Skip to main content Accessibility help
×
Home

Information:

  • Access
  • Cited by 54

Actions:

      • Send article to Kindle

        To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

        Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

        Find out more about the Kindle Personal Document Service.

        Mental health and psychosocial wellbeing of Syrians affected by armed conflict
        Available formats
        ×

        Send article to Dropbox

        To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

        Mental health and psychosocial wellbeing of Syrians affected by armed conflict
        Available formats
        ×

        Send article to Google Drive

        To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

        Mental health and psychosocial wellbeing of Syrians affected by armed conflict
        Available formats
        ×
Export citation

Abstract

Aims.

This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees.

Methods.

We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed.

Results.

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 conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. 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.

Conclusions.

Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

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, 2015). 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, 2015). 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., 2015).

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. 2015).

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, 2014). 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, 2014). 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, 2015). 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, 2014; 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. 2003; Mollica et al. 2004; Momartin et al. 2004; Pérez-Sales, 2012; El Masri et al. 2013; IMC and JHAD, 2013; IRC, 2013; IMC and UNICEF, 2014; Vukcevic et al. 2014; Wells, 2014a , 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. 2014; Acarturk et al. 2015). 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. 2003; Mollica et al. 2004; Momartin et al. 2004). 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, 2013; Almoshmosh, 2015). 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. 1996; Ellsberg et al. 2008; IRC, 2012; Parker, 2015; Usta & Masterson, 2015).

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, 2015).

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, 2014). 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, 2015). 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. 2012). Use of fenethylline is reportedly popular among combatants because of its stamina-enhancing effect (Kalin, 2014). 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, 2015).

Specific groups

Survivors of torture

Many Syrians have to deal with the effects of having been tortured (Leigh, 2014). 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. 1998; Steel et al. 2009). 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, 1998). 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. 2015) 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. 2014). 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. 2014; 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, 2015). The psychological and social impacts of SGBV can be devastating for the survivor (Ellsberg et al. 2008; Usta & Masterson, 2015), 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, 2013; 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, 2013). 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, 2014). 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. 2015).

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. 2015). Some validation research has been done with refugees in the Middle East region, for example with Iraqi refugees (Shoeb et al. 2007), Palestinian refugees (Makhoul et al. 2011) and with Syrians before the crisis (Alsheikh, 2011). 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, 2010, 2014; Patel, 2014). 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. 2012; Budosan, 2014). New instruments assessing positive coping and growth are being validated for use in conflict affected populations in the Middle East region (Davey et al. 2015).

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. 2014). 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. 2003; Tribe & Morrissey, 2004).

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. 2012). 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, 2013; UN Security Council, 2014b ). In health settings, such experiences of sexual violence may be expressed by survivors through bodily symptoms or concerns (Al-Krenawi, 2005). 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. 2008). 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, 2008; Kirmayer, 2012). 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. 2014, 2015). 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. 2011; Bhugra et al. 2014). 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. 2015).

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, 2014).

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. 2015; 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.

