Building a Mental Health System in Iraq
Elizabeth Butler Award winner 2010
In 2004, the first time he traveled to northern Iraq, Scott Petersen expected to find a society devastated by war and violence, an arid, depopulated land where ordinary life had become impossible. Instead, as he gazed out the window during the long slow drive from the Turkish border to the northern Iraqi city of Sulaymaniyah, he saw a lush, beautiful landscape filled with people: kids playing soccer, men gathering in cafés for tea, marketplaces crowded with shoppers.
The loss and the suffering he expected to find were there, too, but they took longer to see. As Petersen was to learn in the years to follow in his work with the Heartland Alliance's Integrated Torture Treatment Services in Rural Iraq project, a full picture of contemporary Iraq has to take into account both the intensity of deprivation and adversity in the past-quarter century and the Iraqi people's drive to put that past behind them.
"The resilience of the Iraqi people is remarkable," Petersen says. "In the past 25 years, they've lived through the rule of Saddam Hussein; U.S. sanctions, in which they were without routine access to basic needs; the constant fear of being kidnapped, of being tortured. And they continue to live their lives, in midst of everything that's gone on and is still going on."
Going so far away to help people who've endured such dramatic trauma was new for Petersen, a 2002 graduate of Crown Family School's master's program. Before this project began, he spent more than 13 years in social services in the Chicago area, mostly focused on helping people struggling with drug use and mental illnesses. His regular role at Heartland is as director of clinical practice for Mental Health and Addiction Services. But in the aftermath of the 2003 U.S. invasion Petersen felt a personal responsibility to get involved.
"What I can bring as a social worker is a different way of responding to the violence and social injustice that people had experienced," Petersen says. "I wanted to offer people an experience of the U.S. that wasn't from behind a Humvee or a tank."
Under Saddam Hussein, detention and torture were ubiquitous and routine, a way of ensuring social order. Based on surveys in the Kurdish region and on the number of people who have registered with former-prisoner organizations, perhaps as many as 500,000 people in the south and more than 150,000 people in the north may have been jailed and abused. Political oppression took other forms: One Kurdish family gave Petersen a tour of the brutally cold mountain passes where they and others hid from the Ba'athist forces during the genocidal anti-Kurd al-Anfal campaign.
"War, internal conflicts, embargo, arrest, tortures, al-Anfal and chemical weapons, forced displacement—all those events traumatized our people in a way or another," says Dr. Ahmed Amin, the Iraqi medical director of Heartland's project. "And we don't have any institute or agency for delivering psychosocial support for those in need." Although many rural Iraqis are living with the aftereffects of torture and trauma—post-traumatic stress, substance abuse, anxiety, depression, family conflict—the country has never had a modern mental health system: Iraq currently has as few as 100 psychiatrists, mostly in the cities. This history of pervasive trauma and dearth of resources was what inspired the Heartland Alliance, a large Chicago-based human rights and social service organization, to bring mental health services to rural areas of the country.
Heartland, with a history of counseling refugees in the Chicago area who had survived torture, secured State Department funding to work in Iraq. The agency decided to bolster Iraq's existing extensive health network rather than try to establish a new bureaucracy, inspired, in part, by the Iranian system, where most health centers include mental health and addiction services. Through the program, paraprofessional health care workers in rural clinics sprinkled across Iraq come to the Kurdish city of Sulaymaniyah, Duhok, also in northern Iraq, or Najaff in southern Iraq, for a series of six weeklong courses in mental health diagnosis and treatment. The focus is on community education to decrease the stigma of mental illness, case management—addressing basic needs such as safety, financial stability, and family conflict—and easing psychological symptoms with medication when appropriate.
To minimize cultural and linguistic difficulties, the project uses a "train-the-trainer" model. Petersen and others teach a mental health curriculum to a team of Iraqi health professionals, who, when they return to their towns and villages, present the course to larger groups of health care workers. The training process was built to be responsive, allowing feedback from the local staff to help design the final curriculum. About 240 of these community mental health workers have now completed the training.
