beirut Initiative with the support of the other co-authors, some of whom are Lebanese and others who bore no connection to Lebanon prior to this project. The heterogeneity of experiences and perspectives we brought to the research may have enhanced the quality and transferability of the findings, especially because of the input of lived experience of the blast’s impact. However, due to the closeness to the topic it was emotionally difficult for some research members. We sought to manage interacting characteristics of the research team with the research itself by taking an inductive approach to interpreting the data, working closely as a research team, and providing informal support to one another.

3. Results

Four supporters and four recipients volunteered and took part in the semi-structured interviews. Participants’ characteristics can be seen in Table 1.

Table 1. Participant characteristics (n = 8).

Characteristic		Supporter	Recipient
		Mean
Age		22.8	23.5
		Range
		21–24	23–25
		n
Gender
Men		1	2
Women		3	2
Geographical location
Lebanon		0	2
United Arab Emirates		1	1
United Kingdom		3	0
United States of America		0	1

Note: Geographical location refers to where the supporter/recipient were based at the time of the intervention.

Interviews were completed in September 2021 and lasted between 11 and 37 min. Through reflexive thematic analysis of the interviews, we identified five themes (see Table 2).

Table 2. Themes and subthemes identified from the reflexive thematic analysis.

Theme	Subtheme(s)
Access
Alienation
	Cultural and generational gap
	Physical and social isolation
	Emotional burden
	Unhelpful narrative of resilience
The relationship
	An unexpected bond
	Like having a friend
	An outsider’s perspective
	Seeing progress
	Cultural needs
Elements of the safe space
	Time to talk and be listened to
	Welfare: monitoring, maintaining, and signposting
Unmet needs and areas for improvements

3.1. Access

Both supporters and recipients reported finding out about the initiative on Instagram through posts shared by AB. Supporters were motivated to join for altruistic reasons and felt empathetic to those affected by the blast due to similar but different disastrous experiences of the pandemic and political unrest. The perceived importance of the initiative was an integral reason why supporters joined.

I think all these things that were happening around me really prompted me to try and take action and make a direct impact if possible. I didn't want to sit back and not do anything about it. When social media exposes so many things to you repeatedly, it’s really hard to ignore any of it … Being able to empathise and feeling like there is a familiar sense to the disaster has drawn me into taking part. (Lea, supporter)

On the other hand, recipients joined the initiative to receive free support. Some felt more inclined to access the support than formal treatment because of past negative experiences with psychological therapy and not knowing if they needed professional support.

I reached out for the initiative because I understood the consequences of the Beirut explosion and that I needed help. This was a free service so I decided to take it. (John, recipient)

3.2. Alienation

3.2.1. Cultural and generational gap

After the blast, recipients who moved abroad felt culturally disconnected to those around them, especially as the host countries in which they arrived did not speak their native language or share their culture. This made recipients feel alone, despite others trying to understand their situation.

When I went [to United States], most people I met were foreigners and American. I didn’t even have professors who were Lebanese or of Arab descent so I felt very alone. I didn’t know anyone there. Although I reached out to my professors and I told them what happened, and they were very nice about it, no one understood. (Farah, recipient)

One recipient reported feeling misunderstood by the older generation in Lebanon who experienced the trauma of the Lebanese civil war in the 1970s. There was a sense that they were desensitised by war and loss and therefore felt reduced sympathy for the younger generation who were facing trauma for the first time.

My surrounding here in Lebanon come from the generation of war that faced explosions every day. They were not as sympathetic to the sentiment that I saw death with my own eyes. (Petra, recipient)

3.2.2. Physical and social isolation

Those who were abroad at the time of the explosion reported feeling lonely being away from family and friends, and worried they were unable to be there to provide direct support. This was exacerbated by COVID-19 and associated social restrictions which prevented recipients from making new connections during this time and brought on a sense of being ‘stuck outside’ of Beirut.

We discussed a lot about the explosion that happened and a lot about his family and isolation. He was in a different country to his family at that time so there were a lot of worries surrounding that … I know what it’s like to be away from your family when they’re struggling and you’re not able to be there for them. (Lea, supporter)

3.2.3. Emotional burden

Recipients experienced significant distress after the blast but felt unable to talk to those in their direct social network about it. This was due to a feeling of guilt about potentially burdening others with their difficulties or exacerbating others’ trauma. Recipients acknowledged they needed a safe space to express their distress and feel heard which amplified the importance of this initiative.

