War and Displacement Stressors and Coping Mechanisms of Syrian Urban Refugee Families Living in Istanbul

Abstract

The overall purpose of this study was to achieve a contextual understanding of war and displacement stressors and coping mechanisms among urban refugee families from Syria living in Istanbul. This study was informed primarily by Walsh’s family resilience framework and Weine’s Family Consequences of Refugee Trauma empirical model. Qualitative family interviews were conducted with a purposive sample of 30 Syrian refugee families from the Çapa and Esenlerneighborhoods of Istanbul. Data were analyzed using a grounded theory approach and Atlas/ti software. The analysis identified a total of 21 war and displacement stressors for families across three categories: 1) Surviving war and border crossing; 2) Living as urban refugees, and; 3) Parenting children in refuge. The analysis also identified a total of 16 coping mechanisms for families across four themes: 1) Flexible and reciprocal family organization; 2) Hopeful family beliefs and communication; 3) Staying connected with family in Syria and in exile, and; 4) Making the best of living in a new country. These findings underlie the need for several practice and policy priorities including: 1) Increasing the number of children attending Turkish schools and decreasing child labor; 2) Incorporating faith into psycho-social and mental health interventions, and; 3) Developing family focused interventions conducted by community-based lay providers that draw upon empirical models of family stressors and coping.

Approaches to helping persons in humanitarian crises have moved away from a heavy emphasis upon traumatic stress in individuals and towards a more balanced view of both psychological injury and resilience, of individuals, families, and communities. One important theoretical contribution is Froma Walsh’s family resilience framework (Walsh, 2002), which is based upon family theory and clinical practice. It delineates the strengths and coping mechanisms of families under stress, in crises, or when facing adversity. According to Walsh (2016), family resilience centers on particular characteristics of the family’s belief systems, organizational patterns, and communication processes. Researchers have utilized the concept of resilience and applied it to war-impacted children (Betancourt & Khan, 2008) and families (Siriwardhana, Ali, Roberts & Stewarts, 2014).

Based in part upon Walsh’s family resilience framework, Weine et al. (2004) conducted prior qualitative research with Bosnian refugee families in Chicago so as to construct an empirical model of the consequences of political violence for refugee families. This model, called Family Consequences of Refugee Trauma (FAMCORT) identified 15 family stressors and 16 family coping mechanisms across four realms of family life: 1) changes in family roles and obligations; 2) changes in family memories and communications; 3) changes in family relationships with other family members, and; 4) changes in family connections with the ethnic community and nation state. One key benefit of this model is it provides an empirical underpinning specifically focused on refugee families for developing family resilience oriented mental health and psychosocial prevention and care (Laban, 2015). Both the Walsh and Weine frameworks were used to approach the situation of Syrian refugees living in Istanbul.

Currently an estimated 68.5 million people are forcibly displaced worldwide of which 25.4 million are refugees and 6.3 million are refugees from the war in Syria (UNHCR, 2018a). Turkey is presently the world’s largest refugee hosting country with about 3.6 million refugees of which are 3.2 million are from Syria. Only about 240,000 Syrian refugees live in Turkey in state sponsored refugee camps, while others are living in urban areas, with 500,000 in Istanbul (UNHCR, 2018b). Syrians refugees in Turkey are considered “guests,” not refugees, according to the Temporary Protection Regulation adopted in 2014 (UNHCR, 2018c). This law grants them temporary protection, and it is assumed they will return to Syria once the conflict ends (Içduygu, 2015).

Before leaving Syria, many adult and child refugees were exposed to physical and war related violence, the loss of loved ones, and other traumatic experiences (Sirin& Rogers-Sirin, 2015). Living in Turkey, Syrian refugees cope with multiple daily stressors such as: high housing costs, low wages, exploitation in the labor market, discrimination, and uncertainty about their future (Kaya &Kiraç, 2016). Despite the increase in school enrollment of refugee children, over 40% of Syrian refugee children are still not in school (UNICEF, 2018).

Available studies with Syrian refugees are predominantly focused on common mental health disorders and are largely based on quantitative methods. Several prior studies assessed the mental health of adult Syrian refugees in Turkey and found rates of common mental disorders in adults between 23% and 42% (Alpak et al., 2015; Quosh, Eloul, &Ajlani, 2013) and half of children had PTSD (Sirin, & Rogers-Sirin, 2015). Syrian refugees resettled in Turkey reportedly have a higher incidence of mental health problems when compared to other refugees settled in Western countries (Karaman& Ricard, 2016). Syrian refugees show little knowledge and awareness of mental illness, self-care strategies, or clinical treatment, and express high stigma towards mental illness (Hassan, Ventevogel, Jefee-Bahloul, Barkil-Oteo, &Kirmayer, 2016). Syrians are a family-oriented culture, which typically includes not just the nuclear but also the extended family, and special care is given to vulnerable members such as the elderly (Hassan, et al., 2015). Hassan identified several positive individual coping strategies (e.g. talking to friends and family, praying, or thinking about good times) and several negative individual coping strategies (e.g. losing hope, worrying about family in Syria, obsessively watching news and behavioral withdrawal or “doing nothing”). However, neither Hassan nor others provide empirical data on how Syrian refugee families cope with war and displacement stressors. Further research is needed to understand the coping mechanisms of families, which could help in developing programs for refugee families. Practical recommendations for the design and delivery of mental health and psychosocial interventions for the 3 million plus Syrian refugees in Turkey are urgently needed, (Hassan et al., 2016) as well as for other low- and middle-income countries (LMICs) hosting refugees. These should be informed by an empirically based framework, which is focused on refugee families and their perspectives. The current study was grounded in both the resilience processes described in Walsh’s family resilience framework (Walsh, 2002) and the manifestation of family stressors and coping mechanisms in refugee families depicted in the FAMCORT model (Weine et al., 2004). The current study was also informed by Bronfenbrenner’s ecological model (Bronfenbrenner, 2005), which perceives refugee families in interaction with their immediate environment (e.g. neighborhood or diaspora community), the meso environment such as the socio-cultural context (e.g. norms and customs), and macro environments (e.g. governmental laws and non-governmental programs).