"It makes more sense to invest training knowledge in a core technical team of Iraqis so they could continue to provide training as needed," says Mary Bunn, A.M. '05, associate director of Heartland's international program and a social worker at Heartland's Marjorie Kovler Center for the Treatment of Survivors of Torture. "It's more collaborative, more sustainable, and it avoids language issues." The system does, however, illustrate some of the dangers of working in Iraq today: Sulaymaniyah, in the Kurdish-controlled northern part of the country, is relatively safe, but health workers who travel from the south for training must sometimes conceal their affiliation with an American aid group out of fear of retribution.
Scott Petersen has now made five of the three- to four-week-long trips to Iraq to do trainings. The project's dual focus on social service and human rights was especially appealing to Petersen, who sees the two as intrinsically interlinked. Although he's been a social worker essentially his whole life—he volunteered in high school and his first job out of college was at a organization for the homeless—his perspective changed radically when he went back to school for a master's degree at Crown Family School. "My education was a transformative experience professionally," he says. "It equipped me to do the work I do today, including this project in Iraq."
When Petersen enrolled at Crown Family School, he was planning to prepare for a career as an administrator or executive director. Within the first month of classes, though, he began to see social work in a new light. He realized that his true calling was really in direct service, what had inspired him to get involved in social work to begin with. Petersen says his professors at Crown Family School—in particular William Borden and Julia Henly—deeply impressed him, bringing an intellectual rigor to social work that he hadn't realized was possible, and combining that scholarly approach with deep personal commitment.
"There's a part of them that I take with me in all of what I do, the core values of social work practice: The centrality of human relationships. The power of people to transform their lives," he says. "Scott brings heart and mind and spirit to what he's doing. He's read widely, he's thought deeply, thought critically," says Borden, who is a senior lecturer at Crown Family School and a lecturer in the department of psychiatry. The two meet frequently to talk about professional decisions and intellectual concerns. "It's been instrumental in many ways, just invaluable," says Petersen. Crown Family School is "like a professional lifeline," he adds. "Even when I'm in Iraq, I exchange emails with people from this community."
Trauma survivors everywhere have some of the same problems: long-lasting pain from injuries, anxiety and mood disorders, physical complaints like headaches or stomach pains. But survivors in Iraq face additional difficulties. The country's ongoing conflict makes it harder to recover. And to publicly admit that you'd been tortured was (and in some cases still is) dangerous, Petersen says, tantamount to an admission that you opposed the Ba'athist government.
When creating the project's program, Petersen and his colleagues also tried to take into account cultural differences and the character of rural life. Because community and family influence are strong in rural Iraq, the community mental health workers try to destigmatize mental illness, encouraging family members to see post-traumatic symptoms such as depression and crippling guilt as normal and natural rather than signs of insanity or spiritual failure. And while the culture's strong family networks can provide powerful support, they may also be at odds with standard Western-style mental health services, which emphasize independence, confidentiality, and a medical model for dealing with a patient's emotional problems.
"The idea of reaching out to a stranger is foreign," Petersen says. "In some ways we are introducing a Western model, so we're trying to be open to adapting it to the needs of the country, which are diverse." One part of the strategy is to get local paraprofessional health care workers involved, since they may know more about the community than do doctors, who are typically assigned by the Ministry of Health to rural areas for two-year appointments.
Although the State Department did not renew funding for the humanitarian mental health assistance, Heartland is continuing the program as part of its other Iraqi projects, which include a parallel program to assist displaced persons, focusing on substance-use problems. The program will also continue to provide technical support for the mental health advocates who've already gone through the training. These ongoing efforts will bring Petersen back to Iraq— which he's grateful for.
"In Iraq, there's a tragic history, but there's a lot more that's going on in people's lives than that they were tortured or lived under a repressive regime," Petersen says. "They want people to know about Iraq—it's a beautiful country, and they're a remarkable people."
By Kathleen McGowan