We can talk amongst each other, but sometimes you’re already going through so much, your family is going through so much, your friends are going through so much, you feel like you don’t want to add to their burden, and you don’t want to listen to their burden. You just want an escape. (Farah, recipient)

3.2.4. Unhelpful narrative of resilience

One recipient expressed a perspective that is ingrained in Lebanese culture which promotes emotional resilience in the face of adversity. This unhelpful narrative permeated their sense of being and made it difficult to accept that it was okay to need help.

As Lebanese people, we have to be resilient. We have to be these strong people that emerge from the crisis. The phoenix that always rises from the ashes … We are all traumatised, we are all destroyed, nothing is going right, but somehow, we are expected to go by business as usual … This initiative showed me that asking for help is not something that is wrong … . (Petra, recipient)

3.3. The relationship

3.3.1. An unexpected bond

The relationship developed over time and supporters and recipients reported it as a positive experience. Although it was expected the supporter would listen, participants highlighted that an unexpected bond between recipient and supporter was formed despite fundamental differences, such as living in different countries and life experiences. Recipients felt they could trust their supporter, which was important in helping them open up about their distress.

I expected someone to show up and listen to me, but it was more than that. I truly feel like I built a bond with my supporter and they provided immense help. (Petra, recipient)

3.3.2. Like having a friend

The supporter-recipient relationship was described as different to a professional therapist-patient relationship; it was informal, supportive, and personal. Recipients felt they could talk about their distress openly on a regular basis without feeling like they were burdening the supporter. Recipients also reported that the supporters’ skills and experiences facilitated the conversation, including active listening and probing for information.

Because it was informal and it was someone close to my age, I didn’t feel like I needed to put on a show. It just felt like I was talking to someone I knew or could trust. It was really the same thing as talking to a friend who’s only job was to listen to you and ask you about your day, which is very selfish of you to ask of your friends … Someone who knew what to say or where to probe and where to stop. (Farah, recipient)

An important element of this relationship was the space to share experiences, views, and feelings. One supporter highlighted that because the recipients shared so much about themselves, it was easy to develop strong rapport and a friendship that went beyond the sessions.

3.3.3. An outsider’s perspective

It was important that supporters were disconnected from the recipients’ personal life and circumstances. To one participant, seeing their supporter empathise and listen to their experiences validated their emotional pain and its impact, which helped normalise their distress. This perspective was especially important for people directly affected by the blast because they were constantly in ‘survival mode’ and were unable to process their feelings.

To speak to someone who was not affected at all by the explosion, the empathy they had to the magnitude of what happened to us … made me realise that my pain is big enough to disrupt my life. The whole surrounding was just get back on your feet and be productive be active and you’re like “can we please pause for a bit and realise we just faced death?” … It’s not right for someone to go through this and to be okay the next day. Having this outsider’s perspective reinforced this idea that your pain is not in your head just because no one else can see it. It was traumatising. Seeing death with your own eyes at that age is not normal. (Petra, recipient)

3.3.4. Seeing progress

Supporters mentioned being able to witness significant progress in their recipients throughout the intervention which was emotional but rewarding and relieving.

To hear first-hand their experiences and the ways they were navigating their trauma and supporting other people around them through the trauma was really touching and empowering. It was humbling to be a part of their process. (Chelsea, supporter)

On the other hand, one participant expressed doubt about their role in their recipient’s improvements directly through the sessions. However, they were hopeful that the sessions could help enhance natural recovery after experiencing mass trauma.

As we progressed, I could see that there was a really big improvement through our support sessions … I’m not going to claim that it was of my own volition that he got better, but I think it was his own internal resilience … People are resilient and they can get back on their feet without talking to someone who’s tangentially related to mental health support in a way. (Lea, supporter)

3.3.5. Cultural needs

One recipient mentioned that because their supporter was from a similar culture, they felt that she was able to empathise and understand the context of the sociocultural pressure they experienced. This was emphasised by supporters who were not from the same culture as their recipients who voiced feeling like they were unable to fully understand their recipient’s experiences of the blast that had cultural and sociopolitical undertones.

My supporter happened to also have Arab descent so my supporter really sympathised with the Arab mentality that your surrounding can be very pressuring in the expectation for you to get back up quickly. Their understanding of that really helped me. (Petra, recipient)

3.4. Elements of the safe space

3.4.1. Time to talk and be listened to

Echoed by many participants, was the feeling that recipients could speak about anything they wanted and be listened to. Recipients found this regular protected time to speak to someone about themselves and their difficulties in a supportive, safe, and non-judgemental environment very therapeutic.