The overall purpose of this study was to achieve a contextual understanding of the war and displacement stressors and the coping mechanisms used to address these stressors among urban refugee families from Syria living in Istanbul. The specific aims of the study were to: 1) identify the war and displacement stressors experienced by urban refugee families living outside of refugee camps; 2) identify the coping mechanisms these families use to protect their family and its members, and; 3) discuss the implications for service priorities for urban refugee families including family resilience-oriented mental health and psychosocial interventions.

Methods

Participants

This study gathered data from 30 interviews with urban refugee families from Syria living in Istanbul. Of the 88 adults in these families, 67 participated in the interviews. The families had 86 members below age of 18. Thirty-three percent (n=10) were in Turkey for 6–24 months, 33% (n=10) for 25–36 months, 30% (n=9) for 37–48 months and only one family was in Turkey for 60 months. The number of family members living in each household ranged from 2 to 13 (mean = 6.4). Twenty percent (n=6) of the families reported monthly income between $195 to $300, 47% (n=14) of the families reported income between $301to $500 and 33% (n=10) of the families reported income between $501 to $650. (Note: The minimum wage in Turkey in 2017 was 460 USD (CSGB, 2017). Regarding monthly rent, 33% (n=10) paid $130 to $190 USD, 40% (n=12) paid $191 to $270 USD and 27% (n=8) paid from $271 to $430 USD.

Sampling & Recruitment Procedures

Thirty families were recruited using a purposive stratified sampling approach from two community-based organizations working directly with Syrian refugee families in the Çapa and Esenler districts of Istanbul. The inclusion criteria were: a) families living in Turkey for more than 6 months; b) families with at least one of the head of household living in Turkey; c) living in Istanbul; d) head of household actively engaged in family financial matters and decision making; e) willing to give consent for participating in study; f) above 18 years old; g) willing to be interviewed twice and to be contacted for the second interview, and; h) having at least two adult family members present during the interview.

Prior to recruitment, the study received approval from the Institutional Review Board at both the University of Illinois at Chicago in the U.S. and Koç University in Istanbul, Turkey. Field workers with previous experience in psychosocial projects were trained to use the developed protocols to approach families and make sure that families understood the study and their activities. The field workers initially contacted the head of households through phone and explained to them the aim of the study following a script prepared beforehand. Recruitment was done via cell phone since it is very common for Syrian refugees to have cell phones. In Turkey, 95% of Syrian refugee men and 85% of women had mobile phones (Jauhiainen, 2018).If the families accepted (a total of two families declined), then a field worker met face-to-face with the head of household and explained again the aims of the study and asked for their consent and the consent of the other family members, above 18 years of age, who would be present during the interview. By the end of the meeting, the fieldworker arranged the day and time for the interview to take place in the homes of the refugee families. Each interviewed family was compensated with $25.

Family interviews

The family interviews were conducted by the authors and took place in the apartments/houses where families lived. They ranged from 50 minutes to 120 minutes averaging about 75 minutes in length. The families already knew the interviewers because they were involved in recruitment. The number of family members over 18 years of age present in the interviews ranged from 2 to 6. The study used minimally structured interviews as a qualitative method of inquiry combining a predetermined set of open-ended questions with the opportunity for the interviewer to explore particular themes or responses further. As noted earlier, these questions were informed by Walsh’s family resilience framework, Weine’s FAMCORT model (Weine et al., 2004), and Bronfenbrenner’s ecological model (2005).

Sample questions included: “Tell us about your family and life in Istanbul.”; “What are the main stressors that your family is coping with?”; “How do you cope with these stressors you mentioned?” The interviews covered the following five domains: 1) family relationships, including organizational patterns and communication; 2) parenting/raising children; 3) everyday life in Istanbul for individual and family, including interaction with pertinent environmental systems, such as host community, health, social welfare, schools, and work; 4) mental health and coping, and; 5) help-seeking behavior. Interviewing families in their homes enabled interviewers to observe firsthand the living conditions and other living arrangement details which also became a prompt for interview questions and discussions.