References

Abassi, K (2015). Europe's refugee crisis: an urgent call for moral leadership. British Medical Journal 351, h48332; 351. doi: http://dx.doi.org/10.1136/bmj.h4833.
Acarturk, C, Konuk, E, Cetinkaya, M, Senay, I, Sijbrandij, M, Cuijpers, P, Aker, T (2015). EMDR for Syrian refugees with posttraumatic stress disorder symptoms: results of a pilot randomized controlled trial. European Journal of Psychotraumatology 6, 27414. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4438099/.
Al Akash, R, Boswell, K (2014). Listening to the voices of Syrian women refugees in Jordan: Ethnographies of displacement and emplacement. In Conference Paper – Refugee Voices 2014 Refugee Studies Centre (Rsc) Oxford.
Al-Krenawi, A (2005). Cross-national study of attitudes towards seeking professional help: Jordan, United Arab Emirates (UAE) and Arabs in Israel. International Journal of Social Psychiatry 50, 102104.
Almoshmosh, N (2015). Highlighting the mental health needs of Syrian refugees. Intervention 13, 178181.
Alsheikh, M (2011). Methods of coping with posttraumatic stress and their relationship with other variables: a comparative field study of children (ages 9 to 12) who were exposed to car accidents in the province of Damascus. Damascus University Journal 27, 847887.
Arslan, MM (2015). Increased drug seizures in Hatay, Turkey related to civil war in Syria. International Journal of Drug Policy 26, 116118.
Assessment Working Group for Northern Syria (2013). Joint Rapid Assessment of Northern Syria II (J-RANSII). Final Report. http://reliefweb.int/report/syrian-arab-republic/joint-rapid-assessment-northern-syria-ii-final-report.
Berns, J (2014). Syrian Refugee Access to Care Study: Medical Service need Among Post-Emergency Syrian Refugees in Dohuk Governorate, Kurdistan Region, Iraq. World Health Organisation and Ministry of Health, Kurdistan Regional Government, Iraq: Erbil.
Bhugra, D, Gupta, S, Schouler-Ocak, M, Graeff-Calliess, I, Deakin, NA, Qureshi, A (2014). EPA guidance mental health care of migrants. European Psychiatry 29, 107115. doi: 10.1016/j.eurpsy.2014.01.003.
Boswall, K, Al Akash, R (2015). Personal perspectives of protracted displacement: an ethnographic insight into the isolation and coping mechanisms of Syrian women and girls living as urban refugees in northern Jordan. Intervention 13, 203215.
Bou Khalil, R (2013). Where all and nothing is about mental health: beyond posttraumatic stress disorder for displaced Syrians. American Journal of Psychiatry 170, 13961397.
Budosan, B (2014). Mental Health and Psychosocial Report for Syrian Refugees in Kilis, Turkey. Report (July 2013–March 2014). Malteser International & International Blue Crescent: Unpublished Report.
Care Jordan (2013). Syrian Refugees in Urban Jordan. Baseline Assessment of Community-Identified Vulnerablities among Syrian Refugees Living in Irbid, Madaba, Mufraq, and Zarqa. Care Jordan: Amman.
Cartwright, K, El-Khani, A, Subryan, A, Calam, R (2015). Establishing the feasibility of assessing the mental health of children displaced by the Syrian conflict. Global Mental Health 2, e8.
Child Protection Working Group (2013). Child Protection Assessment 2013. Retrieved 19 September 2013 http://www.crin.org/docs/SCPA-FULL_Report-LIGHT.pdf.
Ciftci, A, Jones, N, Corrigan, P (2012). Mental health stigma in the muslim community. Journal of Muslim Mental Health 7, 1732.
Davey, C, Heard, R, Lennings, C (2015). Development of the Arabic versions of the impact of events scale-revised and the posttraumatic growth inventory to assess trauma and growth in Middle Eastern refugees in Australia. Clinical Psychologist 15, 131139.
De Jong, JT, Komproe, IH, van Ommeren, M (2003). Common mental disorders in postconflict settings. Lancet 361, 21282130.
De Maiziere, T (2015). Germany to receive up to 800,000 refugees. Deutsche Welle. Retrieved 19 August 2015 http://www.dw.com/en/de-maiziere-germany-to-receive-up-to-800000-refugees/a-18658409.
