Psychosocial support in the Syrian refugee response: challenges and opportunities

Since the start of the conflict in Syria in 2011, over 5 million Syrians have fled to neighbouring countries. At least 1.5 million school-age Syrian children now live in Jordan, Lebanon and Turkey. Around half of these children do not have access to formal education, with many working informally to provide for their families. Domestic violence is increasingly reported as Syrian parents struggle to cope with their circumstances. Bullying is said to be on the rise, reflecting tensions between host and refugee communities caused by the tremendous pressure on basic services. These daily stresses have severe and lasting impacts on Syrian children’s psychosocial wellbeing, and for some children can worsen the effects of trauma.

Psychosocial support (PSS) programmes in Jordan, Lebanon and Turkey aim to help Syrian refugee children and their families to deal with these issues. In 2014, at least 47 organisations were providing PSS services to Syrian refugees in Jordan alone. As the 2007 Inter-Agency Standing Committee (IASC) guidelines for mental health and psychosocial support show, PSS services vary in type and intensity – ranging from community-level interventions, such as child-friendly spaces, to case-specific clinical management of mental disorders. PSS is also increasingly being provided to children in schools, in the form of social and emotional learning (SEL) programmes.

Although the IASC guidelines are explicit that PSS programmes should be ‘contextually appropriate’, very little is known about the extent to which this guidance is followed in practice. This gap in research led to a short Save the Children UK study which aimed to understand the contextual factors around the implementation of PSS in the Syrian refugee response. E. Soye and M. Tauson, Psychosocial Wellbeing and Socio-Emotional Learning in the Syrian Refugee Response: Challenges and Opportunities (London: Save the Children, forthcoming). Twenty semi-structured interviews were conducted with education, child protection and monitoring and evaluation specialists from 15 organisations working in the Syrian response, including national and international NGOs, government agencies, international organisations and donor agencies. This article explores some of the findings of the research in the areas of inter-agency coordination, family and community support, specialised interventions for trauma and monitoring and evaluation in the Syrian refugee response.

Coordination

Restrictive refugee policies on work, housing and legal status are sources of chronic stress for Syrian refugees and their families. This points to the clear need for changes in national refugee policy. On the more immediate local level, the IASC pyramid for PSS highlights the importance of providing basic services, in recognition that a failure to meet basic needs will have a knock-on effect in other areas of children’s wellbeing. In the Syrian response, this usually works in practice through cross-sectoral referrals.

When asked about inter-agency coordination in Jordan, an education advisor pointed to referrals for assistance with basic needs such as cash, food and shelter. Other respondents noted that inter-sectoral working groups and coordination mechanisms in Syrian refugee camps were generally working well due to the high concentration of NGOs present and relatively generous funding. Coordination outside the camps, however, is reportedly still lacking, especially in peri-urban and rural areas. A child protection respondent in Jordan highlighted that NGOs are mostly based around Amman, and in general services are limited to capital cities.

Relatable support while fighting stigma

The second layer of the IASC pyramid recognises the significant impact of community and family support on children’s psychosocial wellbeing. Syrian refugee children often depend on parents who are highly stressed. Many organisations are now beginning to recognise the need to promote the psychosocial wellbeing of parents themselves through ‘positive parenting’ and stress management sessions, as well as through cross-sector referrals. An education advisor in Jordan spoke about introducing referral mechanisms in their organisation’s PSS programmes:

We introduced a referral mechanism in programmes because of these issues seen in parents – we saw that this was an obstacle to the success of the programmes. Fine, school is going great, everything is going great, it’s a safe environment for the kids, but once they go back home, it’s not the same thing. There’s more stress, there might be yelling, there might be beating … the parent is under stress, and it’s going to affect the child.

Despite these increased efforts, interview respondents emphasised that involving parents in PSS programming in the Syrian response remains a challenge. Several participants noted that the staff who deliver parent support sessions are often very young. A child protection respondent in Lebanon talked about seeing a twenty-five-year-old practitioner with no children (and with a middle-upper-class background) deliver positive parenting sessions to Syrian refugee mothers. The respondent doubted the extent to which that staff member could relate to Syrian parents. Another international child protection advisor commented: ‘How do you comfort a mother whose child is lost or missing if you’ve never gone through that, as a twenty-one-year-old, yourself?’. Regional child protection and education staff also said that stigma around the term ‘psychosocial’ may deter parents from getting involved in, or even allowing their children to engage in, PSS programmes. An education specialist in Jordan commented that ‘Any sort of mental weakness is largely taboo, so it is difficult to prioritise it’. Accordingly, it is recommended that staff avoid using ‘PSS’ to describe their activities where possible. Using teachers to provide PSS to children in classroom contexts through the SEL channel may also help reduce stigma.