The interviewers worked actively to elicit feedback from the family members present in the interview. The interviewers were sensitive to family power dynamics, for example respecting the head of the household but also making space for women and younger family members to speak. In some cases, when interviewers considered that the individual family member could contribute more to the study questions, they were interviewed separately during or following the family interview. Interviews were conducted by the authors, who are English speaking, with translation support by the fourth and fifth authors who are experienced translators from Arabic to English language and vice versa. The translators provided summative silent translation during the interviews so as not to interrupt the flow of the discussions. The families were informed upfront that they could end the interview at any moment if they chose to. All interviews ended on positive note by highlighting the strengths and achievements of the families and its members.

Data analysis

The data analysis used a grounded theory approach (Corbin & Strauss, 2007). All of the interviews were audio recorded, transcribed, and entered in ATLAS/ti in English after being translated from Arabic by a professional translator, who included all details from the recorded interviews in the transcripts. The interviewers read through all the interview transcripts and then created a code list with 67 codes, which was also informed by the aforementioned frameworks and models. Coder reliability was established between two coders (based upon 0.8 agreement), and then all the transcripts were coded. One coder was the first author and another coder had a master’s degree in psychology. Both were experienced in using ATLAS/ti for coding and analysis and were supervised by the second author who has extensive experience in qualitative analysis including with Atlas/ti.

Memos were added for passages of interest. Furthermore, to establish more condensed themes we conducted pattern coding by using ATLAS/ti’s query tool. Pattern coding is inductively examining the regularities, variation and peculiarities, identifying patterns and organizing the data into meaning making systems (Gläser&Laudel, 2013).For example, we used the query tool to search for quotations with the codes for “school” and “finance” or “language”. Following this analysis, more memoing was done to analyze for patterns or emerging themes. These emerging themes were identified by analyzing the similarities and differences in the content of the quotes coded earlier and by using the query tool of frequency and combination of codes. The analysis focused on respondents’ perceptions and perspectives on stressors and family processes and dynamics employed to deal with identified stressors. We continued extracting themes until no additional patterns emerged (O’Reilly & Parker, 2012). Finally, the themes were grouped into larger categories, which were also informed by the original FAMCORT model categories and concepts. Table 1 gives select examples of the process of analysis from codes to larger categories.

Table 1.

Selected examples of data analysis from transcript, coding, pattern coding to category

Passages from transcripts	Code/s	Pattern coding resulting theme	Category
“We used to live in Raqqa after the bombings we moved to Afrin and lived there for a year, with 15 people in one room. There was a siege there, with no food no bread coming in. So we left for Istanbul.”	- Life in Syria - War experiences - Traumatic experiences -Displacement	Displacement within Syria.	Surviving War and Border Crossing
“I didn’t want to put all of them to school, because I can’t bear the expenses of the school. Some of them have to work”	- Parenting - Children working - Not attending school - Children & school	Parents cannot afford living costs and children have to work and cannot attend school	Parenting Children in Refuge

Furthermore, following the initial analysis the findings were presented to six community-based organizations working with Syrian refugees in Istanbul and they were given the opportunity to confirm or question the validity and relevance of the findings. They considered the findings to be pertinent and aligned with their firsthand experiences and observations based upon direct work with Syrian refugees in Istanbul.

Results

The result section has two subsections. The first sub-section identifies war and displacement stressors and the second sub-section identifies coping mechanisms.

War and Displacement Stressors

The analysis identified a total of 21 family war and displacement stressors across three categories: 1) Surviving war and border crossing; 2) Living as urban refugees, and; 3) Parenting children in refuge. These stressors are summarized in Table 2 and the narrative below.

Table 2.

Family War and Displacement Stressors

Surviving War and Border Crossing	Living as Urban Refugee	Parenting Children in Refuge
- Direct prior exposure to war related traumatic events in Syria - Family loss and separation - Displacement within Syria Border crossing - Indirect current exposure to war related traumatic events in Syria - Families do not want to talk together about traumatic memories	- Poor family finances - Difficulty in findings apartments and poor housing - Hard working conditions - Discrimination against Syrians - Not speaking Turkish - Traditional gender roles are disrupted - Being stuck in Turkey - We are worried about family in Syria	- Parents cannot afford living costs and children have to work and cannot attend school - Some children cannot get registered for regular Turkish school - Parent cannot help children with homework or other school issues - Father’s not available at home and involved with children - Children bullied and discriminated against by classmates in school - School requires extra payments which families do not have - Children are forgetting Arabic language and culture

Surviving War and Border Crossing

Direct prior exposure to war related traumatic events in Syria

Most of the families reported multiple traumatic experiences including killings, bombings, siege, imprisonment and physical abuse. A mother reported,

The kids were scared sitting next to me. One was throwing up blood. They had guns pointed to our heads and the children didn’t understand. My little son was on my lap. He was throwing up blood from nose and mouth. I asked the man: ‘Brother please let me get something for my son to stop bleeding’. He said, ‘you are not allowed to raise your head, even if he dies on your lap’.

One of the individuals who was also fighting reported, “It was very hard. Bombing everywhere. I survived…war is difficult, you see dead people every day. Blood everywhere. It was difficult.”

