Mercedes Ballbé ter Maat, Ph.D. ATR-BC, LPC,
Professor, Nova Southeastern University

The political, social, and religious crisis in the Middle East has caused millions of Syrian families to seek refugee status in neighboring countries. Lebanon has taken the brunt of Syrian refugees, as the border between Lebanon and Syria has been historically relaxed and elastic in allowing free trade between these two countries.

Now more than 8 years into this crisis, Lebanon has closed its borders to Syrian neighbors after providing refuge to over 1.5 million children and families (BBC Report, 2015). A country of 4 million residents, the refugee population has caused Lebanon resources to be depleted and offer little to nothing to families in need. The social, labor, and political tensions between residents and refugees have increased, causing refugee families to be afraid of leaving their tent settlements for fear of being the target of violence. Understandably, Syrian families feel as though they face a no-win situation: They can either return to their country to face religious and political persecution and possible death or stay in Lebanon to face conditions leading to depression, anxiety, aggressive behavior, and lack of control.

The Kayany Foundation, a Lebanese non-governmental organization and the Red Pencil International, a non-profit humanitarian organization of creative art therapists teamed up to provide a school-based intervention for Syrian refugee children (and parents) attending a Kayany school. I was asked by the Red Pencil International to lead a group of creative arts therapists to Lebanon to provide Syrian refugee children and parents with a means for emotional expression, opportunities to increase their understanding of past experiences (Rousseau et al, 2005), make sense of a challenging present, and build community by offering personal support in group art and dance/movement therapy settings.

One of the reasons why the creative therapies were an important way of conducting therapy and relief was because of the language barrier. Although we had translators, we knew that some children even with translators would not be comfortable expressing verbally the trauma that they had experienced in Syria, in moving to Lebanon, and in the tent settlement camps. At the start of the mission the children looked sad and timid; they were not sure what we wanted them to do with the art materials provided, as though they had not been exposed to (or not often) to art materials.

The Bekaa Valley, Lebanon

Another goal of the mission was for the children and parents to make sense of the lived experiences in their own country and make sense of the challenges that they were facing at present time. These challenges included animosity with the host community, parents struggling to find jobs, financial hardships, not getting along with community members, living in tent settlement camps in below- poverty conditions, and the frustration of wanting to return to their native country but could not.

Tent Settlements The Bekaa Valley, Lebanon

A final goal was to develop social and community cohesion by offering personal support in group art therapy experiences in a contained and unique setting. This was important because the only or one of the only support systems they had was each other. No matter what their life experiences were in Syria before arriving in Lebanon, these families were now dealing with similar issues and shared many experiences.  In Lebanon; they were all refuges, they all had very little money; most of them lived in tent settlement camps; most of them had very little to no resources, such as health care.

Dr. ter Maat at the Kayany School with the school principal

The location was in an elementary school in the Bekaa Valley, central Lebanon. The school was located about an hour west of the mountain range that separates Lebanon from Syria. The school was created by the Kayany Foundation to specifically educate Syrian children (Syrian children were not allowed to attend Lebanese schools). All the teachers were Syrian as well. We served over 100 children ages 5-13, 6 mothers in the parent group, and more than 20 families during family nights. Dads did not participate; they were at work or chose not to attend.

Children at the Kayany School with John ter Maat, a Red Pencil Int. volunteer.

Art Therapy Children’s Groups

Some of the lessons learned and insights gathered revolved around the incredible resiliency that these children portrayed, while expressing difficulty concentrating and focusing on a directive that required the use of art supplies and self-exploration. Some children were not used to working with art supplies. It was hard for some to turn their focus onto their own selves, to pay attention to themselves, to self-express – all qualities that perhaps were not valued or promoted in their upbringing.

