Iraq’s Hidden Wounds

SHERRI KRAHAM TALABANY — Helping vulnerable populations requires an integrated approach to mental healthcare and socio-economic empowerment. 

You founded the Social, Educational, and Economic Development (SEED) Foundation in 2014 with Tanya Gilly-Khailany to promote sustainable socio-economic development. Since then, the political, security, economic, and social environment in Iraqi Kurdistan has changed dramatically. How has SEED’s mission evolved to respond to these new needs, particularly among populations impacted by ISIS actions — how do you balance immediate wartime priorities with longer-term development goals?

I established the SEED Foundation, a local NGO in Kurdistan, in 2014, and SEED for Change, a US 501(c)3 in Washington, DC, in 2014. The context for our operations and mission was quite different when it was first established than it is today. At that time, there was an economic boom in Iraqi Kurdistan, and SEED’s focus as a development organization was to empower those who were not being served — including issues related to vulnerable communities, gender equality, and providing support for women to participate in the region’s economic and political affairs.

It was not long after SEED’s establishment that there emerged a major humanitarian crisis, starting with the Syrian civil war, which pushed many refugees to cross the border into Iraqi Kurdistan. This emergency worsened in summer 2014 after ISIS’s invasion, as many Iraqis became internally displaced inside the autonomous Kurdish region; and the economic downturn that developed around the same time further exacerbated the effects of insecurity. When thinking about how best to focus on and respond to these fast-developing priorities, we recognized that one of the major future development challenges for Iraqi Kurdistan was managing the approximately 1.7 million internally displaced persons (IDPs) who would be dependent on a Kurdish government struggling to barely meet the needs of its own population. As a development organization, SEED focuses on the sectors where it can have the most sustainable impact, making lasting changes for the people of Iraqi Kurdistan.

It was at this point that we decided to center the organization’s work around improving the well-being of people impacted by violence and conflict and their mental health needs, which are deep among both the Kurdish host population and IDP communities. Nearly everyone inside Iraqi Kurdistan has survived conflict at some point and has experienced violence or displacement. The need to address the legacy of upheaval extends far beyond the current emergency context.

After decades of violence and conflict, citizens, policymakers, and institutions in Iraq and Iraqi Kurdistan operate in what you have called “survival mode” — that is, they do not take a strategic view of sustainable recovery and rehabilitation, instead focusing on the day-to-day. What steps must civil society organizations take to build long-term programs in an environment of crisis?

It is critical to remember that, while SEED focuses on recovery and healing psychological wounds, people are unable to focus on psychological or social needs until several basic conditions are met. These requirements include shelter, food security, and safety. There is thus an important role to be played by humanitarian organizations, working alongside the government or United Nations, to meet these needs. SEED does not focus on this emergency relief. Whenever possible, civil society organizations must consider how to make sustainable interventions that help affected populations over the long term — even within the current humanitarian context. For example, rather than give out food or provide housing for a small number of people, an organization like SEED can devote its resources to increasing job skills among IDP populations, training people to generate an income, so that they can support themselves. In some cases, SEED does provide emergency cash assistance through a partnership with Vital Voices Global Partnership assisting survivors of sexual and gender based violence, including women and children who have escaped ISIS by disbursing immediate aid.

However, once pressing emergency needs are met, we are able to pursue our deeper goal of preparing these individuals and groups to help them begin to heal and cope with their live in displacement, through an integrated approach of mental health services and a broad range of other social services. This includes comprehensive case management, and vocational, recreational and educational activities. We teach life skills such as nutrition, personal healthcare, and hygiene. Each of our initiative areas represent an investment in helping people improve their long-term well-being and ability to raise healthy families. Coupled with this work is the need to build local capacity that will support such development in the future. There are many international NGOs in Iraqi Kurdistan today responding to the current crisis; but when these organizations are gone, vulnerable populations will still remain in Kurdistan. SEED is a local NGO, and is extremely integrated within the population, and its staff is mostly drawn from local communities. The few expatriates working with SEED are thus focused on transferring skills to local staff and partners. The ultimate goal is to give these individuals the tools needed to meet the needs of the population now and in the future.