It gave me a nice cadence every week in an informal but very helpful way to discuss anything, help me think through things, make me feel better about some things, having a clearer mind. It was always at the same time, same day, it gave me a rhythm. I would look forward to it. (Ghassan, recipient)

The nature of conversations changed throughout the sessions and were different across participants but were all guided by recipients and what they thought was pertinent. Conversations mainly centred around recipients’ experiences of the blast and the feelings that came up. As the intervention progressed, conversations also touched upon general topics, such as recipients’ personal life, and not the Beirut blast exclusively.

I think a lot of it was me listening to them and providing them with a safe space to vent their emotions, feelings, and thoughts. The most important thing for the initiative was a lot of them feeling like they needed to talk to someone about their experiences of it and support them through the process of processing this very traumatic experience and giving them the space to explore how they feel about things. (James, supporter)

3.4.2. Welfare: monitoring, maintaining, and signposting

Supporters followed the key ingredients of PFA which consisted of checking if recipients were physically safe or in crisis and signposting them to local organisations or services when appropriate for immediate and urgent help. Supporters also checked with recipients if they had systems of social support in place.

Some supporters who had previous clinical experience in delivering psychological interventions felt that their skills inevitably influenced the support sessions. It was perceived to have potentially resulted in more ‘effective sessions’ and they felt more confident in delivering the intervention compared to those delivered by supporters with less experience.

For difficulties that were brought up during sessions that were beyond the initiative’s remit, supporters signposted their recipients to publicly accessible resources and encouraged them to seek professional support.

3.5. Unmet needs and areas for improvements

Although participants saw the support sessions as a much-needed initiative, they also voiced areas that needed improvement. An explicit structure of the support sessions was desired by supporters as many were worried that they would ‘overstep’ beyond the bounds of the informal support. Supporters were unsure about the therapeutic limits of their support and the relationship with their recipients.

We became friends and that’s something we found difficult because we didn’t know where the boundaries lay within the support sessions. Around session three, she asked me a question, “You know so much about me and you’ve been listening to me for so long, can I ask questions about you?” I told her, “Good question, I’m not actually sure”. (James, supporter)

Despite having brief training in the key principles of PFA and access to resources about PFA, supporters wanted more references and formalised training that covered what problems they may face in the support sessions and how to manage them.

Regardless of supporters’ motivation to learn and educate themselves about the sociopolitical climate of the place their recipients lived, they still felt inadequately informed and saw this as a barrier to the quality of the support.

I don’t think I walked into it equipped about the event itself. It was the root of why we were offering support and it was the most significant form of distress in supporters. It sat in such a heavy political context that we were not aware of. It would have been useful to have more information and briefing about that. In some sessions, I felt that I could not ask as many questions because I was not aware of some things or what would be sensitive or inappropriate. (Chelsea, supporter)

There were times that supporters felt helpless or doubted their efficacy in being able to support their recipients due to their own limitations and systemic factors that could not be addressed psychologically. Listening to recipients’ experiences of trauma was also difficult for some. Peer supervision (informal supervision provided by supporters to one another) was not set up due to the immediacy of the requirement for support and because supporters had competing demands outside of their voluntary role. However, supporters retrospectively think peer supervision may be a way to support supporters throughout the intervention and to learn from each other.

We were absorbing a lot of traumatic experiences. It would have been nice for space for supporters to also discuss how they felt, in a group or one-to-one setting, and how we feel supporting our recipients were going. That would allow us to learn about what other people are doing and inform what we’re doing to make sure that our support sessions are as helpful and useful as possible. (James, supporter)

4. Discussion

In this exploratory study, we aimed to qualitatively explore supporters and recipients’ experiences of an initiative for young adults who experienced the Beirut blast. We found that supporters volunteered out of altruism and empathy, but some experienced helplessness and wanted more support. Recipients accessed the initiative for many individual reasons, but many felt alienated. The support sessions created a safe space where recipients could feel listened to and have their welfare monitored. Participants developed supportive relationships, which in the context of the pandemic, loneliness, and emotional pain of the blast, was helpful for recipients. However, further comprehensive training covering the cultural and sociopolitical context of Lebanon was desired by supporters. Peer supervision amongst supporters was also suggested to improve the initiative.

