The Worst of All Horrors

These days, no one seems to have endured just one kind of life-jarring experience in the conflict areas of Iraq. The suffering is multilayered: trauma caused by having witnessed or being victims of Islamic State violence, being displaced or living in an area that may come under attack, facing torture or sexualized violence — the list goes on and on.

Take the case of a teenage girl from the Sinjar area in northwestern Iraq. She and her family didn’t have the means to escape to a safe place when the Islamic State attacked her town a few months ago, nor did they have weapons to fight, says her treating psychotherapist, Sherwan A. Hassan of the Jiyan Foundation for Human Rights, a group that offers free rehabilitation services to survivors of torture and inhuman treatment in Iraq. Eventually, the family fled into the dusty mountains, where they spent 10 days without food and with very little water or sleep. They were terrified of being attacked again. The adults and their daughter made it through; a baby brother and sister, however, died.

After crisscrossing into Syria and back into Iraq on an arduous journey, the parents of the girl realized she needed help. She wasn’t speaking and was physically unable to get up much of the time. A trip over the border into Turkey to seek care proved fruitless — there were no professionals who knew what to do with her. Finally, after arriving in the Iraqi Kurdistan city of Dohuk, the family was referred to the Jiyan Foundation. By now living in a state of prolonged displacement, the girl was cutting her arms and saying things like, “I am crazy,” “I am worthless,” and “I have lost my mind,” Hassan recounts.

Hassan, who looked very tired in a recent Skype interview, describes how, in his first six sessions with the girl, he tried relaxation therapy and family therapy. In the next session, he will try scream therapy, which is when a patient vents repressed anger or frustration through yelling. Whatever works at this point. The same goes for the three or four other patients Hassan treats each day.

It is the complexity of cases, in which there is trauma on top of trauma, that psychologists and social workers in Iraq are trying desperately to get a handle on. Youth psychotherapist Salah Ahmad, who founded the Jiyan Foundation and has been treating patients in Iraq for 10 years, says he has never seen “such a degree of violence and such deeply traumatized persons as those who have fallen victim to the Islamic State.” And the needs — both the number of people and the severity of what they are enduring — are so extraordinarily overwhelming that experts admit they are failing and will continue to do so without further commitments of financial support from the international community.

Some 3.3 million Iraqis are internally displaced, and more than 400,000 have become refugees, according to the Internal Displacement Monitoring Center in Geneva. The number of trained doctors is extremely limited. Hassan has only been working as a psychotherapist for five years, and in trauma for two and a half. “Our therapists need more supervision and special training and must, at the same time, be supported in coping with these extreme cases,” Ahmad explains. Put simply, unless something changes, the job of treating a multiply-traumatized population currently seems insurmountable.

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This most recent mental health epidemic to befall Iraq follows on years of the coalition-led war — which were preceded by more than two decades of Saddam Hussein’s punishing reign. Among the rising number of people Ahmad now sees are “former patients who had long finished their therapies have started to come back as they were once again confronted with memories of terror, persecution, war, and violence.” People persecuted under the Saddam regime are now having flashbacks. (He partly blames journalists for this: “The media constantly floods people with horrifying images, and the news of [the Islamic State] coming closer.”)

Direct survivors of the Islamic State are also flooding his center. Some are women and girls who have been held by the terrorist group, “almost all of whom have experienced and/or witnessed different forms of sexual violence,” he says. Jiyan is planning to open a rehabilitation center specifically for female survivors later this year.

What everyone has in common, Ahmad says, is that they have been “at risk of being killed at any moment.”

Another of Hassan’s patients became pregnant after being abducted and raped by Islamic State fighters, he says. The Yazidi woman, in her early 20s, was kidnapped from Sinjar and held for three months. When she made it to Dohuk, she decided to keep the baby. But the woman’s parents want the pregnancy terminated. The woman now shakes, faints, and dissociates, her doctor says. She’s in her fifth month of pregnancy.

For patients unable to travel to Dohuk, a team at Doctors Without Borders (MSF) has been taking convoys of two trucks into conflict-affected areas. “We travel tightly,” says Sybilla Rulf, psychotherapist and MSF’s mental health activity manager in Dohuk. Towns and villages are in terrible straits; governance is usually absent, hospitals and schools have been destroyed.

Rulf described several patients to me: a man in his 30s who developed an eating disorder from stress and is terrified the Islamic State will come back to his home and find his six sisters and five children. An 11-year-old boy who was shot in the leg and has flashbacks to the event, envisioning the bullet hitting his leg over and over. A Yazidi woman kidnapped while in the last stages of pregnancy, who had the baby in captivity and left it behind — at just 10 days old — when she had the opportunity to escape. “She falls now because she’s so weak and thinks she doesn’t deserve to live,” Rulf says. “Her husband’s brother says that in his community, there are 10 to 15 cases like that.”

MSF has limited time and resources to treat these difficult cases. “You have to work quickly and with very simple tools,” Rulf says. MSF’s field team consists of only two psychologists (neither of whom are clinically trained, only educated) and two social workers. Rulf is coaching them as they work. Currently, she is still looking for a good translator to assist her.

Group therapy is the aim, with so many patients to treat. Rulf says the method can be highly effective. (It has also been used by groups such the Syrian American Medical Society.) She also points out that some of her staff is deeply affected by the work and have their own mental health needs. “A lot of the people who are working for us are from this region — refugees or Iraqi Kurds,” she explains. “They’re close to some of the people who have experienced this.”

While there is a great need for counselors — and for counselors to treat those counselors — Erin Gallagher, who has conducted research in Iraq for Physicians for Human Rights, sees possibilities that can be seized right now. For instance, it’s inevitable that women and girls will continue to be forced into captivity by the Islamic State, and that many will escape or be freed. “Historically, the international community has not often had the luxury to respond to a crisis before it worsens,” Gallagher says. “This is a rare chance to help develop a comprehensive response with local organizations to sexual violence survivors before they return.” Doctors and local hospitals are already treating some survivors, and there has been documentation of abuse; survivors have been willing to speak, and community leaders have helped smooth the way for their reintegration into society. Gallagher says this has created the “perfect situation for the international community to provide the remaining pieces that could create a model response and greatly ease the suffering of survivors and future returnees.”

The Jiyan Foundation, for its part, is looking to the Iraqi government to strengthen local NGOs and invest in improved mental health services. After so many years of horror and so little action taken, could the brutality of the Islamic State finally be the tipping point that brings long-needed care to the traumatized population of Iraq? Rulf says it’s too soon to tell: “That depends on the future of this war. Things can be destroyed again and again, and people can be traumatized yet again.”

Safin Hamed/AFP/Getty Images