Although many resources have gone to manage battlefield casualties and the immediate impact of combat operations on civilian populations, affected communities will bear the memories of wartime experience after ISIS is defeated. How can Iraqi and international NGOs and government policymakers address these psychosocial traumas — what is the current capacity for providing such support?

SEED established its education and training program after approximately two years of working to directly provide mental health and psychosocial support services. During that period, it became clear that, for a number of historical reasons — including the high level of stigma associated with mental health issues and the near-constant cycles of conflict to which Iraqis have been subjected — there is a severe lack of qualified mental health personnel. Case management is not taught at Iraqi universities in a systematic or effective fashion; most psychology programs today are focused on educational psychology and psychiatric services, rather than emergency care for traumatized individuals. The greatest challenge for the handful of organizations working in Iraq today to develop psycho-social care networks is building Iraqi capacity to meet the daunting demand for these emergency services.

The demands on psychological personnel are incredibly high. Many NGOs have hired staff and healthcare practitioners who are effectively learning how to provide psycho-social treatment on the job, with incredibly fragile and vulnerable populations. The simple result of this situation 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. SEED’s program is thus working both to develop an undergraduate training program, but also the above-mentioned professional course for practitioners already in the field — reaching two critical groups of mental healthcare professionals at different career stages.

In addition to investing in its local staff, SEED has also developed psychosocial and mental health training programs for psychologists and caring professionals working inside Iraqi Kurdistan. Today, there’s an extreme shortage of qualified mental health practitioners. Through a US State Department grant, we have created a Center for Mental Health and Psychosocial Support Services (MHPSS) at Koya University, to serve as a training center and a place for ongoing learning for MHPSS professionals.  SEED is working to improve the education program for mental health workers — especially through an undergraduate clinical psychology program, integrating trauma psychology into the existing curriculum. We also have an intensive six month training for psychologists, social workers, community health workers and others who are already in the field, integrating 4 weeks of interactive classroom instruction with clinical supervision when they are back at their workplace providing psychosocial services. This program was designed with sustainability in mind and when SEED’s role in this program is finished, tuition fees will be enough to cover its costs. The initiative at Koya University should be able to graduate approximately 100 new students every year tailored to the local environment, but also bringing in global best practices.

In Iraq and the Kurdistan Region, there is significant stigma surrounding those who seek help for managing psychosocial trauma, particularly stemming from gender-based violence. What steps can be taken to manage this perception of therapy among patients and their families, as well as to effectively deliver services to in-need populations?

The stigma mentioned above translates into significant barriers to psychological treatment for vulnerable populations, on both the supply and demand sides. These challenges are particularly pronounced for women. Some displaced women are not able to access psychological services due to restrictions on their movement within the familial structure; others either are not aware of the services that are available, or lack access to good quality treatment altogether.

In terms of building acceptance for psychological services, SEED has employed a number of strategies. Most importantly, SEED provides psycho-education, which means working with local populations, families, and individuals to help them understand that is natural to experience symptoms of anxiety, depression, grief, nightmares; some of which can be indicators of Post-Traumatic Stress Disorder (PTSD), given the hardships to which many patients have been subjected — torture, sexual violence, death of loved ones, or witnessing others’ trauma. As a result, SEED spends a great deal of time and resources on raising awareness among communities about the natural, human reactions to traumatic events, and increasing these communities’ acceptance of psycho-social services to treat the effects such trauma.

Another element of SEED’s strategy to overcome stigma surrounding mental health issues is to provide a holistic approach to treatment. While designing the SEED program, we examined a variety of other organizations’ models in the camp setting. Interestingly, many of these programs are themselves stigmatizing, making it difficult for those seeking help to do so discreetly, and as a result, many individuals would not want to be associated with mental health services. Some of those in a caring role demonstrated insensitivity in the ways they approached patients, in some cases identifying individuals by name within a group of their neighbors. Rather than perpetuate or duplicate these errors, SEED has developed a comprehensive service center that provides a wide range of social services, including recreational activities like baking, sewing, childcare, or woodworking, as well as therapy, counseling and social work.

