'Against All Odds': UNHCR's Mental Health and Psychosocial Support Programme for Iraqi Refugees and Internally Displaced S

Against‘ all odds’: UNHCR’s mental health and psychosocial support programme for Iraqi refugees and internally displaced Syrians, Intervention 2013, Volume 11, Number 2, Page 190 - 194

‘Against all odds’: UNHCR’s mental health and psychosocial support programme for Iraqi refugees and internally displaced Syrians

Sarah Harrison, Riwa Dahman, Maha Ismail, Edith Saada, Maysaa Hassan, Rasha Hassan, Adam Musa Khalifa & Marian Schilperoord

Intensi¢ed ¢ghting and insecurity in Damascus has gained, territorylost, andthe toll oncivilians. limited the ability of the Iraqi refugees, displaced Sadly, there appears to be little enthusiasm Syrians, partners and sta¡ to physically access many to highlight the important, day-to-day acti- of the ¢xed facilities o¡ering mental health and vities of humanitarian workers continuing to psychosocial services.Those that do, have to travel provide mental health and psychosocial sup- substantial distances through checkpoints and ‘hot port in the midst of this crisis. areas’. However,before the con£ict in 2011,UNHCR Displaced Syrians, who seek shelter within Syria was already in the area, operating a com- host communities or in collective shelters prehensive mental health and psychosocial support across the country, report feelings of fear, programme for Iraqi refugees, building on the anxiety, helplessness, hopelessness, isolation resources and capacities of the refugee population. and profound distress at the events unfolding In 2012, this programme was opened to support around them to outreach volunteers. Syrians a¡ected by con£ict through a mixture of According to the Syrian Ministry of Local (mobile) individualised case management, family Administration, as of 16 April 2013, less than and community level supports provided by outreach 5% of this displaced population live in volunteers, and targeted assistance to displaced per- collective shelters, with the remainder resid- sonslivingin collectiveshelters.So,while notmaking ing within host communities.These commu- the headlines, the quiet, day-to-day activities of nities have shown enormous generosity by humanitarian workers providing mental health opening their homes to fellow Syrians, but and psychosocial support services to an increasingly now are feeling fatigued, over-burdened distressed population continue, against all odds. and ¢nancially exhausted, leading to an overall decrease in their coping capacity Keywords: armed con£ict, internally and resilience levels. Within this environ- displaced persons, outreach volunteers, ment of profound distress of those displaced, refugees, Syria and loss of resiliency and coping within host communities, humanitarian agencies and Introduction organisations are still managing to provide With the con£ict in Syria entering its third assistance and support. Therefore, they are year, it is hard to ¢nd uplifting stories or attempting to alleviate the distress and articles written about the country. There is su¡ering of men, women and children in a daily media diet of bombings, mortar the midst of this unravelling con£ict, against attacks, casualty ¢gures on the rise, territory all odds.

The mental health and psychosocial support a capacity building project targeting programme of UNHCR. national level service providers, such as the In response to the in£ux of Iraqi refugees to Ministry of Health and Education.This pro- Syria in 2006, the United Nations Refugee gramme has been documented previously Agency (UNHCR) realised an overwhelm- (Quosh, 2011), and more publications on this ing need to provide mental health and psy- programme are in preparation. chosocial support (MHPSS) services to a highly vulnerable refugee population. In Expanding needs: from Iraqi refugees to internally 2008, 8.4% of the Iraqi refugee population displaced Syrians reported severe mental health and psycho- During 2012, the programme was gradually social di⁄culties (UNHCR Syria,2011).This outsourced to UNHCR’s main local partner prompted UNHCR to adopt a radically the Syrian Arab Red Crescent (SARC), di¡erent approach towards MHPSS pro- and at the same time expanded to include gramming for refugees in an urban context. all Syrians (including children) a¡ected by Traditionally, UNHCR would address the the con£ict. National nongovernmental psychosocial and mental health problems of organisations (NGOs), local communities, refugees in an ad hoc manner, referring the operational UN agencies (e.g., UNHCR) few individuals in need of more specialised and government ministries have primarily support to local practitioners. The MHPSS provided the humanitarian response to this programme in Syria followed a more con£ict. This is due to the fact that inter- innovative and comprehensive approach national NGOs and other humanitarian whereby, for the ¢rst time in the history of agencies have limited, or no, access to UNHCR, UNHCR sta¡ directly imple- Syria. UNHCR’s MHPSS programme was mented and organised a mental health and in a unique position because it was already psychosocial support programme for refu- established within the country and had gees. This pilot programme was built on the developed strong working relations with capacities and resources of the refugee com- local actors, and key line ministries (Educa- munity, and managed to reach vulnerable tion, Health and Social A¡airs). refugees with complex needs, within an Moreover, the programme approach urban environment. focused on optimising local resources, The programme sought to improve the strengthening existing capacities and psychosocial wellbeing and mental health mobilising volunteers from the a¡ected of the most vulnerable refugees, as well as population to aid with outreach activities. Syrians who have also been impacted, This approach is important, because through comprehensive case management, Syria has a very limited number of holistic community based psychosocial trained MHPSS professionals, (psychia- support and capacity building. From 2008 trists, psychologists, social workers and to 2012, the programme comprised three psychiatric nurses) with only 70 psychia- complementary pillars: (1) individual case trists for a population of around 20 million management for the most vulnerable, (WHO, 2009). The number of MHPSS directly implemented by UNHCR case professionals remaining inside Syria has workers; (2) a community based outreach steadily fallen, as many have been targeted, volunteer programme and an outreach forcing them to £ee the country (Abo-Hilal counselling centre run by refugees; and (3) & Hoogstad, 2013).

