Stigma, insufficient training in mental healthcare for physicians, and subsequent lack of treatment capacity have handicapped efforts to build Iraqi mental healthcare capacity or deliver much-needed psychosocial services.
In August 2014, two months after ISIS swept through Mosul and on the same night then-Prime Minister Nouri al-Maliki stepped down from office, Ahmed had other thoughts on his mind. Wiping tears from his otherwise emotionless face with unsettling calm, he spoke almost in a whisper: “I have become very sad. I don’t care about anything anymore. I cannot sleep. I am never hungry. There does not seem to be any way forward, weighed down with all of my memories.” As a professor at the University of Baghdad and a prominent civil society organizer in the capital, Ahmed had always prized his personal library of nearly 1,000 books, and often found comfort there amidst personal uncertainty. As he spoke, however, his collection was burning after a car bomb had exploded near the doorsteps of his family’s home.
Ahmed’s depression – a feeling shared, to varying degrees, by many of his colleagues and compatriots – highlights a discomfiting reality in modern Iraq. Few people have remained untouched by the trauma associated with years of unrest and instability. Today, as the country emerges from a particularly bloody cycle within a nearly 40-year period of constant conflict, Iraq’s overstretched healthcare practitioners are struggling to treat populations subjected to intense violence. Yet, intertwined histories of stigma, insufficient training in mental healthcare for physicians, and subsequent lack of treatment capacity have handicapped efforts to build Iraqi mental healthcare capacity or deliver psychosocial services to traumatized communities.
As Iraq moves past the ISIS nightmare, it has a great need for a healthy, productive population that can contribute to the country’s recovery. Addressing psychosocial trauma across liberated areas and in communities hosting the internally displaced is a critical step toward national reconciliation and reconstruction.
Iraqi society today has been shaped by a recent history of political repression, punctuated by wars, episodic violence, and internecine conflict during which basic service provision and institutional capacity diminished. According to a 2007 World Health Organization (WHO) study – the last reliable healthcare survey conducted in the country – mental health disorders were the fourth leading cause of ill health in Iraqis over the age of five years. One year earlier, Médecins Sans Frontières (MSF) estimated that as much as one-third of all children in Baghdad, Mosul, and Dohuk demonstrated symptoms of moderate-to-severe mental illnesses. In Mosul, which reported the highest percentage of post-traumatic stress-related cases, less than 10 percent of children in need of care had received any level of treatment. In a separate study, nearly 35 percent of 9,000 self-reporting households suffered “significant psychological distress.” By the end of 2007, the Iraqi Ministry of Health reported that over 70 percent of those with any mental health condition had experienced suicidal thoughts.
Although reliable data is sparse for the post-2008 period, deterioration of security conditions after ISIS’s lightning advances in summer 2014 has the intensified need for skilled mental healthcare practitioners. Surveys from the Ministry of Health, MSF, WHO, and others excluded homeless or internally displaced persons (IDP), leading to significant underestimation of need that only grew as Iraq’s IDP population reached 3.3 million in 2017. Since military operations to liberate Mosul began in October 2016, over 359,000 civilians have fled the city as of April 2017. While some have reached IDP camps in neighboring districts or the semi-autonomous Kurdistan Region, many thousands have resettled in informal and non-camp settings, deepening the challenges caregivers face identifying at-risk individuals or families.
“I have become very sad. I don’t care about anything anymore. I cannot sleep. I am never hungry. There does not seem to be any way forward, weighed down with all of my memories.”
“Many of the patients we identify for continuous treatment may suddenly leave the camp setting, travel elsewhere in Iraq, or become homeless. We simply do not have the funding or staff to reach these people,” explains Dr. Redar Mohamed, the chief psychiatrist at an Erbil clinic covering four IDP camps in northern Iraq. “Sometimes former patients will call our clinic asking for assistance after returning to their homes in places like Ramadi or Fallujah, where they find no support services or care. There is nothing we can do to help them.”
