Introduction
The current conflict in Syria has caused the largest refugee displacement crisis of our time. While neighbouring countries have hosted the majority of the refugees since the beginning of the war, it was not until the summer of 2015 that Europe began to witness a surge of Syrian citizens crossing through Turkey to enter Greece, with the ultimate aim of reaching Western Europe. The ensuing debate about the role of European countries in resolving this crisis has included calls for European politicians to exercise moral leadership, and some countries have done so (Abassi, Reference Abassi2015). In October 2015 alone, the European countries received more than 171 000 asylum applications from Syrians. Germany, with its open door policy, along with Serbia, has allowed the resettlement of more than half of these applicants (UNHCR, 2015a ). The number of refugees resettled in Germany is expected to reach 800 000 by the end of 2015 (De Maiziere, Reference De Maiziere2015). Other European countries have had mixed responses to the crisis (see http://data.unhcr.org/mediterranean/regional.php for updated numbers in every European country). With the steadily increasing proportion of Syrian refugees crossing to Europe, it is essential to advise mental health and psychosocial support (MHPSS) staff (e.g. psychiatrists, psychiatric nurses, psychologists, counsellors, social workers and others) as well as non-specialized health care staff (e.g. general physicians, midwives and nurses) with information on the mental health and psychosocial wellbeing issues facing Syrians affected by the current crisis (Multi Agency Guidance Note, Ventevogel et al., Reference Ventevogel, Schinina, Strang, Gagliato and Hansen2015).
This review paper aims to inform the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement in countries hosting refugees from Syria. Interventions designed to promote mental health and psychosocial wellbeing aim at improving positive aspects of mental health in a recovery-based approach and may be initially focused on assistance for settlement and advocacy or crisis resolution. The interventions however also include specialised interventions such as preventive or therapeutic interventions that address the longer-term consequences of war and displacement on mental health. The specific objectives of this paper are to: (1) inform on the mental and psychosocial effects of war and displacement; (2) discuss issues of language, culture and religion in the assessments of problems and intervention planning; and (3) discuss the designing of contextually appropriate mental health and psychosocial services.
This paper is a synthesis of the main results and conclusions of the report ‘Culture, Context, and the Mental Health and Psychosocial Wellbeing of Syrians: A Review for Mental Health and Psychosocial Support Staff Working with Syrians Affected by Armed Conflict’ (the report can be found on http://www.refworld.org/docid/55f6a8b84.html, among other websites) and prepared for United Nations High Commissioner for Refugees (UNHCR) by the authors (Hassan et al. Reference Hassan, Kirmayer, Mekki- Berrada, Quosh, el Chammay, Deville-Stoetzel, Youssef, Jefee-Bahloul, Barkeel-Oteo, Coutts, Song and Ventevogel2015).
Methods
This report is based on an extensive search strategy designed to capture relevant clinical and social science literature examining the sociocultural aspects of mental health in the Syrian population. The main medical, psychological and social sciences databases (PubMed, PsycInfo) were searched for relevant information, until May 2015. Additionally, manual searches of the reference lists of key papers and books or articles relevant to Syrian mental health were conducted, and included Arabic, English and French language sources. The database search was supplemented with web-based searches in Arabic, English and French media, as well as Google Scholar, to retrieve key books and non-academic literature relevant to the Syrian situation. Important information on displaced Syrians was also found in assessment reports and evaluations, by non-governmental organisations, intergovernmental organisations and agencies of the United Nations. A librarian scientist set the key words and search strategy, and conducted literature searches in academic databases. A research team of four conducted the grey literature searches, selected relevant papers/documents and conducted the literature review. The draft report was extensively reviewed and refined by more than 40 professionals with clinical experience working with Syrian populations.
Results
Refugees from Syria and internally displaced people in Syria
Since March 2011, nearly half of the Syrian population has been displaced, comprising almost eight million people inside Syria and more than four million registered refugees who have fled to neighbouring countries (UNOCHA, 2014; UNHCR, 2015b ). More than half of those displaced are children. Repeated displacements have been a striking feature of the Syria conflict, as frontlines keep shifting and formerly safer areas become embroiled in conflict. Both refugees from Syria and internally displaced people have suffered multiple rights violations and abuses from different actors, including massacres, murder, execution without due process, torture, hostage-taking, enforced disappearance, rape and sexual violence, as well as recruiting and using children in hostile situations. Increased levels of poverty, loss of livelihood, soaring unemployment and limited access to food, water, sanitation, housing, health care and education, have all had a devastating impact on the population putting them at further risk of exploitation (Norwegian Refugee Council, 2014; UNHCR, 2014a ; UNHCR and REACH, 2014) (see Syrian Centre for Policy Research (SCPR), 2014, Syria – Alienation and Violence: Impact of Syria Crisis Report 2014).
