Issues Associated with Addressing Mental Health and Psychosocial Wellbeing in Turkey’s Syrian Refugee Youth

Author: Jacquelyn Easterwood, 2018.

Syrian_refugee_center_with_group_in_center

“Photos of distressed and innocent children fleeing from war-torn Syria have flooded the media since the influx of refugees into various countries began in 2015…”


Photo of the Ceylanpınar tent camp posted on Wikipedia under Public Domain.

 

Photos of distressed and innocent children fleeing from war-torn Syria have flooded the media since the influx of refugees into various countries began in 2015. The refugee crisis followed the start of a vicious civil war which broke out in Syria in 2011, pitting rebel groups against the Syrian government. The result has taken a devastating toll on the citizens of Syria. Furthermore, the instability in the country has created a breeding ground for other violent groups, including the Islamic State of Iraq and the Levant (ISIL), to gain territory and incite more fear and violence within Syria. The violence has diminished the quality of life for a staggering number of Syrian citizens and has caused families, unaccompanied youth, and other civilians to flee for safety.

While exact numbers are uncertain, recent reports by the United Nations High Commissioner for Refugees (UNHCR) suggests that well over 5.5 million Syrians have fled the country, 6 million are displaced within Syria’s borders, and 4.5 million are in dangerous and unreachable zones (“Syria Emergency”). A significant proportion of the refugee population is under 18, and UNHCR mentions in their Regional Refugee and Resilience Plan (3RP) Syrian Response report that half of them are out of school. With malnourishment on the rise, health services lacking, and education nearly inaccessible, the UNHCR High Commissioner, Filippo Grandi, refers to Syria as “the greatest humanitarian and refugee crisis of our time” (“Syria Emergency”).

 

Meeting Refugee Needs

As mentioned in UNHCR’s 3RP 2017 Syrian Response report, most of the people fleeing Syria are seeking refuge in neighboring countries in the Middle East, including Jordan, Lebanon, Iraq, and Turkey. While most have settled in Turkey, a significant number have also fled to various European countries. In fact, Milovancevic, Ispanovic, and Stupar (2016) found that between the second and third quarters of 2015, the number of asylum applicants in the European Union (EU) increased by 100 percent. Furthermore, UNHCR reports on their “Inter-Agency Information Sharing Portal” that most Syrian refugees in the EU are residing in Germany, as over 500,000 asylum applications have been received and over one million refugees have entered the country. Of the refugees seeking safety in Germany in 2015, over 60,000 of them were unaccompanied minors; refugee children are especially prone to mental health issues since they are at a higher risk of neglect and exploitation through trafficking and abuse (Milovancevic et al. 2016). While the world is experiencing the effects of record-breaking refugee numbers, host countries as well as the international community must pay special attention to how the mental health and psychosocial wellbeing (MHPSS) of young Syrian refugees is being addressed. The following analysis focuses on issues associated with the mental health of displaced conflict-affected children and youth, specifically young Syrian refugees currently living in Turkey.

In complex emergency situations, it is generally understood that basic human services must be provided to the affected population. The Inter-Agency Standing Committee (IASC) Guidelines on Mental Health (2007) highlight the importance of providing food, water, shelter, access to education and basic healthcare as the immediate minimum needs of refugee communities, but Rousseau, Measham, and Nadeau (2013) stress that the mental health of refugee children is not commonly addressed as a top priority. One explanation for this is that children can seamlessly shift between exhibiting normal patterns of behavior and displaying struggles in mental health or negative behavioral traits (Özer, Sirin, and Oppedal 2016). This observation helps explain the under-prioritization of mental health research and psychosocial support of refugee children, as their abnormal behavior can become normalized if it persists. Despite this, IASC Guidelines on Mental Health (2007) recognize that when youth experience traumatic incidents, negative psychosocial effects and mental health struggles tend to be closely related. These health effects can be internal, as exhibited through depression, PTSD, anxiety, and stress, or external, as exhibited through behavioral issues and violent outbursts (Reed, Fazel, Jones, Panter-Brick, and Stein 2012). War and violence can have a particularly detrimental effect on displaced children and youth as they grow and develop into young adults (Reed et al. 2012). Therefore, it is important to assess and address their mental health as early as possible as Syrian refugees are likely to have experienced many different forms of trauma.