Ellsberg, M, Jansen, HAFM, Heise, L, Watts, CH, Garcia-Moreno, C, On behalf of the WHO Multi-country Study on Women's Health and Domestic Violence against Women Study Team (2008). Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet 371, 11651172.
El Masri, R, Harvey, C, Garwoo, R (2013). Changing Gender Roles among Refugees in Lebanon. ABAAD-Resource Center for Gender Equality and OXFAM: Beirut, Lebanon.
El Sarraj, E, Punamäki, RL, Salmi, S, Summerfield, D (1996). Experiences of torture and ill-treatment and posttraumatic stress disorder symptoms among Palestinian political prisoners. Journal of Traumatic Stress 9, 595606.
Global Protection Cluster (2013 a). Gender-Based Violence Area of Responsibility, The Hidden Cost of War in Syria Gender Based Violence. http://gbvaor.net/wp-content/uploads/sites/3/2015/02/The-hidden-cost-of-War-in-Syria-Gender-Based-Violence-2013-English1.pdf.
Global Protection Cluster (2013 b). Child Protection Priority Issues and Responses Inside Syria. http://mhpss.net/?get=152/1374219013-Desk-Review_summary-of-CP-needs-and-resoponses-in-Syria-FINAL.pdf.
Gorst-Unsworth, C, Goldenberg, E (1998). Psychological sequelae of torture and organised violence suffered by refugees from Iraq. Trauma-related factors compared with social factors in exile. British Journal of Psychiatry 172, 9094.
Hassan, G, Kirmayer, LJ, Mekki- Berrada, A, Quosh, C, el Chammay, R, Deville-Stoetzel, JB, Youssef, A, Jefee-Bahloul, H, Barkeel-Oteo, A, Coutts, A, Song, S, Ventevogel, P (2015). Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians. UNHCR: Geneva.
Help Age and Handicap International (2014). Hidden Victims of the Syrian Crisis: Disabled, Injured and Older Refugees. HelpAge International and Handicap International: London/Lyon.
Hijazi, Z, Weissbecker, I (2015). Syria Crisis: Addressing Regional Mental Health needs and Gaps in the Context of the Syria Crisis. International Medical Corps: Washington.
Holmgren, H, Søndergaard, H, Elklit, A (2003). Stress and coping in traumatised interpreters: a pilot study of refugee interpreters working for a humanitarian organisation. Intervention 1, 2228.
Human Rights Watch (2012). Syria: Sexual Assault in Detention: Security Forces Also Attacked Women and Girls in Raids on Homes. Accessed 25 September 2014 https://www.hrw.org/news/2012/06/15/syria-sexual-assault-detention.
IASC (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Inter-Agency Standing Committee: Geneva.
IMC (2014). Rapid Gender and Protection Assessment Report. Kobane Refugee Population: Suruç, Turkey. https://data.unhcr.org/syrianrefugees/download.php?id=7318.
IMC and Jordan Health Aid Society (2013). Displaced Syrians in Jordan: a Mental Health and Psychosocial Information Gathering Exercise. Analysis and Interpretations of Findings, J. IMC: Amman.
IMC and UNICEF (2014). Mental Health/ Psychosocial and Child Protection for Syrian Adolescent Refugees in Jordan. IMC & UNICEF: Amman, Jordan.
IRC (2012). I.R.C., Syrian Women & Girls: Fleeing Death, Facing Ongoing Threats and Humiliation. A Gender based Violence Rapid Assessment. Syria Refugee Populations. IRC: Beirut.
IRC (2013). Cross-Sectoral Assessment of Syrian Refugees in Urban Areas of South and Central Jordan. International Rescue Committee: Amman. data.unhcr.org/syrianrefugees/download.php?id=2960.
IRC (2014). Are we Listening? Acting on our Committments to Women and Girls Affected by the Syrian Conflict. IRC: New York.
James, L, Sovcik, A, Garoff, F, Abbasi, R (2014). The mental health of Syrian refugee children and adolescents. Forced Migration Review 47, 4244.
Jefee-Bahloul, H, Moustafa, MK, Shebl, FM, Barkil-Oteo, A (2014). Pilot assessment and survey of Syrian refugees’ psychological stress and openness to referral for telepsychiatry (PASSPORT Study). Telemedicine and e-Health 20, 977979.
Jefee-Bahloul, H, Barkil-Otteo, A, Pless-Mulloli, T, Fouad, FM (2015). Mental health in the Syrian crisis: beyond immediate relief. Lancet 386, 1531. doi: http://dx.doi.org/10.1016/S0140-6736(15)00482-1.
Jordans, MJD, Semrau, M, Thorinicroft, G, van Ommeren, MV (2012). Role of current perceived needs in explaining the association between past trauma exposure and distress in humanitarian settings in Jordan and Nepal. British Journal of Psychiatry 201, 276281.
