For several generations, people in Iraq have found themselves in wars or war-like circumstances. Flight, expulsion and mass destruction have influenced this society to a particular extent. The hope that democracy might develop after the Saddam era, and that the various ethnic and religious groups might live together peacefully, has been shattered, since 2014 in particular. Rather, it is now evident that the country is facing dissolution.
Since June 2014, the IS (“Islamic State”) is occupying large parts of Iraq and Syria and committing gruesome massacres against the population, especially against religious minorities such as Yarasan, Shabaks, Christians, Mandaeans, Alawites, Shiites and Yazidis. For example, more than 7000 Kurdish-Yazidis have been killed in Iraq. Thousands of women and children have been enslaved, men executed, and towns, villages and holy sites destroyed. With the influx of Syrian civil war refugees into Northern Iraq and the Iraqis who are refugees in their own country, there have been, since 2014, around three million refugees in the Kurdish region of Northern Iraq alone. Basic supplies and services for people barely meet the needs. Severely traumatised young women who, as IS hostages, have lived through torture, slavery and rape, then finally escape, are suffering especially badly, as medical and trauma treatment are hardly available.
The state government of Baden-Wuerttemberg has therefore created the ‘Sonderkontingent für bedürftige Menschen aus dem Irak 2014’ (‘Special contingent for Iraqis in Need 2014’) project. Through this project, it has been possible to bring up to 1000 women in need of protection and their relatives to Baden-Wuerttemberg for treatment by the end of 2015. This is important and urgently needed, as this group of people, given the severity of their trauma, does not have access to treatment options in Iraq or Syria. At the same time, however, it is necessary to train specialists locally, who will be able to help people with a mental illness and to train their own specialists in order to guarantee broad-based health services in the long term. This requires establishing scientific institutions for research, teaching and practice in order to, among other things, build up the currently non-existent psychotherapy services infrastructure with a focus on trauma. It is therefore especially necessary, apart from training practitioners, to enable local specialists to train 30 others using a train-the-trainer approach to provide psychosocial services, especially trauma treatment, in the region of Iraq and Syria.
The psychological effects of war
Life-threatening experiences can be so significant that nothing in life is as it was before. Accidents, disasters, war, acts of terrorism, rape and abuse are some of the events that can cause a deeply traumatic psychological breakdown and can hit a person at any time in their life. Some people who experience such an event, and also some of those who witness it indirectly as helpers, witnesses or relatives, find it difficult to regain their mental balance.
Traumatic events trigger feelings that life itself is in jeopardy as well as helplessness and shock. The reactions that may follow in the first few days afterwards may inlude disturbed sleep, nightmares, nervousness and lack of concentration, but also distrust in others, being on edge, joylessness and a general sense of lack of purpose. Often, such changes, which are not necessarily recognised as connected to the traumatic event, creep up on people without being noticed. In the long term, physical and psychological symptoms such as multiple types of pain, anxiety, sleep disorders and depression etc. can develop, and in some circumstances may expand into long lasting and complex disorders. In many cases, those affected feel ignored and abandoned by their surroundings.
In countries such as Iraq and Syria, violence and aggression have been persisting over several generations and have dominated people’s lives. Over the long term, this also impacts the whole society and the generations that follow. Apart from psychotherapeutic treatment, working through the numerous stresses as well as forgiveness and reconciliation are central during wars, and for several generations after times of war, which is essential for peace in a country. In this context, dealing with the past also means reconstruction and planning for a healthy and peaceful future.
Sexualised violence as humiliation of an entire society is of particular significance. Especially the de-humanising sexualised violence against women in the former Yugoslavia, and now against Kurdish women in Iraq ad Syria, has shown us the cruelty that people are capable of. The victims, and the collective to which they belongs, may be traumatised for decades as a result. Forms of violence range from rape, harassment, mutilation, enslavement and physical marking to the killing of the victim. Rape is an extreme assault on the intimate self, triggers massive feelings of invalidation and humiliation, and violates privacy.
Over the last 20 years, research has also examined psychological effects. However, in this case, mainly the short-term effects of terrorist activities such as hostage taking, bomb attacks and shootings. According to estimates, the probability of acquiring PTSD after a terrorist attack lies between 7.5 and 50 percent, depending on the degree of victimisation (Verger et al., 2004). Although terrorist attacks are increasing globally, there is hardly any evidence on their medium to long-term psychological effects; this is especially true for post-traumatic stress disorders.
Road accident victims, for example, show a high susceptibility to PTSD; rates for the period between one and five years after the accident are between 11 and 46 percent (Mayou et al., 1997). Studies on earthquake victims show that long-term PTSD is present in up to 45 percent, even one year after the disaster (Livanou et al., 2005; Basoglu, 2009).
Another aspect – in this context a truly innovative approach – is intertwining psychotherapy training with transcultural transfer. Trainers as well as trainees in psychotherapy must face up to the frames of reference within which different cultures and academic institutions operate. There is no longer any doubt that the need for a transcultural approach to research, professional development and treatment, on the basis of specific transcultural competencies, is increasing. This can lead to better service provision and therefore to a reduction in the risks of mental illness becoming chronic. For this to occur, a transcultural perspective on health and disease is a fundamental prerequisite.
Different cultures have developed different coping strategies to deal with the multiplicity of different stresses. In general, these strategies often represent the most important resource for integration into a society that will remain successful in the long term. Especially in a culture characterised by collectivist values such as that of Iraq, the individual can hardly be understood without looking at the collective whole. In this society, above all in rural areas, relationships with the people in one’s closest social circles are, as a consequence of traditional upbringing and socialisation, particularly important, including the relationships with the treating doctor and therapist.
Today, the transcultural process ensures that the existing treatment concepts from the western world (individual perspective) can be used successfully with people from other countries (collective perspective). For this and another reason it is very important to implement on the academic level, in field of researches and practices the subject of Psychotherapy and Psychotraumatology in Kurdistan Region.
This institute for Psychotherapy and Psychotherapy is aimed to research topics of psychotherapy and psychotraumatology in its entire breadth and develop culturally sensitive modules and approaches for psychotherapeutic practice. This also covers interdisciplinary crossover with medicine and psychology and their sub-disciplines. Psychotherapy research can today no longer be reduced to the application of classical theories of learning or psychoanalytical theories, but builds on the combined body of research from medicine, psychology, biology and the social sciences, and will be further complemented by transcultural aspects of trauma.
Moreover, the institute will support participants and other researchers in combining the goals of postgraduate training with accreditation as practitioners. This allows synergetic effects to be used. The applicants are confident that it is possible to establish a training institute including one year Prepare-Program, two year Master-Program to get a Master in Psychotherapy and Psychotraumatology as well to train students as therapists specialising in trauma.Psychotherapy training follows the German examination regulations for psychology-based psychotherapists involving at least three years of study in full-time mode or at least 5 years in part-time mode. In Iraq, clinical placements will be conducted, among others, in refugee camps and hospitals, and organised and supported by the Dohuk Directorate General of Health. Lecturers from Germany and Iraq provide theory teaching, supervision and self-awareness development.