Interview participants highlighted the importance of community programming in enhancing children’s resilience to stressful and challenging environments. One noted that, in the context of displacement, children ‘need some stability, safe spaces, and relearning of principles of fairness and friendship and safety, and normality’. One child protection manager thought that ‘normality mainly comes through peers, and families, and schools and youth clubs, and the mosque’. Another said that programming at the community level in the Syrian response often tends to be very unstructured, so that PSS becomes ‘a little bit everywhere, and therefore, nowhere’. This lack of structure is reflected in attitudes that anyone can work at the level of community-based interventions, or that it does not require skill or expertise. Several respondents described seeing PSS staff implementing community activities ‘thrown together off the top of their heads’. Others emphasised the importance of involving skilled facilitators in community engagement: ‘the more sensitised and trained people you have that can facilitate a healthy process, the better’. Teachers may provide a particularly effective conduit for community engagement, and working with local religious leaders can also go some way towards building social bonds between refugees and host communities.

Zooming in on daily stressors

It is unsurprising that Syrian refugee children often show signs of distress as a result of everyday experiences in displacement. This research found, however, that these commonplace reactions to difficult everyday life are often presumed by PSS practitioners to be post-traumatic stress disorder (PTSD) or trauma related to war exposure. The pathologisation of normal reactions to chronic stress in Syrian refugee children may be leading to over-diagnosis of mental health issues and an unbalanced focus on clinical interventions. While recognising that a certain proportion of Syrian children are suffering from trauma and therefore require specialised treatment, one regional child protection manager felt that too many are getting clinical treatment for mental health problems that aren’t actually there. The same respondent also warned against over-training PSS practitioners, in this case teachers, on identifying mental disorders:

If for instance, a big agency comes in [with a lot of diagnostic tools and referral mechanisms for depression or PTSD to specialised services], I think that’s a terrible idea. You always find what you’re looking for. You end up diagnosing and labelling two-thirds of your class as having a mental disorder … I’m absolutely against these teacher trainings to make little ‘detectives’ of mental disorders.

One respondent emphasised that interventions for one-off traumatic events ignore the huge opportunity to reduce psychosocial distress by targeting the stressful conditions of everyday life in a displacement context. Programmes targeting day-to-day sources of stress for Syrian refugee families might include livelihoods, poverty reduction, life skills training and community-based child protection. The same respondent thought that these types of programmes may not be as ‘flashy’ as trauma interventions, but are ‘probably more important’.

The conundrum of measuring wellbeing

The dominant research focus on PTSD or trauma in the Syrian response can be explained in part by the limited funding available, which increases the need for organisations to demonstrate measurable outcomes. One interview respondent commented that the outcomes of one-to-one interventions for trauma are easier to measure than non-specialised interventions for psychosocial wellbeing on a group level. A regional child protection manager pointed out that ‘wellbeing’ is very difficult to quantify because it is a process and not just an outcome, and means different things to different people. They also pointed to the difficulties of using linear log-frame models and the push to quantify PSS outcomes:

the donors] ask you questions like ‘How many men, how many boys, how many women, how many girls are leading a better life because of your programme?’ … This is really a slap in the face of all social science, you can’t really do it like that.

Interview participants emphasised the need for a more adaptive, qualitative approach to explore local concepts of wellbeing and to meet the IASC’s recommendation of tailoring assessment tools to the local context. One respondent thought that organisations should use monitoring and evaluation tools that find out ‘what is a problem for people, and not so much the pre-construed scales that are simply coming from a different context’. Both child protection and education participants noted that evaluative surveys need to be designed with children in mind. One respondent was horrified by a questionnaire for children that included the question ‘Do you think life has meaning?’, noting that this type of question would ‘probably depress an adult, let alone asking it to a child’. Another participant recommended asking open questions:

I think that the way to approach it would be to look at, ‘Why are you not feeling good? What are the biggest conflicts, the biggest stressors, the biggest fears, the biggest feelings of loss around you that are weighing on your shoulders?’ and then take it from there.

One participant suggested that the recently published IASC and IFRC tools for monitoring and evaluating PSS programmes were two ‘bits of light at the end of the tunnel’ – both tools are adaptive and offer a combination of quantitative and qualitative assessments to explore local concepts of wellbeing. Gaining donor and government support for these less linear methods of evaluation will be key.

The benefits of an everyday, qualitative approach

Organisations providing PSS in the Syrian refugee response confront many challenges. First and foremost, they face the formidable task of helping refugee families to deal with wide-ranging daily stressors. Interviews conducted with PSS practitioners in the Middle East suggest how these challenges might be overcome through NGO programming. First, organisations need to improve inter-agency coordination in non-camp settings. Skilled and experienced facilitators, including teachers, can help ensure the inclusion of parents and communities in PSS programming. Programmes which target daily stressors for families through livelihoods, poverty reduction, life skills training and community-based child protection all have the potential to help reduce psychosocial distress in Syrian children. Finally, monitoring and evaluation tools that use qualitative as well as quantitative methods, as well as being more adaptive than linear log-frame models, can help organisations assess the strength of their programmes against what wellbeing really means to Syrian refugees and their hosts in the Middle East.

Emma Soye is a doctoral researcher at the University of Sussex. She has researched refugee wellbeing for organisations including Save the Children UK, GIZ and the Institute of Development Studies.