Mental health and psychosocial wellbeing among conflict-affected Syrians
Central issues in armed conflict settings are loss and grief, whether for missing or deceased family members or for other emotional, relational and material losses. Ongoing concerns about the safety of family members are reported to be a significant source of stress (UNHRC, 2013; IMC and UNICEF, 2014). In displacement settings, the social fabric of society is often severely disrupted, hence many Syrian families become isolated from larger support structures (Thorleifsson, Reference Thorleifsson2014). Feelings of estrangement, yearning for the lost homeland and loss of identity, run high as displaced Syrians struggle to adapt to life as refugees within a foreign community (Care Jordan, 2013; Moussa, Reference Moussa2014). In some countries, discrimination against refugees and social tensions also contribute to additional stress and isolation. Many refugee women and girls feel particularly isolated and may rarely leave their homes due to concerns over safety or lack of opportunities (International Rescue Committee, 2014; Boswall & Al Akash, Reference Boswall and Al Akash2015). Women and children may be vulnerable to forced or child marriage, survival sex and child labour (IRC, 2013). This same sense of isolation can affect boys, with some refugee boys rarely leaving their homes (UN Women, 2013). In the current protracted crisis, with no end in sight, a pervasive sense of hopelessness is setting in for many Syrians (Al Akash & Boswall, Reference Al Akash and Boswell2014; International Rescue Committee, 2014).
Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by the conflict related violence and displacement; and (3) issues in adaptation related to the post-emergency context, for example living conditions in the countries of refuge. Psychological and social distress among refugees from Syria and internally displaced persons (IDPs) in Syria manifests in a wide range of emotional, cognitive, physical, and behavioural and social problems (De Jong et al. Reference De Jong, Komproe and van Ommeren2003; Mollica et al. Reference Mollica, Cardozo, Osofsky, Raphael, Ager and Salama2004; Momartin et al. Reference Momartin, Silove, Manicavasagar and Steel2004; Pérez-Sales, Reference Pérez-Sales2012; El Masri et al. Reference El Masri, Harvey and Garwoo2013; IMC and JHAD, 2013; IRC, 2013; IMC and UNICEF, 2014; Vukcevic et al. Reference Vukcevic, Dobric and Puric2014; Wells, Reference Wells2014a , Reference Wells b ). Emotional manifestations include sadness, grief, fear, frustration, anxiety, anger and despair. Cognitive manifestations include loss of control, helplessness, worry, ruminations, boredom and hopelessness as well as physical symptoms such as fatigue, problems sleeping, loss of appetite and medically unexplained physical complaints. Symptoms related to past traumatic experiences have also been widely documented, such as nightmares, intrusive memories, flashbacks, avoidance behaviour and hyperarousal (Vukcevic et al. Reference Vukcevic, Dobric and Puric2014; Acarturk et al. Reference Acarturk, Konuk, Cetinkaya, Senay, Sijbrandij, Cuijpers and Aker2015). Social and behavioural manifestations of trauma-related disorders include withdrawal, aggression and interpersonal difficulties. While common among Syrian refugees, these symptoms do not necessarily indicate mental disorders, which must be assessed on the basis of configurations of symptoms and associated functional impairment. Most refugees and IDPs are tremendously resilient and MHPSS practitioners must work on establishing the conditions that promote such resiliency.
Emotional disorders
As with other populations affected by collective violence and displacement, the most prevalent and clinically significant problems among Syrians are symptoms of emotional distress related to depression, prolonged grief disorder, posttraumatic stress disorder and various forms of anxiety disorders (De Jong et al. Reference De Jong, Komproe and van Ommeren2003; Mollica et al. Reference Mollica, Cardozo, Osofsky, Raphael, Ager and Salama2004; Momartin et al. Reference Momartin, Silove, Manicavasagar and Steel2004). These problems can amount to a mental disorder if they include high levels of suffering and functional impairment, but psychosocial problems or emotional distress in themselves do not necessarily imply that the person has a mental disorder (Bou Khalil, Reference Bou Khalil2013; Almoshmosh, Reference Almoshmosh2015). Difficult life circumstances often contribute to phenomena such as demoralisation and hopelessness, which may be related to profound and persistent existential concerns of safety, trust, coherence of identity, social role and society (El Sarraj et al. Reference El Sarraj, Punamäki, Salmi and Summerfield1996; Ellsberg et al. Reference Ellsberg, Jansen, Heise, Watts and Garcia-Moreno2008; IRC, 2012; Parker, Reference Parker2015; Usta & Masterson, Reference Usta, Masterson, Djamba and Kimuna2015).