Traumas typically associated with refugee children and youth include witnessing the death of a loved one, experiencing torture, sexual assault, abduction, exploitation, and separation from loved ones. Additionally, youth who are victims of malnutrition and poverty pre-migration are particularly susceptible to anxiety and other mental health issues when arriving in their host country (Alpak et al. 2015). When addressing mental health and psychosocial problems in youth populations, IASC Guidelines on Mental Health (2007) emphasize the importance of reestablishing a sense of normalcy and security by providing the minimum basic services mentioned above to allow youth to feel more comfortable in the host country. Refugee youth often find themselves in situations where access to education is limited, language barriers are a challenge, family dynamics have shifted, and their sense of normalcy is nearly depleted. Oftentimes, youth have also been exposed to violence during their journey. These issues can have a direct impact on the mental health and psychosocial wellbeing of youth cohorts and are felt by a significant population of young Syrian refugees residing in Turkey.

 

Syrian Refugees in Turkey

According to the UNHCR’s 3RP Syrian Response report, Turkey currently hosts the largest number of refugees in the world. The report mentions that of the millions of refugees emerging from Syria, more than three million are currently registered refugees in Turkey, while many more are assumed to be living in the country unregistered. Furthermore, the report shows that only eight percent of these refugees are residing in Turkey’s 21 government-run refugee camps, which leaves 2.5 million people living in urban, semi-urban, and rural communities within Turkey (3RP Regional Refugee 2017). The rapid influx of Syrian refugees in Turkey has threatened both the security of the country and the legitimacy of the social services sector.  Doganay and Demiraslan (2016) report that this influx has caused food and water shortages in certain regions of the state and gaps in both somatic and mental healthcare. The authors found that overall healthcare needs are increasing and supplies are running short, which is causing children to go unvaccinated and crucial drugs to become unavailable. Additionally, the Syrian refugees living in Turkey are often living in overcrowded spaces, leading to the spread of diseases (Doganay and Demiraslan 2016).

The strain on Turkey’s social services leaves little room for addressing the mental and psychosocial support of traumatized refugees of all ages. While it is important to address the mental health and psychosocial support of refugee youth, the stress levels and mental health of adults and parents contribute to the mental success of the children (Milovancevic et al. 2016). It is therefore necessary to seek help for both the parents (or acting parents) and the children. In a PTSD study done in a tent city in Turkey involving face-to-face interviews with adult aged Syrian refugees, one-third of the participants were diagnosed with PTSD (Alpak et al. 2015). The study found that more women suffered from PTSD than men, and while it was possible for individuals to experience spontaneous remission, odds of remission decrease as exposure to trauma increases. While there are insufficient studies on the mental health of refugees in Turkey, the study by Alpak et al. and the study by Özer et al. described below could be helpful tools in generating more interest on the topic given the high frequency of PTSD found in these camps.

 

Mental Health of Children in Islahiye Camp

Another study done by Özer et al. (2016) in a Turkish refugee camp in Gaziantep utilized interview techniques and art therapy sessions to understand the mental and psychosocial struggles that refugee children were experiencing in the camp. Despite the need, there is limited research on this topic. This study sought to contribute useful information regarding the way refugee youth in the Islahiye camp respond to traumatic experiences. Özer et al. noted that the children observed in the study attended the camp’s school, which may have skewed the results toward more emotionally stable children and was not representative of the entire population, since only 25 percent of the camp’s children attended school. This indicates that the MHPSS issues within the camp may be worse than this study suggests. Regardless of this, they found that 60 percent of the participating youth displayed signs of depression, and 20 percent displayed symptoms so severe that their condition is likely to disrupt their emotional and behavioral development (Özer et al. 2016). Investing in children’s formative years and mental health development could positively impact the economy and community dynamics of host cities in Turkey. Additionally, the results of the study show that 45 percent of the youth had PTSD and 22 percent displayed aggressive behaviors (Özer et al. 2016). Failure to address these MHPSS issues in refugee youth could result in the externalization of symptoms, prompting violent outbreaks among youth cohorts in communities, which could ultimately threaten the security of Turkish cities and citizens.