Family loss and separation

Many families reported the death of family members and the separation of families because either some family members remained in Syria or other Middle Eastern countries or because some family members moved to Europe. One said, “My family lost 15 young men. A few are in prison either injured or we don’t know their whereabouts.” Another said, “I have five children, 3 daughters and 2 sons. One son died in Syria in the war. I have one son and daughter here in Istanbul and two others remain in Syria.” Another reported, “I have four sisters and a father in Germany, one sister in Belgium, two sisters with my mom in Lebanon, my eldest sister in Syria and I am here in Turkey.” Another said, “We have nothing left in Syria, nothing. His family (husbands) is scattered and mine too. Only his mom is in Syria. My sister in Lebanon, a brother in Mardin, two brothers died in Syria and their sons are orphans now.” Family losses also included material losses, as one noted, “My shop and home is in rubbles now.”

Displacement within Syria

Families reported long periods of displacement within Syria prior to fleeing to Turkey. One recalled, “We used to live in Raqqa, after the bombings we moved to Afrin and lived there for a year, with 15 people in one room. There was a siege there, with no food, no bread coming in. So we left for Istanbul.” Another said, “When the bombing started in Aleppo I moved my children to a village and then joined them later on with whatever I could carry from home. We had to move towards the Turkish border after we were imprisoned by ISIS.”

Border crossing

Most of the families reported having crossed the Turkish border illegally by paying high fees and experiencing multiple risks. One said, “The brother who came before me tried to cross the border and was shot. We took him back to Syria for treatment. He stayed in the hospital for 2 months.” Another said, “We tried in 5 attempts…there were families trying to cross during night, they had small children with them some of them would fall, hurt leg and break arm. They suffered a lot. Thank God we didn’t have baby.”

Indirect current exposure to war related traumatic events in Syria

Families continue to hear about family and friends in Syria being exposed to war violence and continuous threat. One woman reported, “They are suffering a lot in Syria from war. A lot. My daughter suffered a lot when her son died.” Another said, “Recently I heard about the death of my nephew in Syria. I couldn’t cry because I didn’t have anyone to talk with.”

Families do not want to talk together about traumatic memories

Families often reported they did not want to burden family members or other relatives about the difficult emotions related to traumatic experiences in Syria or news of losses of family members received while in Istanbul. A young man in a family reported,

My family can’t help me because they didn’t go through the same tough experiences as I went through. They had also tough experiences, but different ones, not siege or shelling. They don’t understand me. I need someone else with the same or with stronger means.

Another respondent said, “I don’t talk to anyone at all, I sit and cry. A woman explained not having anyone to talk to, she explained,

You can’t talk about war experiences. For example, we got the news about my nephew’s death, you can’t talk so as not to burden others. You get upset; you stay by yourself, just like that. After a while you get back to normal.

Living as Urban Refugees

Poor family finances

All the families reported poor family finances more than any other stressor. One said, “When there is no work, we can’t afford our living costs.” Another said, “We have great difficulties meeting costs from month to a month.” A parent reported, “We have to ration food in order to be able to pay the rent.”

Difficulties in finding apartment and poor housing

All the families were left to their own devices in finding housing which they said was difficult. About 80% of the apartments where interviews were conducted were in basement floors with very poor conditions especially in the winter (e.g. cold, damp, mold). One participant reported, “I want to change this house. Because it’s very cold, we pay a very high gas bill and still it is cold. It’s difficult to get another.” Another participant reported, “I tried to change my house, because it gets cold in this one. It is difficult to get an apartment as a Syrian as often they do not rent, and if they do the prices are higher for us.” Another participant said, “We are 10 people living in a 50-meter square room.”

Hard working conditions

All the families reported having family members who worked as unregistered workers, with long working hours, and often not being paid regularly. A respondent said, “The Turkish workers are getting paid around 2000 Turkish Lira while he gets paid 1100 Turkish Lira. Big difference.” Another one reported, “I worked in a print house company and was not paid.” Another reported, “Working hours are from 9 a.m. till 11 p.m. and in the end we didn’t get paid.”

Discrimination against Syrians

The families often complained about being discriminated against in Turkish society. Some people, they claimed, harbored prejudices against Syrians, which stemmed from misinformation and from a handful of negative experiences with a select few. A father reported, “Once a health personnel during a visit told us; why are you coming here, why don’t you go back to your countries. Go fight there.” A mother shared, “The problem is, being a Syrian, and they don’t even speak to you properly. For example, in some cases immediately they say yok, yok (NO in Turkish).”

Not speaking Turkish

Families mentioned that not knowing the Turkish language was a major handicap for the adjustment of both children and adults. One young adult reported, “Here it is hard to make friends because the language is a big obstacle.” A mother spoke of her son, “He doesn’t have friends, we might understand people and communicate with them, but he does not understand his friends.”

Traditional gender roles are disrupted

Families reported that the previously clear role division between men and women was challenged by living in Istanbul. A woman reported, “Here the father has less responsibilities, back in Syria he was responsible for everyone and everything including shopping, women didn’t go out in Syria. Here I have to go out I have to help him.” Another man reported, “The problems in families occur because the women goes out to work and interacts with others. She becomes like Turkish and wants to impose her opinion and personality to man, and problems occur.”