Redar shares these challenges with mental healthcare practitioners across northern Iraq, who struggle to meet overwhelming needs with limited resources. Today, there are only 80 practicing psychologists in Iraq and Iraqi Kurdistan, working alongside a limited number of psychiatrists. Managing overwhelming need for psychosocial care options has pushed local and international organizations to, in some instances, employ under-qualified practitioners who lack the training to treat severe trauma. Many doctors study mental illness from a theoretical standpoint, rather than gain practical skills like case management, doctor-patient ethics, or emergency care for traumatized individuals. Sherri Talabany, President and Executive Director of the SEED Foundation, an NGO working to develop psychosocial healthcare capacity in Iraqi Kurdistan, concludes thus: “Many NGOs have hired staff and healthcare practitioners who are effectively learning how to provide psychosocial treatment on the job, with incredibly fragile and vulnerable populations.” The simple result of this situation, she says, “is that people are not receiving the care they desperately need. Regrettably, there are often mental health crises that are not resolved sufficiently, leading to suicides.”
For mental health practitioners, this patient influx translates into over-stretched working hours and diminished care. In a single day, Redar may split his time between three separately-run facilities within Erbil, including a government-operated public hospital. Altogether, he manages 200 psychiatric cases each month, many of which require intensive medication and follow-up care for post-traumatic stress and other disorders. According to psychiatrists interviewed in Erbil and other caregivers who work in IDP camps across northern Iraq, it is often only possible to assess a patient’s needs in only a few minutes; at the Erbil Psychiatric Hospital, staff receive five new patients every day. This overwhelming need ultimately means that doctors often over-rely on drugs (which can be expensive or hard-to-find) rather than more time-consuming methods like therapy or counseling.
“Iraqi psychiatrists always need more money and medicine,” Redar explains, “but more than anything else, we need more colleagues who are qualified to treat patients. Iraq’s current psychiatric capacity is not sustainable.” As a result, healthcare professionals report a significant treatment gap for those experiencing conditions better resolved without hospitalization or medication, including anxiety and depressive disorders that are most prevalent across the country today.
Although these current humanitarian conditions and healthcare capacity shortfalls largely drive the types of prescriptions offered those suffering from mental illness, a history of institutionalization also shapes current perceptions. Before 2003, the main component of Iraq’s mental health system was reliance on institutionalized care for those suffering from chronic psychiatric disorders, complemented by a relative disregard for therapies like psychological counseling. By 2008, Iraq had only two functioning psychiatric hospitals to serve a growing patient population, relying on insufficient equipment, medication, and staff; the situation had deteriorated by 2010 to the point that patients were receiving electro-shock therapy for lack of alternative treatment options.
In today’s climate of upheaval and displacement, however, such institutionalization is impossible for those who have experienced the worst traumas. While some NGOs, including the SEED Foundation, operate psychosocial support services in IDP camps scattered across northern Iraq, approximately 65 percent of the displaced population reside in non-camp environments and with family members in host communities; in Iraqi Kurdistan, for example, many IDPs have built ad-hoc shelters in unfinished apartment towers, left over from the region’s period of economic prosperity.
Addressing psychosocial trauma across liberated areas and in communities hosting the internally displaced is a critical step toward national reconciliation and reconstruction.
Identifying and reaching these transient communities remains extremely difficult, and mental health caregivers must rely on patients to self-diagnose and seek treatment at state-run hospitals in major cities where psychiatric services are available. Such a journey presents significant financial and social challenges for the most vulnerable patients. According to administrators at one public hospital in Erbil, many people who live in villages and towns far from the city are unable to stay away from home for the amount of time needed to receive adequate treatment. “Patients often ask whether the government will provide money for transportation and lodging, but it is impossible to help these people with the funding currently allocated to us,” according to Talabany. She concludes, “this dynamic creates huge demands on government service providers…and local institutions are overwhelmed by rising needs” – a situation that can create friction between displaced and host populations, especially within the context of economic hardship in both Iraq and Iraqi Kurdistan.
For individuals already struggling to access psychosocial services due to diminished capacity or financial hardship, social stigma surrounding mental illness in Iraq deepens a sense of crisis. A 2010 survey of public opinion regarding mental health conducted jointly by the Iraqi Ministry of Health and International Medical Corporation outlined this challenge. Approximately 60 percent of respondents agreed with the statement that “mental illness is caused by brain disease,” 65 percent declared that psychological problems were borne of “personal weakness,” and 80 percent affirmed that people with mental health problems are largely to blame for their condition. On the other hand, approximately 65 percent agreed that “mental illness was caused by something bad happening to you.” Highlighting the social isolation many Iraqis suffering from mental illness experience, only one-fifth of respondents said they would marry a person with unmet mental health needs, and over half declared that they would feel ashamed if a family member suffered from mental illness.