 

Challenges for MHPSS in Turkey Refugee Youth

EU-Turkey Deal

Turkey is a key point of entry for refugees into Europe due to its ideal location between the Middle East and Europe, which means the EU has a vested interest in Turkey’s actions regarding migrants. In 2016, the EU-28 established a controversial deal with Turkey to reduce the numbers of refugees entering the EU, promising billions of euro in aid and resettlement assistance within various European countries. As a result, Human Rights Watch (HRW) has documented that refugees have been contained on Greek islands waiting to be sent back to Turkey. When reporting on the refugees’ mental health, HRW found a drastic increase in mental health challenges, some of which have resulted in suicide attempts, aggression, psychosis, and self-harm in the refugees secluded on the islands (“Q&A: Why the EU” 2016). Therefore, refugees who are eventually sent back to Turkey will have been exposed to more trauma due to this agreement. Although the EU-Turkey deal grants the Turkish government billions in aid funding, Turkey has consistently struggled to provide basic services to refugees. Additionally, according to HRW, the EU has not held up its end of the deal and has not received and resettled the number of refugees it agreed to within various European countries (“Q&A: Why the EU” 2016).

Aid Allocation and Funding

Aid from the EU and the international community is funneled into programs that provide education and health services for children; however, due to the overwhelming number of refugees residing in Turkey, the resulting progress reports are bleak, particularly regarding the mental health and psychosocial support of the population. 3RP, which is an inter-regional project established by UNHCR to implement programs addressing the basic needs of Syrian refugees in the Middle East, reported that only one percent of their target population of 800,000 individuals has received mental health consultations in Turkey (3RP Regional Refugee 2017). Various other basic needs of refugees may take precedence while Turkey struggles to keep up with the ever-growing refugee population. The education of these Syrian refugee youth is prioritized and widely publicized by media outlets, often referring to this cohort as possibly becoming a “Lost Generation.” This could influence the amount of funding allotted to programs not pertaining directly to education; however, strengthening mental health and psychosocial support could positively impact the education programs by improving the overall functioning of the youth (Rousseau et al. 2013). Additionally, the Turkish government is scrambling to prioritize immediate somatic healthcare to Syrians. By the end of 2015, Turkey had spent over $800 million on the health of Syrian refugees, possibly lending to the under-prioritization and inaccessibility of mental health resources for refugee youth cohorts in Turkey (Doganay and Demiraslan 2016).

 

The Importance of MHPSS for Syrian Refugees in Turkey

State Security

As the study by Özer et al. (2016) found, refugee youth with unaddressed MHPSS issues could ultimately respond with violent and destructive behavior which could threaten the security of Turkey and Turkish citizens. These grievances could become heightened in a country which is politically unstable and has an overworked health system (Reed et al. 2012). Additionally, insecurities brought on by uncertainty and hopelessness can contribute to various forms of violence. Youth violence can also manifest itself through criminal acts and gang activity in communities. Hilker and Fraser (2009) highlight that a general lack of social services, such as inadequate healthcare and poor education infrastructure, is likely to lead to youth grievances (Hilker and Fraser 2009). Tending to youth mental health and insecurities will likely assist in creating a safe and normal environment for young refugees, which could minimize the likelihood of violent outbreaks due to social grievances later in life (Hebebrand, Anagnostopoulos, Eliez and Linse 2016). Likewise, as Özer et al. (2016) found in their camp study, mental health issues can negatively affect behavioral development in children, which could ultimately discourage them from being law-abiding and productive citizens in the future.