191 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Against‘ all odds’: UNHCR’s mental health and psychosocial support programme for Iraqi refugees and internally displaced Syrians, Intervention 2013, Volume 11, Number 2, Page 190 - 194

Additionally, the psychiatric hospitals in the refugees, displaced Syrians, partners and country have su¡ered severely1.Capacity sta¡ to physically access many of the ¢xed building activities that originally focused facilities (such as SARC-primary health on providing MHPSS support to refugees clinics) o¡ering mental health and psycho- in a stable urban environment have had to social services. Refugees and Syrians are adapt their focus more towards providing understandably very scared and reluctant MHPSS in emergency settings. Capacity build- to leave their houses or collective shelters to ing activities are also now aimed at local travel substantial distances across the city, communities, NGOs and Syrian psycho- through checkpoints and ‘hot areas’, to access social outreach volunteers, in addition to services. In an attempt to make services more national level partners previously included accessible, UNHCR plans to provide ¢nan- under the refugee programme. cial and technical support to SARC’s mobile psychosocial and mental health teams, to Opening the programme for Syrian internally identifyand refer cases requiring more inten- displaced persons sive case management, and to provide struc- Due to security issues, the outreach counsel- tured social and recreational activities for ling centre in Damascus had to close for men, women, boys and girls living within two months during the summer of 2012. It collective shelters and host communities. reopened in another Damascus neighbour- hood during the autumn of 2012, but once Working through partners again had to close due to security issues Psychosocial support (PSS) is also inte- arising in the area.This prevented both out- grated within the work of partner run com- reach volunteers and bene¢ciaries (Iraqi munity centres (sometimes called outreach refugees and Syrians) from accessing the counselling centres), which are planned to centre. Psychosocial support is now increas- open in: Aleppo,Tartous, As-Sweida, Homs, ingly integrated into SARC run centres, Damascus and rural Damascus, as well as where regular activities for refugees and partner run shelters for survivors of gender Syrians take place, such as: yoga, peer sup- based violence, monitored by UNHCR’s port groups for women and men, awareness protection and community services teams. raising sessions, story sewing (where women PSS is also increasingly integrated into and girls use embroidery as a means in which the education, community mobilisation to convey their life story) and sewing. Acti- and livelihood activities conducted by the vities are monitored by a Psychosocial community services unit for refugees and Technical Coordinator, but facilitated by displaced Syrians. Since 2013, all community outreach volunteers and other contracted centres and shelters are opentoboth refugees sta¡. Case management of the most vulner- and Syrians a¡ected by the con£ict. The able refugees and Syrians continues to be centres are designed to provide an oasis of providedby SARC, in additionto psychiatric calm and a trusting, safe space where men, specialised services in three SARC poly- women, andchildren canbeginto share their clinics located in Damascus. thoughts, emotions, hopes, fears and dreams. With many Syrians and refugees forced to Working within a volatile context live in overcrowded and squalid collective Intensi¢ed ¢ghting and insecurity in shelters (many of which are public buildings Damascus has limited the ability of the Iraqi such as schools or former municipal

buildings) the community centres represent children and persons with disabilities. More one of the few spaces that people of all back- specialised outreach volunteers (called grounds can feel safe enough to begin to ‘psychosocial outreach volunteers’) identify and re£ect and process the events around them, refer possible cases requiring more special- and to plan for their future. ised MHPSS care to the case managers within SACR primary health care clinics. The importance of outreach volunteers They also conduct home visits as part of Each community centre is also supported by the follow-up for people with psychosocial outreach volunteers who provide structured problems. The psychosocial outreach volun- and semi structured social, recreational, teers are currently drawn from the Iraqi educational and livelihood activities at the refugee population, with plans to involve centres, conduct community mobilisation Syrians recruited from the a¡ected popu- and awareness raising activities (e.g., on lation in 2013. the importance of breastfeeding, or helping The box below highlights one of the spon- parents to manage a distressed child). Out- taneous initiatives conducted by Iraqi refu- reach volunteers also conduct home visits gee outreach volunteers, who themselves for extremely vulnerable and isolated su¡er from displacement, to support Syrians people, such as the elderly, unaccompanied a¡ected by the con£ict.