As a result, it is easier for people to enter the SEED Center and seek care confidentially. For example, a mother can take her child to an art class, and simultaneously sit down with a therapist while her children are occupied. Additionally, many psychosocial services have been integrated into SEED’s other programming. In some cases, social workers might attend a baking or knitting class, where they can identify individuals who are in need of care and build trust with participants. This process is done very warmly and carefully, in the context of other activities. Most of SEED’s clients come to our program to take advantage of the wide range of programs offered, not initially to seek psychological care. Of course, this approach does not work in all circumstances; SEED also uses mobile services to reach survivors of trauma across Kurdistan, who may not be able to access a Center like ours.

The majority of IDPs and those directly affected by the war reside outside formal camp settings. What challenges does your organization face in terms of reaching those impacted by violence and trauma, especially in insular communities or areas still undergoing upheaval and conflict, as well as those outside of formal camp settings?

Approximately 65 percent of displaced Iraqis are living outside formal camp settings, with some integrated into host communities. In many cases, displaced and host populations are linked by familial bonds or relationships. To some degree, these connections have helped some displaced people assimilate, find jobs, and access social support networks in their new areas. Yet, this dynamic also creates huge demands on government service providers, and local institutions — health, education, electricity, and other services — are overwhelmed by rising needs. If the government cannot provide sufficient services to its host population – frictions may emerge.

Iraqi Kurdistan is currently experiencing a financial crisis, and the local population is struggling; adding a new, needy group to this already financially strained population can lead to some resentment and anger among host communities. It is thus critical for service providers to reach not only displaced people, but also their host communities. With regards to hard-to-reach communities, SEED has worked with ethnic and religious minorities, including people who were very marginalized and neglected prior to this conflict. Working with some of these groups is extremely challenging with low literacy and skills, high rates of gender based violence in the communities, and a number of other factors impacting their recovery and well-being. However, by employing many who come from the communities, it was possible to build a high level of trust between our staff and the people we serve. Ultimately, SEED has been able to reach societies that were traditionally extremely neglected within Iraqi society and difficult to reach with services prior to the conflict.

Another interesting yet under-examined result of the upheaval across Iraq has been transformation of traditional gender roles and hierarchies in communities that have been affected by ISIS violence. Based on a recent needs assessment among SEED clients, some clients from the areas around Mosul were, in fact, better-off in displacement settings than they were in their home villages. This surprising finding was partly a result of the transformed social and familial structures for those who reached IDP camps. For example, many women who now live in such 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 ultimately shook some of these gender roles, empowering some women by removing them from a toxic environment and providing greater security through the lack of privacy.

Today there is a shortage of qualified psychologists in the Kurdistan Region of Iraq responsible for treating a population of 3.5 million. Several training programs have emerged in the KRI to train a new generation of psychologists, including one facilitated by the SEED Foundation at Koya University. How can NGOs, universities, and government ministries work together to build this psychiatric and psycho-social care capacity? 

Because psychological treatment is a relatively new field in Iraq, it is critical to strengthen education programs for psychologists so that it is more practical and clinical rather than only theoretical. In most psychology programs, students leave with an understanding of psychological foundational concepts, but are not ready to meet workplace needs or meet directly with clients. As a result, SEED seeks to make the Koya program more practical by introducing new content such as case studies, developing an experiential learning curriculum, and moving away from the standard lecture format. Now, before students graduate, they are required to complete a two month practicum through which they will work in the environments where they are most likely to get jobs. Some students will work for SEED or other NGOs operating in the field.

In addition to this reformed undergraduate curriculum, Koya University is also now home to a new practitioner training program for those already practicing psychology. This effort seeks to raise their skill level through an intensive six month experiential learning curriculum, comprising four weeks of instruction punctuated by four-to-six week periods during which they apply these lessons in their workplace under SEED supervision. As a result, these students are able to return to the classroom setting with concrete examples of how they applied lessons and concepts in the field. This work aims to address significant shortcomings in Iraqi and Iraqi Kurdish psycho-social caregiving, including appropriate methods for crisis intervention, treating victims of sexual and gender-based violence (SGBV), and ethics and confidentiality, and case management. SEED also hopes to collaborate with similar new programs, including one at the University of Dohuk, which provides a three-year executive Master’s Degree in clinical psychology while allowing students to continue working.