Psychosis and other severe mental disorders
There is little research data on Syrian people with psychosis and other severe mental disorders. Most likely, the number of Syrians with psychotic symptoms will have gone up given the increase of risk factors, such as potentially traumatic events, forced migration and the breakdown of social support. The largest psychiatric hospital in Lebanon has seen an increase in admissions of Syrians over the past few years, with more severe psychopathology and suicidality. The International Medical Corps has treated more than 6000 people in their centres in the region, of whom almost 700 were diagnosed with psychotic disorders (Hijazi & Weissbecker, Reference Hijazi and Weissbecker2015).
Alcohol and drugs
There is limited data on the use of alcohol and other psychoactive substance in displaced populations from Syria. Consumption of alcohol in Syria was traditionally low (WHO, 2014). However, use of alcohol may have increased in recent years: a study among Syrian refugees to Iraq found that about half of the respondents had more than five alcoholic drinks per week (Berns, Reference Berns2014). Figures on the use of illegal drugs are not available, but may have increased due to the greater production and trade of illegal drugs as a result of the crisis (Arslan, Reference Arslan2015). A worrying trend is the use of synthetic stimulants such as fenethylline (‘Captagon’), a drug that is popular throughout the Middle East and that is produced in Syria and neighbouring countries (Rahim et al. Reference Rahim, Yagoub, Salih Mahfouz, Solan and Alsanosi2012). Use of fenethylline is reportedly popular among combatants because of its stamina-enhancing effect (Kalin, Reference Kalin2014). Adults, especially women dealing with loss, are also prone to substance abuse. In some refugee camps, several cases of addiction to prescription medications were reported (Mohammed & Abou-Saleh, Reference Mohammed and Abou-Saleh2015).
Specific groups
Survivors of torture
Many Syrians have to deal with the effects of having been tortured (Leigh, Reference Leigh2014). While there are limited research data on the specific mental health and psychosocial problems of Syrian survivors of torture, in general, survivors of torture are vulnerable to developing psychological problems, particularly depression, posttraumatic stress reactions, panic attacks, chronic pain or medically unexplained somatic symptoms and suicidal behaviour (Shrestha et al. Reference Shrestha, Sharma, van Ommeren, Regmi, Makaju, Komproe, Shrestha and de Jong1998; Steel et al. Reference Steel, Silove, Marmane, Bryant and van Ommeren2009). Emotional and social support can buffer the severity of posttraumatic stress disorder and depression, while ongoing insecurity, economic difficulties and social isolation can aggravate symptoms (Gorst-Unsworth & Goldenberg, Reference Gorst-Unsworth and Goldenberg1998). Conventional diagnostic classifications are often insufficient as many clients have symptoms of various torture-related problems, but symptom reduction in one area can have beneficial effects on other stress-related problems.
Mental health and psychosocial wellbeing of Syrian children
More than 50% of Syrians displaced internally or as refugees are children, and of these, nearly 75% are under the age of 12 (UNHCR, 2014b ). Some have been wounded and many have witnessed violence first-hand or endured physical and/or sexual abuse (Refugees International, 2012; UNHRC, 2012; Assessment Working Groups for Northern Syria, 2013; Care Jordan, 2013; Research Center at La Sagesse University and ABAAD, 2013; SGBV Sub-working Groups Jordan, 2014), the destruction of their homes and communities, lack of access to basic services and recruitment by armed groups (IMC, 2014; UNHCR, 2014c ) putting them at further risk of death, injury, psychological distress or torture (UNICEF, 2014a , b ). About half of displaced Syrian children, especially older children, are unable to continue their education (UNHCR, 2013a ; UNICEF, 2014c ; UN Security Council, 2014a ).
Studies of Syrian refugee children have documented a wide range of psychosocial problems (Mercy Corps, 2014; Cartwright et al. Reference Cartwright, El-Khani, Subryan and Calam2015) including: persistent fears and anxiety; difficulties sleeping; sadness, grief and depression (including withdrawal from friends and family); aggression or temper tantrums (shouting, crying and throwing or breaking things); nervousness, hyperactivity and tension; speech problems or mutism; and somatic symptoms. Violent and war-related play, regression and behavioural problems are also found among children (IMC and UNICEF, 2014; IRC and C. International, 2014; James et al. Reference James, Sovcik, Garoff and Abbasi2014). Adolescent boys may have a profound sense of humiliation resulting from exploitation as child labourers, with poor pay and dangerous conditions as well as the mounting social tension between Syrian refugees and host communities (Mercy Corps, 2014).