The changing of the meaning of self-esteem was of importance in these groups. The self (in a collectivist society such as the Syrian culture) was a foreign concept to most children. What is best for the tent settlement, what is best for the people living in the tent, what is best for the family and the community takes priority. The whole was more important than the individual, and perhaps that is why some were at a loss when the focus of the art therapy directives was on themselves. We know that in collectivistic societies the emphasis is on external locus of control and external locus of responsibility; the focus is on others. At first children were vulnerable to the circumstances they were facing, they were vulnerable to talk about themselves, and they were reluctant to express hardship for fear of possible reprimand, criticism, and judgement by adults and other children. They were going through a transformation that encompassed what they understood of the past and their identity as Syrian children, combined with the newfound refugee status while trying to grow by the values of a world turned upside down. They were in a society where the present was chaotic and the future uncertain. The present circumstances prevented them from thriving, developing, thinking, creating, focusing on hope, and focusing on the future. The art therapy groups aimed to provide a place of containment, a place where children could feel comfortable talking about themselves and their circumstances, where they could trust one another. Confidentiality among children, teachers, and translators was emphasized; we counted on the rapport already built among the teachers, translators, and children to help decrease the behavioral outbursts that were inherit in these large groups.

Children participating in an Art Therapy Group

Some of the directives that we introduced in the children’s art therapy group were:

  1. Name illustrations – as they created a picture of themselves they shared the meaning of their name.
  2. Scribble drawings—used for warm-up
  3. Trees of life—a tree in mural paper as a check-in activity – each day children would add something to the tree whether it was a leaf, a flower, a branch, a root… This initiated dialogue about how they were doing and feeling.
  4. Hand tracings—to address personal strengths and identity represented in each of the fingers traced.
  5. Mandalas—representative of the world according to them and of a response to the “miracle question:” If you had the opportunity to create your own world, what would it look like?
  6. Illustrating a folk story – important messages that children remember growing up in their native country told thru a folk story. What was most important to them?
  7. Dream catchers— many children spoke of having nightmares related to the trauma experienced prior to leaving Syrian. We shared the meaning of dream catchers rooted in the Native American culture and created them so that they children could take them home to get rid of nightmares.
  8. Boxes—represent and provide a place of containment, a sacred or secret space for oneself. We created paper boxes for children to decorate inside and out. After the decorations, children create tiny things that are personal and meaningful to them. These tiny treasures ranged from possessions to experiences. We emphasized that these treasures did not have to be shared with others.
  9. Miniature books – created with paper, yarn, and hole punchers so that each child illustrates his/her own story. Each child is the main characters.
The Tree Dialogue
The Scribble Drawing
Hand Tracings
Mandala Drawings

Folk Stories, Boxes and Miniature Books

The Mothers’ Art Therapy Group

The goal was to offer mothers an art therapy experience that provided a safe and comfortable space where they could connect, find support, and share experiences while creating art. We had anticipated that the mothers needed their own group because of the trauma they had suffered. Moreover, we suspected that they would be more free to share personal and inner thoughts if their children or husbands were not present in the room – preventing additional traumatization to their children by listening to their stories. The topics addressed were primarily related to (1) life in Syria; (2) Life in Lebanon as a refugee, and (3) feelings, such as depressed mood and loss of self-identity due to traumatic experiences in Syria and living in refugee camps.

The Red Pencil International team and a family in their settlement tent.
The kitchen inside a settlement tent.

On the topic of life in Lebanon compared to how life was in Syria, mothers mentioned that it was hard, unbearable for some, and that they were living in sub-human conditions. One of the mothers took us to visit her tent, and we witnessed the very small living space (one area covered in carpets where up to 11 individuals slept), a cloth dividing an area for the bathroom where a hole was used as the toilet, and another small space separated by a cloth delineated the kitchen, with a made-up shelf holding pots and dishes, and a portable, single gas burner for cooking. Mothers mentioned that some families only had what the United Nations humanitarian relief fund gave them to survive ($13 per person per month), and that the tents were fragile and crowded – yet they were grateful they had a place to live. They also talked about the hostility that existed between Syrian refugees and Lebanese people, understandably so, as the Lebanese government did not have the resources to host over a million and a half refugees. To add to the tension, Syrian male refuges looking for jobs to support their families began to take jobs from Lebanese people at very low wages. The historical hostility from the Syrian occupation of Lebanon in 1982 also played a part in the not-so-welcoming reception by the Lebanese community.