There is a clear need for mental health support for people after the Beirut blast. The newly launched Embrace mental health centre in Beirut was a rapid response to the mental health needs of those affected by the blast providing outpatient and inpatient mental health services; they have successfully provided remote psychological support to more than 750 children and adults in Beirut and abroad (Embrace, 2020). Interestingly, only 12% of calls received by the Lebanon National hotline for emotional support and suicide prevention after the blast were exclusively related to the Beirut blast (Embrace, 2020), which suggests that the event itself may have exacerbated mental health needs existing prior to the blast or was a catalyst for help-seeking behaviours.

Our findings suggest that PFA-informed support delivered remotely by volunteer supporters could be a potentially acceptable way to support people after the Beirut blast. We highlight that this initiative is a useful and acceptable framework to guide supporters to provide basic psychological support, although further training is warranted. Training around the delivery of support and the sociopolitical and cultural context of Beirut was needed by participants. This aligns with previous qualitative research on PFA-informed intervention training for non-specialist volunteers to manage humanitarian crises, specifically the Ebola outbreak in Liberia and Sierra Leone, which found that although brief training is adequate for basic active listening skills, additional training is necessary to ensure treatment fidelity (Horn et al., 2019). Future implementation of PFA-informed support delivered by volunteers remotely in Lebanon needs comprehensive training and readily accessible structures of support at every stage of provision. Within an over-stretched and under-resourced mental health system, the scalability of the intervention may mean it is less costly to implement, which is a priority in humanitarian settings (Tol et al., 2020). In the light of the recent earthquakes in Turkey and Syria, the potential implications for affordable and scalable mental health may even extend beyond the Beirut blast. The novel remote delivery of the intervention also enhanced the reach and accessibility of the intervention without putting supporters at risk in the context of sociopolitical unease and limited resource provision. The initiative having been rapidly developed and delivered by volunteers without funding highlights the potential ease of implementation by larger organisations and services.

Some participant interviews suggest that the initiative may not be adequate for the full range of mental health problems that have arisen from or were exacerbated by the blast, including post-traumatic stress. A recent randomised controlled trial of PFA in trauma survivors in emergency departments in Chile found a significant reduction of PTSD symptoms, but not frequency of PTSD caseness, in the active group compared to controls (Figueroa et al., 2022). This emphasises the need for PFA interventions to be delivered with adjunct support. PFA-informed support is not a formal treatment and is meant to be delivered as the first line of support, and thus recipients were signposted to evidence-based, formalised treatments for psychological trauma, if appropriate. However, there needs to be readily available provision of accessible mental health services that can provide the necessary higher-intensity treatments as needed. This should be considered within a larger framework and clinical governance before a roll-out of this intervention can be executed feasibly.

Supporters vicariously struggled with the content and topics that the sessions addressed and potentially needed more support, especially those with connections to Lebanon and shared lived experience. This complements qualitative studies that show mental health professionals who support people post-crisis events may unwittingly expose themselves to vicarious trauma (Billings, Abou Seif, et al., 2021; Satkunanayagam et al., 2010). These professionals also tended to subjugate their own needs when responding to a crisis (Billings, Abou Seif, et al., 2021). In the current study, this burden was limited and factored during planning, hence supporters did not have lived experience of the blast. Interventions where supporters have shared the same traumatic experiences with recipients have been found to be difficult for supporters and potentially burdensome on top of coping with their own experiences (Billings, Biggs, et al., 2021). Future implementation of this initiative should be within an organisational structure that can provide support to the workforce delivering the intervention to prevent vicarious trauma and burnout, such as offering senior therapist supervision and peer-delivered supervision.

Despite the visual and anecdotal evidence of the consequences of the blast, empirical research on the mental health impact of it is still scarce. It is unclear how the blast has impacted the rates of mental health problems or what factors may predict worse outcomes. Our qualitative findings may hint to potential mechanisms contributing to worse mental health outcomes, such as loneliness, perceived pressure to be resilient, and lack of social support. However, further robust epidemiological studies need to be conducted to understand the impact of the Beirut blast on the mental health of people in Lebanon on a population-level.

To our knowledge, our study is the first to qualitatively explore a remotely delivered PFA-informed initiative as a novel intervention for mental health problems following and within the context of the Beirut blast. It contributes to an under-researched area of PFA literature that urgently needs to be prioritised to strengthen the evidence base (Shultz & Forbes, 2014). In response to future disasters in similar settings, we need to be able to set up controlled studies rapidly to better assess the potential benefit of this type of intervention.