These data also indicate a general lack of awareness regarding mental health treatment options and illness among the general population. Just 15 percent of respondents felt that Primary Healthcare Clinics (PHCs) provide adequate information to patients regarding psychological and psychiatric care, and 14 percent thought they could receive adequate care for mental illness at their local PHC. Only half of those surveyed believed mental illness was curable.
For mental healthcare educators and caregivers, overcoming the barriers presented by widespread stigma is a significant obstacle to providing effective treatment. Talabany acknowledges that any solution must integrate mental health services with other livelihood and social support programs, particularly in terms of delivering psychological therapy and other non-medication treatment plans. In the town of Akre, for example, the SEED Foundation operates a community center at the local IDP camp that offers a range of social services – including recreational activities like baking, sewing, childcare, or woodworking – alongside psychosocial care.
Dr. Hunar Assaf, a psychologist working for SEED in Akre, understands the impact such a holistic and discrete approach has for patients. “Every time an individual comes to the center to participate in a cooking class or drop their child at daycare presents an opportunity for one of the psychologists to have a conversation with them,” he explains. “For many of the patients, classes provide an excellent excuse to seek therapy without any shame.” These sessions also afford the chance to help local populations, families, and individuals understand their experiences and symptoms of anxiety, depression, grief, nightmares – thus building “awareness about the natural, human reactions to traumatic events,” as Talabany notes.
A New Opportunity for Mental Healthcare?
The upheaval to which many Iraqis have been subjected since ISIS’s lightning advance in summer 2014 has reshaped the dynamics and etiology of mental illness and care. Recent needs assessments conducted by SEED in several IDP camps in northern Iraq have indicated that for some women who fled villages in the areas surrounding Mosul, the displacement setting offered new opportunities for personal empowerment outside the traditional familial structure.
Choman Hardi, a professor at the American University of Iraq in Sulaimani, explains that displaced men are often forced from their position as primary providers for their families. As a result, she argues, “we can challenge gender structures and have a more fluid and dynamic society after ISIS.” Talabany echoes this sentiment, noting that “many women who now live in camps come from extremely patriarchal backgrounds dominated by their husband’s family — a situation that allowed for and encouraged a great deal of violence within the home. The process of displacement empowered some women by…providing greater security through the lack of privacy.”
These transforming familial and gender structures within the displacement setting – as well as the experience of particularly intense violence – has fostered new interest among displaced populations regarding psychosocial services and their availability. Results from the 2010 public opinion survey presaged this development, indicating that two-thirds of respondents “felt comfortable discussing intimate psychological problems with a physician.” After 2014, the dissolution of familial and local support networks through mass displacement has forced many individuals to seek alternative sources of comfort, regardless of associated stigma. Psychologists working in displacement camps across northern Iraq reported a sharp increase in the number of individuals seeking mental healthcare over the past six months – a trend that is especially pronounced for women. Such anecdotal evidence, while not representative of the national situation across Iraq, nevertheless highlights the growing need for mental health practitioners to manage social changes wrought by the ISIS nightmare.
For individuals already struggling to access psychosocial services due to diminished capacity or financial hardship, social stigma surrounding mental illness in Iraq deepens a sense of crisis.
Yet, new opportunities to expand mental health services into vulnerable communities today are limited by the human and financial resources available. As Iraqi policymakers look to rebuild their country after nearly three years of brutal urban conflict, and manage over 3 million displaced civilians, provision of mental healthcare is not a priority. Baghdad faces a severe economic crisis, with $125 billion in debt for 2017, even as post-ISIS reconstruction cost estimates reach over $50 billion and emergency humanitarian needs remain unmet – including chronic health crises among populations deprived of adequate care since 2014.
As a result, the onus for capacity building across the country’s mental healthcare system has fallen on private organizations like SEED, as well as international NGOs that provide funding for new training programs. At Dohuk University, a new degree program funded by Germany’s University of Tuebingen offers clinical training for psychologists, allowing students to continue their work while building practical skills that strengthen their case management abilities. At Koya University, the SEED Foundation established a similar initiative for those already practicing psychology, comprising an intensive six month experiential learning curriculum and clinical internships under professional supervision. Altogether, these new training efforts aim to produce 100-110 graduates per year if current funding levels remain steady.
For mental healthcare practitioners overwhelmed by immediate need, these developments form part of a long-term development plan for post-ISIS Iraq. “However,” declared one psychiatrist in Erbil, “for now we expect to see more suffering, more emergencies, and more suicides.”