Kalin, S (2014). War Turns Syria into Major Amphetamines Producer, Consumer. Reuters. Accessed 13 January 2014 http://uk.reuters.com/article/2014/01/13/uk-syria-crisis-drugs-idUKBREA0B04K20140113.
Kirmayer, LJ (2012). Rethinking cultural competence. Transcultural Psychiatry 49, 149164.
Kirmayer, LJ, Narasiah, L, Munoz, M, Rashid, M, Ryder, A, Guzder, J, Hassan, G, Pottie, K, Rousseau, C (2011). Common mental health problems in immigrants and refugees: general approach to the patient in primary care. Canadian Medical Association Journal 183. doi: 10.1503/cmaj.090292.
Lewis-Fernández, R, Krishan Aggarwal, N, Bäärnhielm, S, Rohlof, S, Kirmayer, LJ, Weiss, MJ, Jadhav, S, Hinton, L, Alarcón, RD, Bhugra, D, Groen, S, van Dijk, R, Qureshi, A, Collazos, S, Rousseau, S, Caballero, L, Ramos, M, Lu, F (2014). Culture and psychiatric evaluation: operationalizing cultural formulation for DSM-5. Psychiatry 77, 130154.
Lewis-Fernández, R, Krishan Aggarwal, N, Hinton, L, Hinton, DE, Kirmayer, LJ (2015). DSM-5® Handbook on the Cultural Formulation Interview. American Psychiatric Association: Washington.
Makhoul, J, Nakkash, RT, El Hajj, T, Abdulrahim, S, Kanj, M, Mahfoud, J, Afifi, RA (2011). Development and validation of the Arab youth mental health scale. Community Mental Health Journal 47, 331340.
Masterson, AR, Usta, J, Gupta, J, Ettinger, AS (2014). Assessment of reproductive health and violence against women among displaced Syrians in Lebanon. BMC Women's Health 14, 25.
Mental Health and Psychosocial (MHPSS) Working Group Jordan (2014). Guidelines on MHPSS Projects. data.unhcr.org/syrianrefugees/download.php?id=6916.
Mercy Corps (2014). Advancing Adolescence: getting Syrian Refugee and Host-Community Adolescents back on Track. https://data.unhcr.org/syrianrefugees/download.php?id=5366.
Middle East Monitor (2013). Amidst Syrian refugees, Domestic Violence Grows. Accessed 9 October 2013 http://shar.es/QAuqr.
Miller, KE, Rasmussen, A (2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine 70, 716.
Miller, KE, Rasmussen, A (2014). War experiences, daily stressors, and mental health five years on: elaborations and future directions. Intervention 12(S1), 3342.
Mohammed, T, Abou-Saleh, PH (2015). Mental Health of Syrian refugees: looking backwards and forwards. Lancet Psychiatry 2, 870871. doi: http://dx.doi.org/10.1016/S2215-0366(15)00419-8.
Mollica, RF, Cardozo, BL, Osofsky, HJ, Raphael, B, Ager, A, Salama, P (2004). Mental health in complex emergencies. Lancet 364, 20582067. http://mhpss.net/resource/mental-health-and-psychosocial-support-for-refugees-asylum-seekers-and-migrants-on-the-move-in-europe-2.
Momartin, S, Silove, D, Manicavasagar, V, Steel, Z (2004). Complicated grief in Bosnian refugees: associations with posttraumatic stress disorder and depression. Comprehensive Psychiatry 45, 475482.
Moussa, I (2014). Identity Crisis in the Syrian Society during the Crisis. Thesis for Executive Master in Psychosocial Support & Dialogue. IOM and Lebanese University: Beirut.
Nasir, LS, Abdul-Haq, AK (2008). Caring for Arab Patients- A Biopsychosocial Approach. Radcliffe: Oxford.
Norwegian Refugee Council (2014). The Consequences of Limited Legal Status for Syrian Refugees in Lebanon. NRC Lebanon Field Assessment Part Two: North, Bekaa and South. NRC: Lebanon.
Ouyang, H (2013). Syrian refugees and sexual violence. Lancet 381, 21652166.
Parker, S (2015). Hidden crisis: violence against Syrian female refugees. Lancet 385, 23412342.
Patel, V (2014). Rethinking mental health care: bridging the credibility gap. Intervention 12(S1), 1520.
Pérez-Sales, P (2012). Assessment of Trauma Experiences, Mental Health and Individual and Community Coping Resources of Refugee Syrian Population Displaced in North Bekaa (Lebanon). M.D.M. Editor: France, Spain.
Rahim, BEEA, Yagoub, O, Salih Mahfouz, M, Solan, YMH, Alsanosi, R (2012). Abuse of selected psychoactive stimulants: overview and future research trends. Life Sciences Journal 9, 22952308.