The bathroom inside a settlement tent.

A topic discussed by the mothers was the reason for leaving Syria. This was a difficult topic because it revealed the hardships that families suffered and the horrific circumstances forcing them to flee. Mothers talked about burning and bombing of their homes, about not having water, food, or electricity for weeks at a time, and about fleeing to relatives’ homes (but those homes also got bombed) prior to leaving the country. They also talked about being shot at and persecuted (especially the males in the families), young girls being raped by soldiers and government militia, and husbands, sons, and brothers that either disappeared, were tortured or killed. The latter was a major reason for leaving Syria. Mothers also shared the journey from Syria to Lebanon, which mostly involved a combination of walking for days, riding trucks, and walking some more. Many got sick and died on the journey.

A mother’s drawing leaving her home in Syria and the sadness that it caused her.

At the end of the two-week experience, the mothers had very positive comments about the art therapy group. A mother that was pregnant mentioned that before coming to the group she wanted to kill herself because she did not want to bring a baby into this horrible world in war conditions (her fifth child). After the group, she found hope for her, her family, and for her unborn child.  A different mother mentioned that her husband encouraged her to attend the art therapy group because he had not seen her this happy since arriving in Lebanon. Another mother said that she appreciated the feeling of togetherness, that being in a women-only group allowed her to express herself freely in a fun, stress-free, and trusting environment. This feeling was shared by many who found friendship in each other, something that was difficult even within the Syrian settlement community. One mother noticed that even though they had different socio-economic status, they had a lot in common: shared lived migration experiences, witnessed and suffered trauma, compassion for their children, and passion for their homeland. She liked the bond that she felt with other members of the group and how much they laughed together – something she had not done in a long time. The art therapy group ended up being the only source of support for many of these women.

Women participating in the Mother’s art therapy group.

The final project that the mothers created in the art therapy group was a mural that they wanted to hang at the Kayany School. The goal was to send a message of hope to all children. To this end, they created a mural that represented what the mothers wished for their children: A bright, prosperous, and happy future in Syria where there is a solid education (the school is the structure on the left), a place of worship (the large building in the center), nature where children can fish and play outside (the river, flowers, and trees), and fun outdoor activities (the bicycle). Also in the mural there is an airplane symbolizing their strong wish to return to Syria. Indeed, it was unanimous that these mothers wished to return to Syria rather than to stay in Lebanese tent settlements. Two major obstacles were (1) the high tariffs imposed by the Lebanese government to refuges wishing to leave Lebanon and (2) the rule that once departed, Syrian refuges could not return to Lebanon. They titled the mural, “Mercedes Group” in my honor although I insisted that the group was a success because it was by them, for them.

Final mural created in the Mother’s Art Therapy Group, hang at the Kayany School.

Family nights

Family night music and dance station

In an effort to bring families together, we offered two family nights (one per week) lasting 2 hours each that offered three rotating stations. One station was “art,” where a piece of cloth and paints were offered to each family to create a mural together. The second station was “games,” such as children tossing a water balloon to their respective mothers, hitting a target with a water balloon, Frisbee, and four-corners. And the third station was “music and dancing,” where mothers and their children danced together to local, Arabic music. 

Family Night Game Station
Family night art station

Mothers appreciated a long-awaited opportunity to laugh and do fun, relaxing activities as a family, though they were a bit shy at the start of each event. Because the children wanted to eagerly participate (but could not unless a parent was present), they encouraged their moms to join in and do things together. It did not take long for the mothers to dance, laugh, toss water balloons (get wet), and paint. Some mothers reported feeling sad at the start of family nights because these events bought up memories of past happy times in Syria; they reminded them of how “empty” they felt inside in the present. Yet music and dance, and their rooted passion for happier times, brought the mood of these family nights to festive events that easily lasted more than the two hours allocated.

Mural created by a family during Family Night.