Being stuck in Turkey

Many families reported it was difficult, if not impossible, to reunite with their family members in Europe following the agreement between the E.U. and Turkey. Some families preferred to be in Europe. A family member who had most of his family in Germany reported, “The future is either here or Germany. We don’t know which. The plan is to reunite with our family there. We are trying. I visited many organizations, to try and migrate there, but it is not working out.” Another man reported, “We will continue to try this year to go to Europe. Going to Europe is very difficult. Going back to Syria is difficult, although there is a cease-fire in Aleppo but there are no schools or work. I am depressed to be honest.”

Worried about family in Syria

All the families reported being concerned about the safety of their family members remaining in Syria. One woman reported, “We talk a lot about our family in Syria, my girls and my mother, and my brother. Most of the talk is about our family. We wonder how they live in war. They don’t have electricity, and we worry about them.” Another woman reported, “I tell my brother constantly that I need to see my parents. They are getting old and have no one. I can’t go back there. It is not safe there.”

Parenting Children in Refuge

Parents cannot afford living costs and children have to work and cannot attend school

Many children did not attend school as they had to work so the family had enough money to survive. A father with two of his underage children working reported, “I didn’t want to put all of them to school, because I can’t bear the expenses of the school.” A parent with underage children reported, “Two of my children are working just to survive…the girls work as cleaners. They get paid around 200 TL a month so living here is very difficult.” A concerned parent said, “I am trying to work for my children and have them in school but I am not succeeding.” A parent reported, “It’s 9 in the evening and he was supposed to be in bed and not working.” Another family member reported, “There is nothing to do about it. He used to study, but now we are forced to work, to survive.”

Some children cannot get registered for regular Turkish school

Families reported facing serious difficulties in getting their children into regular Turkish schools. In 2018, all the Syrian schools were closed and the Turkish Government planned to integrate Syrian refugee children into public schools by opening language courses and including children in regular classes after they learn the language. A mother reported, “They won’t let my child in school. They say you can enter only in certain grades, so this year he is not learning anything.”

Parents cannot help children with homework or other school issues

Families reported that their children are facing difficulties in schools especially when integrated into Turkish classrooms. Parents felt unable to help their children with homework. A father reported, “They come from school with homework, and they to me and ask for help with homework, what is this? They say. I say I don’t know. They ask their mother also she says I don’t know. They start to cry.” Mother reported, “I can’t help my children with homework as I don’t know the language.”

Fathers not available at home and not involved with children

Many families reported long periods of absence of the father at home due to long working hours or living in another location. Fathers are mainly considered wage earners and are not involved in addressing the social and emotional needs of children. A woman reported, “My husband works in another country. He used to visit us every 3 months. Now it has been a year and 2 months since he was allowed to enter Turkey. I am alone here with the children, 13, 10 and 2 years old.” One father reported, “I can’t follow up with him about his school, I am at work most of the time, his mother follows up with him. Only she knows what the teacher says.”

Children bullied and discriminated against by classmates in school

Families reported cases of bullying of children based on their ethnicity. A parent reported, “He finds it difficult to go to school because of the language. And his Turkish friends always beat him. They don’t like the Syrians.” Another mother reported, “They treated her bad because she is Syrian. She used to come home and cry and say, ‘I don’t want to go to school.’”

School requires extra payments which families do not have

Parents said that costs related to books, uniforms, extracurricular activities were difficult to meet. One parent reported, “The school is very good, but they ask for things we can’t provide. They ask for money, they ask for books.” Another reported, “We put them in public school expecting it’s free, but they need uniform, books, we couldn’t by him a uniform.”

Children are forgetting Arabic language and culture

Parents expressed concerns about children forgetting Arabic (or Kurdish) language. One woman stated, “I don’t want them to forget the Arabic language. They are trying to teach them Turkish and they might forget Arabic.” Another mother said, “We want them to learn Turkish, so we can communicate with people. But also, we don’t want them to abandon our Arabic language.”

Staying in Turkey

Most of the families reported skepticism about returning to Syria due to the ongoing conflict and lack of safety in Syria, and how invested they were in establishing life for their families in Istanbul. A woman reported, “If possible I would send my mother to Syria to stay with my sister. I want to stay here with my children. I am comfortable here, where would I go back to there. My house is destroyed.” Another man reported, “We would like to go back, but we don’t know when we can. Syria is almost all destroyed. Any person would love to go back to his country.” Another young woman said, “We are all trying to learn Turkish language, because now, it doesn’t seem that we will go back to Syria.”

Family Coping Mechanisms

The analysis identified a total of 16 coping mechanisms across four themes: 1) Flexible and Reciprocal Family Organization; 2) Hopeful Family Beliefs and Communication; 3) Staying Connected with Family in Syria and in Exile, and 4) Making the Best of Living in a New Country. These are summarized in Table 3 and explained in the narrative below.

Table 3.