Economy and Social Impacts

Addressing and assessing the mental health and psychosocial wellbeing of refugee youth is essential to the future of the economy and social services of Turkey and other refugee host countries. Refugees can stay in their adopted host country for long periods of time. According to UNHCR’s 3RP Syrian Response report, Turkey is attempting to integrate Syrian refugee youth into its education system, which could ultimately encourage the growth of Syrian employees in Turkish companies. If Turkey invests in the mental health of refugee youth now, future employees and employers are likely to be more stable. Mental health issues can have a detrimental impact on economies since they account for most sick days and unemployment (Özer et al. 2016). High unemployment rates, substance abuse issues, lower levels of education, and other social issues are associated with individuals who have experienced traumas as youth (Hebebrand et al. 2016). Additionally, per Hebebrand et al., stress and anxiety issues tend to reoccur throughout generations, which could possibly impact the social constructs and economy of Turkey for decades to come if not appropriately addressed.

 

Recommendations

Government of Turkey

  1. Continue to prioritize the accessibility of social services, such as education and healthcare, for refugee youth. Additionally, establish community programs that encourage young refugees to engage with other youth populations, encouraging a sense of normalcy and comfort in their communities. Address the uncertainties felt by the refugee population and seek to establish a refugee policy that is more inclusive by communicating with neighboring countries who have taken in refugees. Combat insecurities by ensuring that all children born to refugees in Turkey are registered with the government.
  2. Share information with the EU and neighboring countries to promote stronger systems of monitoring and evaluating mental health and psychosocial wellbeing of refugee youth. Train staff members in social services sector to understand and appropriately address mental health disorders so they may provide psychosocial support for affected refugee youth.
  3. A study implemented by Hebebrand et al. (2016) found that due to language barriers, it could take between one and two years for individuals to find appropriate mental health services. Therefore, establish incentives for Arabic-speaking Turkish citizens to provide Turkish language lessons to allow for the successful mental assessments of refugees. Train more Syrian professionals in the education and health sectors so they may contribute to the growth of the youth, the elimination of the gap in social services, and the minimization of the language barrier for refugee youth.
  4. Ensure the prioritization of the familial and group social structures by allowing young refugees to stay with those whom they are comfortable with, while placing a strong emphasis on familial reunification. Unaccompanied youth may grow attached to certain groups during migration, which may help transition them into refugee society. Encourage safety and security of refugee youth, particularly those who are unaccompanied, noting their vulnerability to abuse, exploitation, and mental distress.

European Union

  1. Continue to support Turkey with funding so they may address potential grievances of their refugee population and state citizens. The EU should promote and invest in regional security and should seek to maintain peaceful relations by upholding agreements and providing support.
  2. Appropriately address the terms of the EU-Turkey deal and note the negative consequences being experienced by Syrian refugees in Greece. Modify the goals of the deal to promote the safety and dignity of the affected individuals. Additionally, uphold the terms of the deal and allow for the negotiations of Turkish accession to the EU. Assist the Turkish government in resettling Syrian refugees in various European countries to alleviate the strain being felt by the Turkish government and social service sectors.

International Community

  1. Continue to assist Turkey in supporting the influx of refugees through in-country programs and financial assistance. Ensure that refugee camps maintain humane and safe conditions in accordance with international standards, including by providing social services through education and health systems.
  2. Continue to prioritize education; but include mental health evaluations and assessments in the education system. Monitor the ethical standards of mental health and psychosocial support by addressing cultural barriers and practices. Encourage community-driven psychosocial support groups to combat the cultural and social stigmas surrounding mental health support.
  3. Hold Turkey accountable for human rights abuses committed against Syrian citizens within the country. Make certain that the EU acknowledges its role in human rights violations occurring in Greece and continue to seek to end abuses.

 

Conclusion

Addressing mental health issues is a crucial step in building resilience in young refugees. Resilience in this case is described as “the process of overcoming rather than succumbing to the effects of exposure to risks during an individual’s life” (Reed et al. 2012). Some refugees may spontaneously build resilience in emergency situations, and while not all Syrian refugee youth are impacted by mental health issues, research suggests that a large portion are continuing to suffer from issues related to mental health and psychosocial wellbeing. This is significant as there are long-term effects associated with failing to address mental health issues that could impact both the youth, the community, and even the security of Turkey and its economy, as mental health disabilities can be debilitating for individuals. The Turkish government needs to immediately address these mental health gaps and should not take this task lightly. Additionally, the EU’s invested interest in regional security, and the international community’s commitment to human rights and dignity should encourage increased dialogue about the mental health and psychosocial support services for Syrian refugees. Ensuring mental wellbeing early on for refugee youth should be prioritized when host countries are mapping out their plans for intake as it can ultimately assist in creating resilient individuals, strong communities, and successful societies.