Working with Translators

When doing humanitarian work in places where one does not speak the native tongue, therapy is conducted via translators. In our case, Kayany School teachers who spoke English served as translators. Although we wanted literal translation, we noticed that the teachers were interpreting, not translating. This was in spite of the training held with translators prior to the start of this mission. We also noticed that the translators were disciplining children during groups. This was instinctual given their role as teachers but was not appropriate in the role of translators. This and the interpretation of art therapy directives caused power struggles among some art therapists and translators, and confused children in understanding who was leading the group, to whom to speak, respond, and go for therapeutic help, and whose rules to follow. This led to additional trainings were translators assumed a more active role and became co-leaders. The therapy sessions were conducted in a culturally-relevant way that enhanced a partnership naturally developed and was very effective.

One last interesting fact about working with translators involved vicarious traumatization. Many of the translators had not experienced the trauma that these Syrian families had experienced or had they heard children/moms express traumatic experiences so vividly. Listening to the mothers’ and children’s stories triggered issues that some of the translators were dealing with themselves or caused them to experience vicarious trauma by listening and translating. An example of this was clear when working with the translator in the mother’s group. She was a young Syrian teacher, single, no children, who had not experienced war trauma. As she listened to the horrific stories of rape, violence, torture, and killings from mothers in the art therapy group, she would gasp loudly, and her body would jerk up in an involuntary motion, reacting in shock. It took careful de-briefing, training, and supportive consultation after each group (and the option of removing herself from the mother’s group) for this young translator to develop the personal and professional skills necessary to take on this role. Working with translators in these type of humanitarian missions adds additional considerations, especially when it comes to roles, vicarious trauma, transference, and counter-transference issues.


We came to the realization that when we stopped clinging to our agenda, the children and mothers started to take the lead, the tone of the groups changed, we learned what they were able to handle, what they preferred doing, and what was off limits. We were able to follow a schedule that seemed to work for them while creating a safe environment where they could talk freely about past, present, and future. That was one of our goals, and I believe we accomplished it.

It was helpful to remember the protective factors we know work in helping children do better in school and in becoming resilient. One was “making things good.” It was important for children and mothers to remember the good things that were part of their lives, to focus on strengths and the positive aspects of their lives, and to be hopeful for the future. That gave them an overall sense of wellbeing, strengthened their identity as Syrians, and increased their sense of self-worth. This strength-based approach proved to be very helpful in the art therapy groups, allowing participants to move beyond their struggling present and giving them hope to survive in the future.

The focus on communal, familial, and cultural resilience was effective in empowering children and mothers to share experiences in less overwhelming group settings, where their inner selves were safe. The participants felt they were not alone in their struggle. Children responded well to the pre-fabricated projects (e.g., boxes and dream catchers). These structured, stress-free projects were easy to complete and bypassed linguistic barriers. It helped children gain a sense of pride by completing tasks yet asking them to create free and spontaneous drawings seemed complicated and challenging. Children did not know what to draw and would copy each other. We realized that simple, concrete activities worked well at reducing frustration and increasing a personal sense of accomplishment, providing an opportunity to express feelings and promote healing.

Lastly, I want to mention (1) the importance of bringing projects home to show their parents, and (2) the importance of fomenting parent-child dialogue. This happened during the day when children would run home after the art therapy groups and during family nights. We encouraged mothers to ask questions about the children’s projects and encouraged children to tell parents about the good things and the not-so-good things they were feeling and experiencing. The dream catcher is a good example…it shaped productive parent-child conversations about nightmares the children were having. Parents wanted to know how their children were feelings; they support their children in coming to the art therapy groups, in expressing feelings, and in getting rid of the “demons” that haunted them.

I want to conclude by emphasizing the value of directives and task-oriented projects for the children, mothers, and family nights in helping the community begin the process of healing. What can be done in two weeks? A lot. We started the process of healing at the individual, family, and community levels.

Our hearts and prayers are with the people of Syria.


BBC Report (January 2015).  Syrian refuges. Retrieved on June 7, 2015 from

Rousseau, C., Aline Drapeau, L., Lacroix, D., & Heusch, N. (2005). Evaluation of a classroom program of creative expression workshops for refugee and immigrant children. Journal of Child Psychology and Psychiatry, 46:2, pp 180–185.