Refugees International (2012). Syrian Women & Girls: No Safe Refuge. Accessed 16 November 2012 http://www.refugeesinternational.org/policy/field-report/syrian-women-girls-no-safe-refuge.
Rehberg, K (2014). Revisiting Therapeutic Governance: The Politics of Mental Health and Psychosocial Programmes in Humanitarian Settings. Working Paper 98, Refugee Studies Centre. Oxford Department of International Development: Oxford.
Research Centre at La Sagesse University and ABAAD (2013). Assessment of the Impact GBV on Male Youth and Boys among Syrian and Palestine Refugees from Syria in Lebanon. ABAAD Resource Center for Gender Equality: Beirut.
Save the Children (2013). Childhood Under Fire: The Impact of Two years of Conflict in Syria. http://www.refworld.org/docid/51403b572.html.
SGBV Sub-Working Group Jordan (2014). Sexual and Gender-based Violence: Syrian Refugees in Jordan. SGBV Sub-Working Group: Amman.
Shoeb, M, Weinstein, H, Mollica, R (2007). The Harvard Trauma Questionnaire: adapting a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Iraqi refugees. International Journal of Social Psychiatry 53, 447463.
Shrestha, NM, Sharma, B, van Ommeren, M, Regmi, S, Makaju, R, Komproe, I, Shrestha, GB, de Jong, JTVM (1998). Impact of torture on refugees displaced within the developing world: symptomatology among Bhutanese refugees in Nepal. Journal of the American Medical Association JAMA 280, 443448.
Skinner, M (2014). The impact of displacement on disabled, injured and older Syrian refugees. Forced Migration Review 47, 3940.
Steel, Z, Silove, CT, Marmane, C, Bryant, RA, van Ommeren, M (2009). Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. Journal of the American Medical Association 302, 537549.
Strong, J, Varady, C, Chahda, N, Doocy, S, Burnham, G (2015). Health status and health needs of older refugees from Syria in Lebanon. Conflict Health 9, 12.
Syrian Arab Republic (1949). Law No. 148/1949 on the Syrian Penal Code. http://www.wipo.int/wipolex/en/text.jsp?file_id=243237.
Syrian Centre for Policy Research (SCPR) (2014). Syria – Alienation and Violence: Impact of Syria Crisis Report 2014. http://www.unrwa.org/sites/default/files/alienation_and_violence_impact_of_the_syria_crisis_in_2014_eng.pdf.
Thorleifsson, C (2014). Coping strategies among self-settled Syrians in Lebanon. Forced Migration Review 47, 23.
Tribe, R, Morrissey, J (2004). Good practice issues in working with interpreters in mental health. Intervention 2, 129142.
UN General Assembly (2014). Protection of and Assistance to Internally Displaced Persons: Situation of Internally Displaced Persons in the Syrian Arab Republic A/67/931, para 61. Accessed 15 July 2013 http://www.refworld.org/docid/522f06964.html.
UNHCR (2013 a). Syria Crisis: Education Interrupted. Accessed 6 January 2015 http://www.refworld.org/docid/52aebbc04.html.
UNHCR (2013 b). Operational Guidance for Mental Health and Psychosocial Support Programming in Refugee Operations. UNHCR: Geneva.
UNHCR (2014 a). 2014 Syria Regional Response Plan. Strategic Overview. UNHCR: Geneva. http://www.unhcr.org/syriarrp6/docs/Syria-rrp6-full-report.pdf.
UNHCR (2014 b). Gender Based Violence. Echoes from Syria (Protection Sector), ISSUE 3, 1–5. http://www.refworld.org/pdfid/53f1b2b34.pdf.
UNHCR (2014 c). International Protection Considerations with Regard to People Fleeing the Syrian Arab Republic, Update III October 2014. http://www.refworld.org/cgi-bin/texis/vtx/rwmain?docid=544e446d4.
UNHCR (2015 a). Syria Regional Refugee Response. Accessed 4 November 2015 http://data.unhcr.org/syrianrefugees/asylum.php.
UNHCR (2015 b). Syrian Refugees: Inter-Agency Regional Update, 19 March 2015. UNHCR: Geneva. http://reliefweb.int/report/lebanon/syrian-refugees-inter-agency-regional-update-19-march-2015.
UNHCR and REACH (2014). Comparative analysis of Syrian Refugees Staying in and Outside Camps. Kurdistan Region of Iraq (Multi-sector needs assessment factsheet). http://data.unhcr.org/syrianrefugees/download.php?id=7039.