Box 1: Local initiatives In July 2012, many refugee outreach volunteers, with strong links to local charitable organisations, decided to informally volunteer to provide services and assistance in the collective/communal shelters springing up across Damascus where UNHCR did not have access. Refugee outreach volunteers collected relief items from host communities for onward distribution to displaced Syrians, in addition to providing social and recreational activities to girls and boys living in collective shelters. Some refugee outreach volunteers have continued to provide remedial classes and recreational activities, through charitable associations, which remain ongoing. One refugee outreach volunteer, an Iraqi refugee, commented on her work; ‘it is such an empowering and good feeling to support children in the shelters, to help them to try and live a digni¢ed and happy life despite their surroundings.’ These psychosocial outreach volunteers represent the foundation of the mental health and psychosocial support programme. This is, in part, due to the fact that Syrian and refugee outreach volunteers are able to access areas that UNHCR sta¡ are currently not permitted to visit, including collective shelters and communities hosting displaced Syrians. The outreach volunteers and the mobile MHPSS case managers are therefore able to provide a crucial outreach function by helping to decentralise psychosocial support and to bring mental health services closer to vulnerable populations. In practice, this means that everyday, outreach volunteers are quietly negotiating checkpoints, and working in very ‘hot neighbourhoods’to alleviate the most distressing e¡ects of the con- £ict for these groups. The work of the outreach volunteers is priceless and it enshrines ongoing information sharing, and ensures soothing contacts with distressed civilians so they do not feel forgotten.

193 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Against‘ all odds’: UNHCR’s mental health and psychosocial support programme for Iraqi refugees and internally displaced Syrians, Intervention 2013, Volume 11, Number 2, Page 190 - 194

Conclusion 60th Anniversary of the1951Refugee Conven- It is not easy providing mental health and tion. psychosocial support services to a mixed target population (refugees and displaced World Health Organisation. (2009). Global Syrians), in a country that is at war with Health Observatory: Country Statistics: itself. Needs seem to grow every day and Syrian Arab Republic. Retrieved from: the ability to support Syrians and refugees http://apps.who.int/gho/data/view.country. to live a life of dignity, despite their sur- 19200D?lang=en. roundings, remains a challenge that the outreach volunteers, our partners and 1 Ibn Khaldoun psychiatric hospital in Aleppo MHPSS programme sta¡ seek to address has been badly damaged by the con£ict, leading daily. to the evacuation of patients to a safer location. UNHCR’s MHPSS strategy in Syria focuses Unfortunately, Ibn Sina psychiatric hospital in on a systems approach that seeks to link rural Damascus may su¡er the same fate. community and home based care, provided by outreach volunteers, to more specialised Sarah Harrison is the International Associate mental health care accessible at the primary MentalHealthandPsychosocialSupportO⁄cer health care level. It is notable that this for UNHCR Syria, currently working from approach has so far centred on Damascus Amman. and its suburbs, where arguably services email: [email protected] and health infrastructure is already most Riwa Dahman, is a National Health O⁄cer for concentrated and developed. The challenge, UNHCR Syria, based in Damascus. now, is to decentralise and expand this pro- Maha Ismail, is a National Senior Psychosocial gramme to the other parts of the country, Case Worker for UNHCR Syria, based in where the need remains acute. Damascus. Edith Saada, is a National Senior Psychosocial Case Worker for UNHCR Syria, based in References Damascus. Abo-Hilal, M. & Hoogstad, M. (2013). Syrian Maysaa Hassan, is a National Senior Com- mental health professionals as refugees in munity Services Assistant for UNHCR Syria, Jordan: establishing mental health services based in Damascus. for fellow refugees. Intervention, 11,89-93. Rasha Hassan, is a National Senior Psychoso- cial Case Worker for UNHCR Syria, based in Quosh, C. (2011). Takamol: multi-professional Damascus. capacity building in order to strengthen the Adam Musa Khalifa is the Regional Senior psychosocial and mental health sector in Public Health O⁄cer for UNHCR covering response to the refugee crisis in Syria. Interven- Syria, Jordan and Lebanon. He is based in tion, 9, 249-264. Damascus and frequently travels to Lebanon andJordan. UNHCR Syria (2011). The Psychosocial and Marian Schilperoord is Chief of the HIV and Mental Health Programme in Syria. Public Health Section for UNHCR, based at External Relations Unit publication for the UNHCR’sHeadquarters in Geneva.