Long-term violence and conflict — culminating in the post-2014 period — has shaped young Iraqis’ experiences over much of Iraq’s modern history. How can aid and NGO organizations create sustainable methods for addressing this deeper history of violence and war that preceded ISIS?

One of the greatest challenges caregivers face when managing the impact of violence in Iraq and Iraqi Kurdistan is that society associates power with physical strength. This perspective is pervasive in politics, as well as in the home environment where men are expected to control women, sometimes through violence to exert authority. Violence and physical power are the norms in the political and legal institutions across Iraq, and are the primary means by which people resolve conflicts and exert their wills. The current conflict with ISIS has been defined by horrendous brutality against men, women, and children. However, the use of sexual violence and enslavement to control women, represents in many ways the deterioration of the female role in Iraqi society.

To address this terrible reality, it will be crucial to dismantle the system wherein physical power is associated with legal and political institutions. Instead, policymakers must build institutions that can be held accountable and deliver services to the Iraqi population. In terms of gender equality, there also needs to be an institutional shift away from a system that imposes a hierarchy between male and female. It will be crucial to change cultural norms and beliefs regarding women’s capabilities and role in society, as well as empower women to make their own choices regarding their family, social, and work lives. To achieve this goal, it is important to foster educational and skills-building opportunities for women. It is also necessary to work with men to change their mindset, by asking them about the kind of family they wish to build: one held together by fear or love and respect? These efforts are tied to the broader need to build a greater tolerance between communities in Iraq and Iraqi Kurdistan, and create a political system in which all these groups are adequately represented.

Transformation at the governmental level in Iraq and Iraqi Kurdistan has thus far been relatively sluggish, creating both opportunity and obstacles for NGOs to drive reform. What challenges does SEED face today, in terms of meeting its goals of restructuring social and political perspectives in Iraq and Iraqi Kurdistan?

SEED’s greatest priority for 2017 is expanding access to high-quality mental health services to those who are most in need. As a result, we are expanding our reach across Iraqi Kurdistan through the use of mobile service units, which focus on trauma among women and children who have escaped ISIS captivity, in addition to the needs of men and boys. It is crucial to develop a family-oriented approach to care, which will build a social support network for survivors of trauma. It is also important to find ways to better reintegrate survivors into their families and societies, if that is something they desire. In addition to these needs, groups like SEED also require access to deeper expertise in areas of child trauma and working with those that may have been radicalized by ISIS.

For example, some children as young as six years have been subject to repeated sexual abuse; others have witnessed intense violence committed against family members or loved ones. These children, in some cases, have become aggressive or violent themselves, or have lost their ability to speak. Some young boys who have lived under ISIS occupation have internalized the militants’ approach to women, and now believe — at eight years old — that they should act violently toward their mothers or sisters. Other children who have been indoctrinated at ISIS training camps are now being reunited with their families. Addressing the psychological and social fallout from these experiences will require specialized services that are currently lacking. We are working with many boys now that have escaped ISIS training camps and they suffered enormously. Although some of these children have undoubtedly committed crimes over the past few years, they must also be seen as victims of ISIS brutality — and treated according to these needs.

Additionally, it is important to develop care options for children who are born of rape. This is not a new problem in war. In Iraq, women who are returning pregnant or with children from ISIS captivity are, in some cases, not being accepted back into their communities. It is crucial to find ways of providing support to these women, so that they are not forced to make incredibly difficult decisions in an instant, or forced to choose between reintegrating with their families and keeping their children. For those children who are given up by their mothers, it will be crucial to develop foster care to meet this need. There is currently no adoption system in Iraq. Ultimately, SEED and other organizations must work with the Iraqi and Iraqi Kurdish governments to build the institutional capacity needed to meet these long-term needs.

You can read more about SEED’s work here

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SHERRI KRAHAM TALABANY is the President and Executive Director of the Kurdistan-based SEED Foundation. She previously served 15 years in the US Government, including at the Department of State and Millennium Challenge Corporation, working on foreign assistance programming and international development. 

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