Family Coping Mechanisms

Realms of Family Life	Family Coping Mechanisms – themes
Flexible and Reciprocal Family Organization	- Family solidarity and support - Women’s empowerment is welcomed - Mothers set a positive emotional tone - Spouses share and support one another
Hopeful Family Beliefs and Communication	- It is God’s will and test for us - Hoping that children will have a better life - Praying and the Koran bring strength and relaxation - Having a positive and optimistic attitude
Making the Best of Living in a New Country	- Families maintain contacts with family members in Syria and Europe using the Internet - Families send money to Syria - Families use Arabic language with younger kids - Families plan for reunification
Staying Connected with Family in Syria and in Exile	- Families share good times together in Istanbul - Getting support from Syrian friends and neighbors - Feeling at home in Turkey because it is close to our culture - Parent going to school and talking with teachers - Not letting discrimination get them down

Flexible and Reciprocal Family Organization

Family solidarity and support

Families reported high levels of togetherness and support from their family members. A member of a 12-person family reported, “We were all working and supporting each other. We don’t distinguish who brings income and who does not. We share everything, income and expenses. We like and have to help each other.” Another family reported, “The tough situation made us stronger to come together as family and stand by each other. Back in Syria I was free to take decision by myself as I would live only with my wife and kids. Here we have to make it together.”

Women’s empowerment is welcomed

Family members reported how the displacement to Istanbul challenged several traditional roles for women and families and how they had to accept these changes in women’s roles and activities. One woman reported,

In the past I wasn’t able to take responsibility of handling things by myself. Now slowly I am depending on myself. Before I used to depend on my husband now I have to depend on myself. Before there were things I couldn’t do. But as a result of circumstances I am forced to do them. Slowly you become stronger and stronger without realizing it.

Another woman reported, “It’s not like before. It changed now. The Syrian women change here. Their minds are more open now.”

Mothers set a positive emotional tone

Families reported the fathers were often out of the home for long hours, so children mainly talked to their mothers for almost all issues they faced. A mother reported, “They tell me about their problems. If they are upset they tell me. They tell me everything…if they are not happy or anything.” Another mother reported, “I can see they are exhausted and so I try to spread joy and happiness for them.”

Spouses share and support one another

Families reported facing difficult living conditions which they discussed together so as to find the best solutions. One woman reported, “We have a good understanding with each other we have to reach a middle ground taking in consideration the kid’s needs.” Another woman reported, “When my father died my husband stood by me. He told me this is God’s will and many people die in war. He told me to adapt to this situation and I did.”

Hopeful Family Beliefs and Communication

It is God’s will and test for us

Family members reported believing that events were directed by the will of God or their fate was “al-qadr” predetermined goal that will be reached. Another reported, “This is what God wants. It happened. It is impossible to change history. But thank God we are going and living with the flow.” Another reported, “This was written by Allah and we all have to follow.”

Hoping that children will have a better life

Families reported that given their loss of houses and properties in Syria and the ongoing conflict, most families were pessimistic about themselves returning, however, they wanted to build a brighter future for their children in Turkey. A woman stated, “To be honest the thing which makes us the most happy is to watch the kids grow in front of our eyes….My kids to succeed in school every year. That’s it.” A father stated, “I am happy as my children are studying Turkish, English and Arabic, I am happy as they are learning and they will benefit from it. I will push them to study, I want them to be better than me. To have things I could not have.”

Praying and the Koran bring strength and relaxation

Family members reported how reading the Koran and praying gave them strength and relaxation. A woman said, “When getting angry I praise God.” Another woman reported, “By praying, my heart and our hearts feel better.” A man reported, “All my nerves calm down after I read Quran.” A woman reported, “When my husband was away, and I was alone with my daughters, I used to wake up at night, pray a lot, cry and then pray again. There was no one else to ask help from. What I asked I got I swear things got better.” Another man when asked whether praying helped him he answered, “I don’t feel helpless. We have little chance to change things and regardless whether we are nervous or relaxed, these things will pass through praying.”

Having a positive and optimistic attitude

In spite of many hardships, the families reported the need for an optimistic outlook. A family member reported, “Life goes on, we shouldn’t stay sad and depressed. The other day I had a job at the center, I was feeling tired but still I did it, I had to. I meet people and change my mood.” Another participant reported,

We lost people in the war. Some died in prison, some in the war. But life continues and does not stop. You have to fight to reach. Fight not only in war but fight in this life. It’s a struggle. You can’t stop, despite death and destruction, despite everything.

Staying Connected with Family in Syria and in Exile

Families maintain contact with family members in Syria and Europe using the Internet

Families reported using various web applications to keep regular contacts with family members in Syria and Europe. One participant reported, “We contact them every day with WhatsApp.” Another participant reported, “My son here (Istanbul), feels that his brother in Germany is not good, so he stays up and keeps talking to him until he makes him feel better.” A mother living alone with one son reported, “They respect and obey their father in Syria. We discuss everything together as family, we take decisions as family, we meet on internet, and we discuss the issue until we agree on one thing.”

Families send money to Syria

Families also reported sending money to Syria, especially to more vulnerable family members. A woman reported one of her sons was internally displaced in Syria and paying rent up to 100 USD per month. He was having difficulty in finding milk for his kids, she said, “He wants to come here. He needs money. Sometimes we send him money. His brother here is trying to help but we can’t afford to pay his rent.” Another woman reported, “My husband’s mother in Syria is sick. We are helping to cover her medical expenses. We agreed that we will help his and my parents back in Syria.”