Key sources of stress for children include discrimination by members of the host community and war-related fears, as well as their own traumatic experiences and educational concerns. Family violence and parental stress, economic pressures and confinement to the home are also reported to contribute to children's distress (UN Women, 2013). Girls more commonly report confinement and harassment as key stressors, while boys are more likely to report physical abuse and bullying. There is some evidence that with adequate support from family, the surrounding community and service providers, many aspects of refugee children's distress are reduced over time (IMC and UNICEF, 2014). Children with intellectual disabilities, including children on the autism spectrum and those with speech difficulties, require extra attention and care. Comprehensive intervention programmes can address their needs by providing adequate information to both specialized and non-specialized support staff members (WHO, 2015).
Mental health and psychosocial distress: diversity and vulnerability
Vulnerable populations that may face specific challenges include men and women survivors of sexual or gender based violence (SGBV), children who have experienced violence and exploitation, older people and Syrians who are lesbian, gay, bisexual, transgender or intersex (LGBTI).
SGBV has increased substantially due to the conflict and the breakdown of protection mechanisms (Global Protection Cluster, 2013a ; IRC, 2014; SGBV Sub-working group Jordan, 2014; UNHCR, 2014b ). Refugees who have fled to other countries may avoid further conflict-related SGBV, but continue to face other forms of SGBV, including: domestic violence (IRC, 2012; Global Protection Cluster, 2013a ; Middle East Monitor, 2013; UNHCR, 2013a ; Masterson et al. Reference Masterson, Usta, Gupta and Ettinger2014; UN Women, 2014); sexual violence; early marriage; harassment and isolation; exploitation; and survival sex (Human Rights Watch, 2012; IRC, 2012, 2014; UN General Assembly, 2014; UNHRC, 2014; Parker, Reference Parker2015). The psychological and social impacts of SGBV can be devastating for the survivor (Ellsberg et al. Reference Ellsberg, Jansen, Heise, Watts and Garcia-Moreno2008; Usta & Masterson, Reference Usta, Masterson, Djamba and Kimuna2015), and may have a ripple effect throughout the family and wider community. In addition to the ordeal of sexual violence, women and girls often fear or actually face social repercussions, including rejection, divorce, abuse and ostracism. In a minority of cases they may suffer from ‘honour’ crimes at the hands of family members (Global Protection Cluster, 2013b ; UNHRC, 2014; War Child Holland, 2014). Boys and men who have experienced sexual violence also face negative social consequences.
The prevalence of early marriage and its associated health risks have increased as a result of poverty, insecurity and uncertainty caused by displacement (Child Protection Work Group, 2013; Save the Children, 2013; UNHCR, 2013a ). Early marriage of girls has become a coping strategy and is perceived as a means to protect girls and better secure their future (Ouyang, Reference Ouyang2013; Save the Children, 2013; UNHCR, 2014b ; World Vision International, 2014). However, early marriage may be a significant source of distress for girls, and is often associated with interruption of education, health risks and increased risk of domestic violence (Ouyang, Reference Ouyang2013). Feelings of abandonment, loss of support from parents and lack of access to resources to meet the demands of being a young spouse and a mother may create additional stress.
The specific challenges facing LGBTI individuals in Syria are often overlooked. Same-sex acts among consenting adults are illegal in Syria (Syrian Arab Republic, 1949) and overt discrimination is present throughout Syrian society. The specific protection risks faced by Syrian LGBTI refugees and IDPs, combined with difficulties accessing safe and supportive services, and extreme stigma and discrimination create specific psychosocial and social difficulties for Syrian LGBTI persons in their social relations, integration and identity.
Older refugees, particularly those who have health problems and a limited social support network, are vulnerable to psychosocial problems (Skinner, Reference Skinner2014). Many have lost facilitating and supportive social and physical environments in Syria built up over the years, including accessible housing and social spaces for people with mobility problems. Studies among older refugees find high levels of feelings of anxiety (41%), depression (25%), lack of safety (24%) or loneliness (23%). Those with poor physical health are significantly more affected (Strong et al. Reference Strong, Varady, Chahda, Doocy and Burnham2015).
Refugees with specific needs due to disability, injuries or chronic disease constitute another group with elevated psychological stress levels. A study by Help Age and Handicap International (2014) among Syrian refugees in Jordan and Lebanon found that people with such specific needs were twice as likely to report psychological distress.