  


 

Works Cited

Alpak, Gokay, Ahmet Unal, Feridun Bulbul, Eser Sagaltici, Yasin Bez, Abdurrahman Altindag, Alican Dalkilic, and Haluk A. Savas. “Post-traumatic stress disorder among Syrian refugees in Turkey: a cross-sectional study.” International journal of psychiatry in clinical practice 19, no. 1 (2015): 45-50.

Doganay, Mehmet, and Hayati Demiraslan. “Refugees of the Syrian civil war: Impact on reemerging infections, health services, and biosecurity in Turkey.” Health security 14, no. 4 (2016): 220-225.

“EU/Greece: Asylum Seekers’ Silent Mental Health Crisis.” Human Rights Watch. July 12, 2017. Accessed November 27, 2017. https://www.hrw.org/news/2017/07/12/eu/greece-asylum-seekers-silent-mental-health-crisis.

Hebebrand, Johannes, Dimitris Anagnostopoulos, Stephan Eliez, Henk Linse, Milica Pejovic-Milovancevic, and Henrikje Klasen. “A first assessment of the needs of young refugees arriving in Europe: what mental health professionals need to know.” (2016): 1-6.

Hilker, Lindsay M., and Erika Fraser. “Youth exclusion, violence, conflict and fragile states.” Report prepared for DFID by Social Development Direct, London (2009).

“Inter-agency Information Sharing Portal.” UNHCR Syria Regional Refugee Response. United Nations High Commissioner for Refugees (UNHCR). November 16, 2017. Accessed November 27, 2017. http://data.unhcr.org/syrianrefugees/regional.php#.

Inter-Agency Standing Committee. IASC guidelines on mental health and psychosocial support in emergency settings. Inter-Agency Standing Committee, 2007.

Milovancevic, Milica Pejovic, Veronika Ispanovic, and Dusko Stupar. “Lessons learned from the past on mental health care of refugee children in Serbia.” European child & adolescent psychiatry 25, no. 6 (2016): 669-672.

Özer, Serap, Selcuk R. Sirin, and Brit Oppedal. Bahçeşehir study of Syrian refugee children in Turkey. Bahçeşehir Üniversitesi, 2016.

“Q&A: Why the EU-Turkey Migration Deal is No Blueprint.” Human Rights Watch. November 25, 2016. Accessed November 27, 2017. https://www.hrw.org/news/2016/11/14/qa-why-eu-turkey-migration-deal-no-blueprint.

Reed, Ruth V., Mina Fazel, Lynne Jones, Catherine Panter-Brick, and Alan Stein. “Mental health of displaced and refugee children resettled in low-income and middle-income countries: risk and protective factors.” The Lancet 379, no. 9812 (2012): 250-265.

Rousseau, Cecile, Toby Measham, and Lucie Nadeau. “Addressing trauma in collaborative mental health care for refugee children.” Clinical child psychology and psychiatry 18, no. 1 (2013): 121-136.

“Refugee Children in Crisis.” United Nations High Commissioner for Refugees (UNHCR). The Future of Syria. Accessed November 27, 2017. http://unhcr.org/FutureOfSyria/executive-summary.html.

3RP Regional Refugee & Resilience Plan 2017– 2018 in response to the Syria crisis. UNHCR and UNDP, 2017. Accessed November 27, 2017. https://reliefweb.int/report/syrian-arab-republic/3rp-regional-refugee-resilience-plan-2017-2018-response-syria-crisis.

“Syria emergency.” UNHCR. United Nations High Commissioner for Refugees (UNHCR). Accessed November 27, 2017. http://www.unhcr.org/en-us/syria-emergency.html.

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