Families use Arabic language with younger kids

Families reported that they were striving to speak and teach especially younger kids Arabic or Kurdish language depending on their origin. A parent declared, “We don’t want them to forget Arabic. It is our language. It is the language of the Quran and I want him to learn. We try to talk to him but is difficult.” Mother declared, “We speak with children in Arabic, because we hope we will return to our country and our homeland. We want them to return and still be able speak their mother tongue.”

Families plan for reunification

Nearly all the families reported having family members in Syria or in Europe and in their daily discourse reunification was often a topic. Reunification challenges were discussed that included the strict border controls into Turkey from Syria or the strict review procedures for family reunification in Europe. A woman with her husband in Syria said, “My son is working and I am receiving some money from my son in Germany and we are working and trying to bring my husband to Turkey in order unite the family.” A father who had an underage son in Germany declared, “We are expecting him to be 18 and to apply for family reunification so we can go to Germany. Getting a visa is very difficult.”

Making the Best of Living in a New Country

Families share good times together in Istanbul

Families reported that despite immense difficulties, they tried to enjoy positive moments with their family. A father reported, “For fun we sit all together here, and we cook a cake like now. And we eat it.” A mother reported, “Special cooking of special dishes is done on Sunday as everyone is home and we eat together as family,” A man reported, “On Saturdays we go to the park and play soccer with other family members from our town of origin.”

Getting support from Syrian friends and neighbors

Family members often mentioned how the interactions with non-family members helped them to cope. This was especially so for women who were at home most of the day or occasionally visiting community-based centers. One woman visiting a center reported, “We talked when I was in a bad situation and sad. They worried about me and stood by me, especially when I lost 17 Kg in a matter of a week. They noticed I was sad. But thank God I am back on my feet now.” A man described the difficulties of the first days, “We didn’t have clothes. My wife and I came here without any belongings. So, we depended on getting clothes from neighbor’s, relatives and other people.” Another woman reported, “I got work at home making handcrafts through a Syrian woman who is our neighbor. There is Syrian guy who brings her work at home and then she brings it to me.”

Feeling at home in Turkey because it is close to our culture

Although families reported cultural differences with Turkey they nonetheless believed that living in Turkey has made it easier for them to maintain their customs and tradition. As one man reported,

In Europe there are positive points. You have health care and support of the government. But here you have a mosque, you go to pray on Friday. Europe is a different culture andits open is so different from our Islamic culture. Turkey is more conservative than other countries. We have the same religion, and they didn’t ask us here to change our values.

Another declared, “In Turkey there is less risk to harm our values than other countries.”

Parent going to school and talking with teachers

Some parents reported taking an active role in communicating with teachers about their children’s challenges in school. A parent of a bullied child reported, “I went to get my child when all the parents go to pick up children. I asked the teacher to get all the parents of kids I told her with names. She agreed, I talked to parents and her. My relationship with teacher is very good now. ” In another case of bullying the mother reported, “The father went to the school to find out what happened, the principal contacted the other parents, and my son did nothing wrong in the classroom or in the school. There are still some incidents and sensitivity with this issue but not as much as before.” Some parents report getting good support from the teachers, “The teacher even hugged her and cried because she was upset for her. She is very calm. Very kind.”

Not letting discrimination get them down

Families reported not letting the experience of discriminations hurt them or let them give up. A woman reported when her son was teased in a park by local children she said to her son, “You should not respond to them. You are in their country and you should learn the language and be good in school.” A mother reported on discrimination on school, “This discrimination is affecting them, but the benefit from studies and language learning is greater.” Another parent reported, “For example, my daughter she is older, and they don’t accept her in school, they say to her it doesn’t seem like you have war in your country. You are not crying. Go to Syria. I tell her not to give importance to what they say.”

Discussion

The study findings offer a family systemic lens upon refugee resettlement and mental health and psychosocial difficulties which complements the typical individually-focused clinical mental health lens which has often been used with refugees. The findings also augment the existing family knowledge on refugee resettlement which largely focus on high-income country contexts, including family resilience models such as Froma Walsh’s. This study demonstrates the important common and context specific dimensions of war and displacement stressors and coping mechanisms for families in an LMIC context.

The study identified 21 family war and displacement stressors in three categories: 1) Surviving war and border crossing; 2) Living as urban refugees, and; 3) Parenting children in refuge. It also identified 16 family coping mechanisms across four themes: 1) Flexible and reciprocal family organization; 2) Hopeful family beliefs and communication; 3) Staying connected with family in Syria and in exile, and 4) Making the best of living in a new country.

The new FAMCORT model derived from urban refugees from Syria in Istanbul has many similarities but some key differences compared with the original model derived from Bosnian refugees in Chicago (Weine et al., 2004). Some common elements were: loss of language and tradition; challenges to patriarchy; scattered families, and; avoiding burdening other members to talk about traumatic memories or problems. However, there were also important new characteristics, which were unique to the context of Syrian refugees in Turkey. These characteristics are represented across all the different domains, including:

• The new family coping mechanism of “Making the best of living in a new country,” replaced the theme of, “Changes in family connections with the ethnic community and nation state” which was identified among Bosnian refugees in Chicago.