Challenges with epidemiological studies
The results of psychiatric epidemiological studies among conflict affected Syrians need to be interpreted with caution. Standard instruments usually do not assess local cultural symptoms or idioms of distress and most have not been validated for use in the Syrian emergency context (Wells et al. Reference Wells, Wells and Lawsin2015). Some validation research has been done with refugees in the Middle East region, for example with Iraqi refugees (Shoeb et al. Reference Shoeb, Weinstein and Mollica2007), Palestinian refugees (Makhoul et al. Reference Makhoul, Nakkash, El Hajj, Abdulrahim, Kanj, Mahfoud and Afifi2011) and with Syrians before the crisis (Alsheikh, Reference Alsheikh2011). Furthermore, most screening tools focus on symptoms of pathology, with little or no attention to resilience and/or coping. A narrow focus on the effects of past events in Syria, without taking current life circumstances into consideration, may lead to conflating symptoms of posttraumatic stress disorder (PTSD) or clinical depression with distress generated by stressors related to the post-displacement context (Miller & Rasmussen, Reference Miller and Rasmussen2010, Reference Miller and Rasmussen2014; Patel, Reference Patel2014). Studies of distress in populations affected by the crises in the Middle East region have found current living contexts impact strongly on mental health (Jordans et al. Reference Jordans, Semrau, Thorinicroft and van Ommeren2012; Budosan, Reference Budosan2014). New instruments assessing positive coping and growth are being validated for use in conflict affected populations in the Middle East region (Davey et al. Reference Davey, Heard and Lennings2015).
Challenges for MHPSS services
Even when MHPSS services are available, displaced Syrians and refugees from Syria may still be unable to access services. Several factors influence access to MHPSS services including language barriers, the stigma associated with seeking mental health care and the power dynamics of the helping relationship.
Language barriers
When language barriers are present, collaboration with Arabic-speaking colleagues or the use of a well-trained, professional interpreter who is familiar with mental health terminology may be essential for accurate assessment and treatment delivery. The use of informal or ad hoc interpreters from the community (or family) poses ethical and practical challenges in terms of safety, confidentiality and quality of communication because of their personal involvement in the client's social network, traumatic experiences and/or a lack of understanding of key terms and the process of clinical inquiry and intervention (Jefee-Bahloul et al. Reference Jefee-Bahloul, Moustafa, Shebl and Barkil-Oteo2014). Therefore, MHPSS practitioners need to ensure that trained and competent interpreters are available, and should be aware of the potential stress for interpreters and attend to their wellbeing by debriefing after the interview, with follow-up when indicated (Holmgren et al. Reference Holmgren, Søndergaard and Elklit2003; Tribe & Morrissey, Reference Tribe and Morrissey2004).
Stigma around psychological distress and mental illness
In Syria and neighbouring countries, overt expression of strong emotions may be socially acceptable and emotional suffering is perceived as an inherent aspect of life. Instead, it is the explicit labelling of distress as a mental health problem that constitutes a source of shame, embarrassment and fear of scandal, because of the risk of being considered ‘mad’ or ‘crazy’. The potential shame extends from patients to their families and affects the use of mental health services. This influences the decision to seek professional help and treatment adherence (Ciftci et al. Reference Ciftci, Jones and Corrigan2012). Practitioners who avoid using psychological jargon and psychiatric labelling may generate less stigma and be more easily understood, resulting in better collaboration and treatment adherence.
Issues of power and neutrality
MHPSS interventions with refugees and displaced people raise issues of power dynamics that must be carefully considered in order to avoid creating situations where people are made to feel subordinate and dependent on the resources and expertise of the practitioner. Displaced and refugee Syrians have been robbed of power and control over most aspects of their lives. Many clients may experience the expert position of the helper as disempowering and disqualifying of their own agency. They are more likely to regain a sense of empowerment if they are actively involved in decision-making of the intervention planning. A person-centred approach to psychosocial support and clinical interaction, seeking dialogue genuine partnership and collaboration, can contribute to mental health promotion.
Ensuring cultural safety and cultural competence in MHPSS programmes
Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored.
The importance of the setting
The context of service delivery is often an important factor in the acceptability of MHPSS services. Psychosocial programmes can help increase access and reduce stigma if they are provided in non-psychiatric settings, such as general medical clinics, community centres, women's groups, child friendly spaces, schools and other places. Safe spaces are particularly important for women and girls facing physical and social isolation, and can enable participants to build social capital and to discuss intimate issues related to life changes, and emotions, including more sensitive concerns like domestic abuse (Mercy Corps, 2014).