UNHRC (2012). United Nations Human Rights Council, Oral Update of the Independent International Commission of Inquiry on the Syrian Arab Republic A/HRC/20/CRP.1, para 83 and 88. Accessed 26 June 2012 http://www.refworld.org/docid/4febf9ae2.html.
UNHRC (2013). United Nations Human Rights Council, Without a Trace: Enforced Disappearances in Syria. Accessed 19 December 2013 http://www.refworld.org/docid/52b44c234.html.
UNHRC (2014). United Nations Human Rights Council, Report of the Independent International Commission of Inquiry on the Syrian Arab Republic, A/HRC/25/65. Accessed 12 February 2014.
UNICEF (2014 a). Recruitment and Use of Children – The Need for Response in Jordan. Prersentation for Child Protection Sub-Working Group. Accessed 24 November 2014 http://data.unhcr.org/syrianrefugees/download.php?id=7547.
UNICEF (2014 b). Syria Crisis: Monthly Humanitarian Situation Report. Accessed 12 June 2014 http://data.unhcr.org/syrianrefugees/partner.php?OrgId=50.
UNICEF (2014 c). UNICEF Infographic: Syria's Children Under Siege. http://www.unicefusa.org/syria-infographic-under-siege.
UNOCHA (2014). Syria Response Plan (Summary December 2014).
UN Security Council (2014 a). Report of the Secretary-General on the Implementation of Security Council Resolution 2139 S/2014/365, Annex, p.12. Accessed 22 May 2014 http://www.refworld.org/docid/53ac00ee4.html.
United Nations Security Council (2014 b). Conflict-Related Sexual Violence: Report of the Secretary-General, S/2014/181, para 55–57. Accessed 13 March 2014 http://www.refworld.org/docid/53abe9114.html.
UN Women (2013). Inter-agency Assessment on Gender-based violence and child protection among Syrian refugees in Jordan, with a focus on early marriage. http://data.unhcr.org/syrianrefugees/download.php?id=4351.
UN Women (2014). ‘We just keep silent’ – Gender-Based Violence amongst Syrian Refugees in the Kurdistan Region of Iraq. http://shar.es/SJZje.
Usta, J, Masterson, AR (2015). Women and health in refugee settings: the case of displaced Syrian women in Lebanon. In Gender-Based Violence (ed. Djamba, YK and Kimuna, SR), pp. 119143. Springer: New York.
Ventevogel, P, Schinina, G, Strang, A, Gagliato, M, Hansen, LJ (2015). Mental health and Psychosocial Support for Refugees, Asylum Seekers and Migrants on the move in Europe: a Multi-Agency Guidance note, December 2015. Accessed 20 December 2015 http://mhpss.net/resource/mental-health-and-psychosocial-support-for-refugees-asylum-seekers-and-migrants-on-the-move-in-europe-2/.
Ventevogel, P, Van Ommeren, M, Schilperoord, M, Saxena, S (2015). Improving mental health care in humanitarian emergencies. Bulletin of World Health Organisation 93, 666666A.
Vukcevic, M, Dobric, J, Puric, D (2014). Psychological Characteristics of Asylumseekers from Syria, in Survey of the Mental Health of Asylumseekers in Serbia. UNHCR Serbia: Belgrade.
War Child Holland (2014). Syria Child Rights Situation Analysis, January 2014. http://reliefweb.int/sites/reliefweb.int/files/resources/SyriaChildRIghtsSituationAnalysis.pdf.
Wells, R (2014 a). Psychosocial Concerns Reported by Syrian Refugees Living in Jordan: a Systematic Review of Unpublished needs Assessments. Sidney University, Australia: Sydney.
Wells, R (2014 b). Community Readiness to Address the Mental Health Outcomes of War and Displacement among Syrian Refugees Living in Jordan. Sydney University, Australia: Sydney.
Wells, R, Wells, D, Lawsin, C (2015). Understanding psychological responses to trauma among refugees: the importance of measurement validity in cross-cultural settings. Journal and Proceedings of the Royal Society of New South Wales 148, 455456.
WHO (2014). Syrian Arab Republic, in Global Status Report on Alcohol and Health – 2014 Edition. World Health Organisation: Geneva.
WHO (2015). Refugees, WHO, UNHCR, mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical Management of Mental, Neurological and Substance Use Conditions in Humanitarian Settings. WHO: Geneva.
World Vision International (2014). Our Uncertain Future. http://www.wvi.org/syria-crisis/publication/our-uncertain-future.