• The family coping mechanisms of “Women’s empowerment is welcomed” or “Mothers set a positive emotional tone”, reflected the new roles of Syrian women in the refugee context, which though largely focused on children and the home, also included new opportunities for activities and relationships outside of the home.

Other findings that were different were associated with the distinct host country contexts; Turkey, compared with the U.S., had refugees living closer to their home country, living in a Muslim country, and having the legal status of “welcomed guests”, but also with more difficulties finding housing, and with more children working and not attending school. Another key difference in the new FAMCORT model is that it depicts family war and displacement stressors and family coping mechanisms separately and does not attempt to directly align a set of both family war and displacement stressors and family coping mechanisms for each family domain. This was done to draw an emphasis on the three different categories of stressors, which were not defined by domains of family functioning. Although the two tables represent family war and displacement stressors and family coping mechanisms separately, we still believe that it is important to consider correspondences between them, which could be approach through examining case vignettes.

The findings also revealed how Syrian refugee families are being challenged to address the vulnerability of their children in the face of child labor, not attending school, language and school difficulties, and discrimination. These findings are similar to the experiences of Syrian adolescent refugees in Lebanon and Jordan who also reported discrimination, child labor and even physical violence (Mercy Corps, 2014). Some parents expressed concerns of being forced to let children work in order to be able to cope with their financial burdens and were interested in interventions that could help these children to attend school or to learn outside of school. Other parents asked for interventions that could help their children with homework and teach them Turkish and Arabic languages. Finding better solutions to reduce child vulnerability, including especially decreasing child labor and increasing school enrollment, should remain a policy priority in Turkey and the region.

The FAMCORT model’s focus on identify contextual and cultural specific family factors and processes, as well as core stressors and resilience processes among refugee families can help to develop practices and policies which take into consideration the specific circumstances of families resettled in LMICs, such as those mentioned above.

One practice and policy priority concerns the potential role of religion in mental health and psychosocial interventions. We documented the families’ beliefs that their current situation is God’s will and a test of their ability to cope, and that praying and reading the Koran brings strength and relaxation. Mental health and psychosocial interventions should consider explicitly incorporating these and other family religious beliefs so as to support refugee family’s endurance and hope (Ai, Tice, Huang, &Ishisaka, 2005).

Another practice and policy priority, given the family orientation of Syrians, is the potential usefulness of family resilience-focused interventions. One possible intervention strategy is to draw upon the multiple family group intervention model of Coffee and Families Education and Support (CAFES), a NIMH funded family support and education intervention that we previously developed and evaluated with refugee families from Bosnia and Kosovo. Given the high rates of common mental disorders in Syrian refugees, we propose combining the family resilience components of CAFES (Weine et al., 2004, 2005, 2008) with the stress reduction behavioral intervention components of the World Health Organization’s Problem Management Plus (PM+) intervention (Rahman et al., 2016), which has been found to be potentially helpful with adults and children amidst social adversity.

Findings from this study can also help in elaborating explanatory models of both distress and resilience at the family level that are needed to develop mental health and psychosocial interventions for refugee families. In particular, we believe that the FAMCORT model offers an empirically based, theoretically grounded, and practical approach which can support building family-focused interventions. Two distinct advantages of the FAMCORT model are that it characterizes both family stressors and family coping mechanisms, rather than focusing only on discrete traumatic events, and does so across multiple experiential and family domains (Miller, Kulkarni, & Kushner, 2006).

Studies using qualitative and ethnographic methodologies can significantly contribute to achieving a more nuanced and complex understanding of refugees (Hinchman&Hinchman, 1997). Such studies can help to better understand their perspectives and meanings, to delineate the family context and processes, and social and cultural context, all of which can assist in the development and implementation of supports and services for the refugee families. Future studies should also consider longitudinal follow-up to see how stressors and coping strategies change over time and impact children and adults. Additionally, these qualitative findings can guide the development and piloting of quantitative measures, which could tap both stressors and coping mechanisms of refugee families, and could be used in evaluating refugee family services.

This study had several limitations. One, the sample was not representative of all Syrian refugee families coming from different socio-economic strata. In order to address the limitation, we selected families with different income and educational backgrounds. Two, the data were collected at only one time point. Three, the study used translations of transcripts, so it is possible that some subtle issues of meaning might have been misunderstood.

In conclusion, urban refugee families from Syria living in Istanbul experience serious family stressors, but also demonstrate important family coping mechanisms, including flexible and reciprocal family organization, hopeful family beliefs and communication, staying connected with family in Syria and in exile, and making the best of living in a new country. These findings underlie the need for several practice and policy priorities that would support family coping amidst adversity, include increasing the number of children attending Turkish schools and decreasing child labor, incorporating faith into psycho-social and mental health interventions, and developing family focused interventions conducted by community-based lay providers that draw upon empirical models of family stressors and coping.