There is also increasing recognition of the need to engage men in psychosocial programmes in culturally and gender appropriate ways, with a particular focus on providing meaningful activities for men at appropriate times and settings, such as evening activities in community centres, worship centres, sport activities and other gathering places. This underscores the need for capacity building, training and support of primary health care providers so that mental health problems and psychosocial distress can be managed within general health care settings.
It is important for MHPSS programmes to engage with the many qualified and educated Syrians refugees who are already working hard to improve community mental health and psychosocial wellbeing through grass roots networks. They can provide crucial links to community and act as culture brokers, or mediators within clinical and social service settings by explaining background assumptions, in order to improve communication and mutual understanding between helper and client.
Clients’ expectations of MHPSS services
MHPSS programmes should address the full range of needs and priorities of their clients by identifying their non-psychological or social needs and referring them to relevant services in their area. Bodily or somatic symptoms accompany most forms of emotional and psychological distress. People who perceive the origins of psychological distress as somatic usually expect their treatment to follow medical lines. As a result of such perceptions and attributions, some Syrians may be reluctant to speak in detail about their memories and experiences, because they do not see the relevance of such personal information to medical condition. Clients who attribute their ailments to bodily problems or social stressors may also expect interventions that assist them in regaining internal and social balance, as well as control over their lives. In precarious living conditions, where daily events may be unpredictable, people may prefer brief, directive interventions with rapid effect. Some people may hope for a space where they can share their experiences with others, to make sense of with their past experiences and restore some sense of moral order, as well as to find ways to deal with their current situation. This kind of work does not usually require clinical mental health services, but rather community based psychosocial support interventions that can re-establish social support networks, to promote sharing problems to identify solutions and reinforce positive coping strategies, and engaging in meaningful daily activities.
Mental health services for SGBV survivors
Because of shame, fear of social stigmatisation and reprisals, as well as concern about lack of confidentiality, SGBV survivors are often reluctant to report instances of sexual violence or harassment, or to seek treatment (IRC, 2012; UNHRC, 2012; Ouyang, Reference Ouyang2013; UN Security Council, 2014b ). In health settings, such experiences of sexual violence may be expressed by survivors through bodily symptoms or concerns (Al-Krenawi, Reference Al-Krenawi2005). Survivors of rape and other forms of sexual violence have an elevated risk of developing mental disorders and therefore, offering mental health services as part of the multi-sectoral services provided to survivors of these kinds of violence, should be a priority (Ellsberg et al. Reference Ellsberg, Jansen, Heise, Watts and Garcia-Moreno2008). Providing safe, non-stigmatising and supportive services with trained specialised staff to receive and respond to disclosures of SGBV in a confidential and appropriate manner, increases the likelihood that survivors will feel comfortable to access services and disclose their concerns.
Ensuring access for victims of torture
Syrians who have experienced torture often have specific mental health and psychosocial needs related to their experiences of trauma and loss. Shame and guilt, related to the often humiliating and degrading experiences of torture, prevent some people from seeking help at general or mental health services. Presenting complaints are often somatic, including headache, body pains, numbness, tingling sensations, stomach ache, or breathing problems. The split between ‘physical health care’ and ‘mental health care’ is unfortunate for torture survivors as labelling problems as ‘somatisation’ (with the assumption that the ‘real’ problem is psychological) can be stigmatising. At the same time, physical diagnoses without effective treatment (for example, ‘damaged spine’ or ‘torture-related neuropathy’) may contribute to a process of somatic fixation and maladaptive coping that can hinder working toward improved functionality. Some specialised centres for treatment of victims of torture in the region, therefore, avoid diagnostic labelling and instead work with each client to reduce symptoms and improve physical, psychological and social functioning.
Torture survivors also commonly face a range of social issues, including difficulties in maintaining relations with friends and family, and feeling not understood or welcomed by community members. This may leave survivors emotionally isolated, while family or friends also struggle with undisclosed feelings, such as guilt for not having been able to protect the survivor from torture. The experience of sexual violence during torture (or even the assumption by others that a torture survivor experienced sexual violence) can lead to social stigma and further isolation of the survivor. Providing mental health services with specialised staff and training in appropriate services for survivors of torture should therefore be a priority.