4.1. Strengths and limitations

We sought to capture the experiences of supporters and recipients of a remotely delivered PFA-informed intervention to enable a rich understanding of the different perspectives of the Beirut initiative. We involved participants in the design, delivery, analysis, and write up of the research. Our research team was diverse, including Lebanese mental health researchers with lived experience of living in Lebanon and the impact of the blast. Their personal insights allowed our research to be as relevant to the Lebanese context as possible. The intervention was delivered remotely to protect our supporters’ physical safety and wellbeing during the treatment process. Our robust qualitative methodology enhances the findings’ trustworthiness and transferability, providing exploratory findings for future research on comparable humanitarian crises in Lebanon and similar settings.

The findings need to also be considered within our study’s limitations. Our interviews only explored the experiences of eight participants (4 supporters and 4 recipients) because other supporters and recipients from the initiative did not respond to the invitation or declined participation in this study. This may have reduced the richness of our data by only capturing a small range of potential views and experiences, where there may be differences in experiences between participants who responded and those who did not. Similarly, the intervention was delivered exclusively in English and was promoted on social media. This precluded participation from certain groups, including those who do not speak English, without access to social media and digital technology, or had to prioritise competing difficulties over accessing mental health support, such as working age adults who had to prioritise maintaining work. However, participants interviewed present a mix of age, gender, geographical locations, and ethnic and cultural backgrounds which maximises our findings’ potential transferability to different populations and experiences. Our sample also represents approximately 50% of people involved in the initiative and the involvement of the participants and the research team in the analysis reduces potential misinterpretation of our analysis.

There are strengths and limitations of the supporters not having shared lived experience of the same trauma. Findings from a systematic review of peer support in mental health services found that sharing similar experiences may promote genuine empathy, empowerment to change, and increased hope for their future (Repper & Carter, 2011). Our qualitative findings demonstrated that recipients did not feel that the supporters not sharing experiences of the blast negatively impacted the support but appreciated being supported without feeling burdensome. Supporters and recipients were able to connect on other shared identities and experiences, such as being young adults and/or students, age, being separated from family (e.g. parallels between the Beirut blast and COVID-19 pandemic), and having lived in Lebanon. Our intervention was purposefully designed to not include supporters with lived experience of the blast to protect the supporters and ensure they could focus primarily on the needs of recipients. Support in the context of shared stressors may be difficult especially when individuals are experiencing the aftermath of the trauma and feeling depleted themselves (Billings, Biggs, et al., 2021). Additionally, see the initiative’s founder’s lived experience commentary (Supplementary materials).

The characteristics of the intervention need to also be considered carefully. Remote support from other countries may make delivery of the intervention physically safer and increase accessibility and uptake of support to a greater number of people in understaffed and difficult-to-reach disaster settings with sparse local in-person provisions (Augusterfer et al., 2015). However, PFA models were developed for face-to-face delivery and remote delivery may render certain elements of promoting safety difficult, such as being able to provide direct and immediate access to food, shelter, water and sanitation, or link members of the community with each other to prevent isolation (WHO, 2011). Signposting recipients to local services remotely may not address cases of urgent need. Moreover, although the intervention adhered to core components of the PFA model, it evolved based on the experiences of the recipients and contained non-specific therapeutic factors (i.e. regular frequency and duration and therapeutic alliance) present in many psychological treatments (Chatoor & Kurpnick, 2001), such as brief-supportive expressive psychotherapy. However, the intervention differed from brief-supportive expressive psychotherapy in that it was not rooted in a psychodynamic/psychoanalytic framework or focused on ‘relationship episodes’ (Luborsky, 1984). This unique blend of PFA and non-specific therapeutic factors needs to be acknowledged and carefully considered in future evaluation (e.g. explicit framework for validity and effectiveness), delivery (e.g. treatment guidance/manual to ensure treatment fidelity), and implementation (e.g. risk management protocols).

The initiative needs further modifications and adaptations. Notably, a wider system of training, support, and resources needs to be prioritised in future delivery to offset potential difficulties experienced by supporters. This may enhance the quality, efficiency, and sustainability of this type of intervention.

5. Conclusion

This study provides in-depth qualitative exploration of the experiences of supporters and recipients of an initiative for young adults in response to the Beirut blast. Our findings elucidate nuanced experiences of the mental health impact of the Beirut blast and the delivery and reception of PFA delivered within an informal support context. Important considerations for future improvements and implementation are noted. Further high-quality research on the mental health of young adults in Lebanon and interventions that may be acceptable, feasible, and effective for mental health problems in its complex context are urgently needed.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, BCFC. The data are not publicly available due to their containing information that could compromise the privacy of research participants.