Culturally relevant assessments
For clinical mental health professionals, such as psychiatrists and clinical psychologists, it is critical to realise that their clients' understanding and manifestation of mental illness and psychosocial wellbeing is rooted in social, cultural and religious contexts. Clinical assessment will be more accurate and appropriate when it integrates questions on the local modes of expressing distress and understanding symptoms (Nasir & Abdul-Haq, Reference Nasir and Abdul-Haq2008; Kirmayer, Reference Kirmayer2012). The Cultural Formulation Interview in the Diagnostic and Statistical Manual (DSM-5) of the American Psychiatric Association provides one simple approach to assist mental health practitioners in this aspect of assessment (Lewis-Fernández et al. Reference Lewis-Fernández, Krishan Aggarwal, Bäärnhielm, Rohlof, Kirmayer, Weiss, Jadhav, Hinton, Alarcón, Bhugra, Groen, van Dijk, Qureshi, Collazos, Rousseau, Caballero, Ramos and Lu2014, Reference Lewis-Fernández, Krishan Aggarwal, Hinton, Hinton and Kirmayer2015). Extensive information on cultural aspects of mental health such as Syrian explanatory models of illness, idioms of distress and cultural/religious modes of coping is provided in the full UNHCR report (http://www.refworld.org/docid/55f6a8b84.html).
Conclusion: implications for designing contextually appropriate mental health and psychosocial services
The ongoing hardships and violence associated with the conflict in Syria have had pervasive effects on the mental health and psychosocial wellbeing of adults and children, both among those internally displaced and those seeking asylum. For refugees, experiences related to the conflict are compounded by the daily stressors of resettlement in a new country, which include language barriers, poverty, lack of resources and services to meet basic needs, difficulty accessing services, risks of violence and exploitation, discrimination and social isolation.
Mental health practitioners' involvement may be focused on initial support and crisis resolution in the short term. However, this initial focus should not be at the expense of addressing risks for longer-term consequences due to the profound losses and ongoing daily stressors that many displaced persons and refugees experience. Some of the most important factors contributing to psychological morbidity in refugees may be alleviated by planned, integrated rehabilitation programmes and attention to social support and family unity (Kirmayer et al. Reference Kirmayer, Narasiah, Munoz, Rashid, Ryder, Guzder, Hassan, Pottie and Rousseau2011; Bhugra et al. Reference Bhugra, Gupta, Schouler-Ocak, Graeff-Calliess, Deakin and Qureshi2014). Art therapy workshops and projects such as the theatre project ‘Antigone of Syria’, may be helpful in restoring the social cohesion between community members in a culturally relevant manner (Jefee-Bahloul et al. Reference Jefee-Bahloul, Barkil-Otteo, Pless-Mulloli and Fouad2015).
It is essential for MHPSS to be aware of the effects of their actions and attitudes on the wellbeing of refugees and displaced persons. MHPSS professionals should be careful not to over-diagnose clinical mental disorders among displaced Syrians, especially among those facing insecurity due to many ongoing daily stressors. In general, MHPSS practitioners should avoid psychiatric labelling because this can be especially alienating and stigmatising for survivors of violence and injustice. MPHSS workers may gain from shifting emphasis from vulnerability-based assessment and intervention frameworks to resilience and recovery-based approaches, recognising refugees and IDPs as active agents in their lives in the face of adversity (MHPSS Working Groups Jordan, 2014a ; Rehberg, Reference Rehberg2014).
For clinical mental health practitioners, building a solid therapeutic alliance with their clients will allow both practitioner and client to navigate among diverse explanatory models and sources of help that may include the formal and informal medical system, as well as religious, community, family and individual resources. Clinical interventions need to go hand-in-hand with interventions to mitigate difficult living conditions, and strengthen community based protection mechanisms, in order to help individuals regain normalcy in their daily lives. Interventions aimed at improving living conditions and livelihoods may significantly contribute to improving the mental health of refugees and IDPs, perhaps more than any psychological and psychiatric intervention.
In times of extreme violence, people often turn to collective cultural systems of knowledge, values and coping strategies to make meaning in the face of adversity. In this context, providing culturally safe environments for respectful dialogue and collaborative work is essential to assist IDPs and refugees from Syria to construct meaning from suffering and finding adaptive strategies to cope with their situation.
Finally, MHPSS interventions should be part of a multi-layered system of services and supports. This has important implications, for both those who work within health services (including clinical practitioners with advanced training in mental health) and those focusing on community-based psychosocial activities (who often have non-clinical backgrounds and are based in social or community work). To effectively support the mental health and psychosocial wellbeing of people affected by the Syria crisis, it is essential that MHPSS activities are formulated in a broad and inclusive way and that the various services and supports are functionally linked within a coherent system with established mechanisms for referral (IASC, 2007; UNHCR, 2013b ). It is also crucial for general health care practitioners to be well prepared to assess and manage any mental health and substance abuse conditions among conflict affected Syrians. The World Health Organization and the UNHCR have developed the mhGAP Humanitarian Intervention Guide to ensure the inclusion of mental health within basic primary care services (Ventevogel et al. Reference Ventevogel, Van Ommeren, Schilperoord and Saxena2015; WHO, 2015).
Acknowledgements
This paper is based on the UNHCR commissioned report to which many persons contributed: Conceptualisation and editing: Ghayda Hassan (University of Quebec, Canada), Laurence J. Kirmayer (McGill University, Canada), Peter Ventevogel (UNHCR, Switzerland). Contributing authors: Abdelwahed Mekki-Berrada (University Laval, Canada), Constanze Quosh (UNHCR, Uganda), Rabih el Chammay, (Ministry of Public Health, Lebanon), Jean-Benoit Deville-Stoetzel (University of Montreal, Canada), Ahmed Youssef (Canada), Hussam Jefee-Bahloul (Yale University, United States), Andres Barkeel-Oteo (Yale University, United States), Adam Coutts (London School of Hygiene and Tropical Medicine, United Kingdom), Suzan Song (George Washington School of Medicine and Health Sciences, USA). Reviewers and other contributors (in alphabetical order): Deeb Abbara (Psycho-Social Services and Training Institute, Egypt), Mohammed Abou-Saleh (University of London, United Kingdom), Mohamed Abo-Hilal (Syria Bright Future, Jordan), Nadim Almoshmosh (Northamptonshire Healthcare NHS Foundation Trust, United Kingdom), Ghida Anani (ABAAD, Lebanon), Homam Masry Arafa (UNHCR, Syria), Najib George Awad (Hartford Seminary, USA), Naz Ahmad Baban (Erbil Psychiatric Hospital, Iraq), Mary Jo Baca (International Medical Corps, Jordan), Alaa Bairoutieh (Psycho-Social Services and Training Institute, Egypt), Ahmad Bawaneh (International Medical Corps, Jordan), Ammar Beetar (UNHCR, Syria), Maria Bornian (UNICEF, Lebanon), Boris Budosan (Malteser International, Croatia), Ann Burton (UNHCR, Jordan), Adrienne Carter (Center for Victims of Torture, Jordan), Dawn Chatty (Refugee Study Centre, University of Oxford, United Kingdom), Alexandra Chen (UNWRA, Lebanon), Rony N. Abou Daher (Lebanon), Paolo Feo (Un Ponte Per, Italy), Ilona Fricker (CVT, Jordan), Muriel Génot (Handicap International, Jordan), Hagop Gharibian (Syrian Arab Red Crescent, Syria), Audrey Gibeaux (MSF, Lebanon), Amber Gray (Center for Victims of Torture, USA), Muhammad Harfoush (UNHCR, Ethiopia), Aram Hassan (Centrum ‘45, The Netherlands), Maysaa Hassan (IOM, Syria), Tayseer Hassoon (in unaffiliated capacity, Syria), Zeinab Hijazi (International Medical Corps, USA), Leah James (CVT, Jordan), Wissam Hamza Mahasneh (Organization of the Islamic Cooperation, Turkey), Cosette Maiky (UNWRA, Lebanon), Tamara Marcello (ARDD-Legal Aid, Jordan), Mamoun Mobayed (Behaviour Health Centre, Qatar), Luca Modenesi (CVT, Jordan), Amanda Melville (UNHCR Regional Bureau, Amman), Redar Muhammed (UPP, Iraq), Mark van Ommeren (WHO, Geneva), Basma el Rahman (International Medical Corps, Turkey), Mindy Ran (Netherlands), Rawisht Rasheed (University of Soran, Iraq), Khalid Saeed (WHO, Eastern Mediterranean Regional Office), Josi Salem (Al Himaya Foundation, Jordan), Marian Schilperoord (UNHCR, Geneva) Guglielmo Schininà (IOM, Switzerland), Mohamed el Shazly (International Medical Corps, Turkey), Team of Un Ponte Per, Dohuk, Iraq (Ramziya Ibrahim Amin, Rezan Ali Isma'il, Diyar Faiq Omar, Sam Jibrael, Bradost Qasem), Ruth Wells (Sydney University, Australia), Gabriela Wengert (UNHCR, Jordan), Eyad Yanes (World Health Organization, Syria).
Financial Support
The literature search for this work was supported by UNHCR.
Conflict of Interest
The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Ethical Standards
This review complies with the ethical standards of relevant national and institutional committees.
