The importance of tackling mental health problems in the Kurdistan Region, and indeed globally, is obvious – these challenges have simply not received enough attention in the Kurdistan Region, as in many parts of the Middle East. That, however, is beginning to change and, in Kurdistan, the Oxford Cognitive Therapy Center (OCTC), which is part of Oxford University, is leading the charge.
Mental health issues pose a significant risk to one’s physical health, educational and work prospects, likelihood of committing a crime, and even longevity. In post-conflict zones, this is particularly acute. In addition to the personal impact on individuals, their families, and caregivers, mental health concerns come at a very high cost to economic well-being. A hallmark of a resilient community is the ability to deal with and respond effectively to peoples’ mental health challenges and manage the disruption caused by them.
World Health Organization figures suggest that depression and other mental health issues are an increasing burden on societies as communicable diseases gradually recede; communities recovering from conflict are also especially vulnerable in this regard.
These factors are as prevalent in the Kurdistan Region and Iraq as elsewhere in the world, but there are other issues that compound the mental health situation. The Kurdistan Region and Iraq have faced decades of trauma and violence, with entire communities engulfed by armed conflict, extreme political violence, and genocide. Forced migration within, into, and out of the country has been a feature for several decades, another significant contributor to trauma and depression.
Addressing the issue
The Kurdistan Regional Government has been fully supportive of the OCTC’s efforts. Kurdish society is noted for its tolerance and willingness to help those who are suffering now or who have suffered in the past from the travails that have rained upon the region and its people.
The need in Iraq contrasts sharply with the provision and conception of mental health services. Only a small number of psychiatrists offer medicalized solutions, while primary health care workers receive insufficient training to detect mental health issues. This is compounded by a profound stigma that is associated with mental health in Iraq.
However, there is evidence to suggest that targeted training in cost-effective ‘talking cure’ therapies can begin to address the gap in Iraq and create a more ‘stepped’ approach, enabling a reliable referral process.
Through a project initiated and coordinated by KR-UK-IMPAKT, a UK-based non-governmental organization (NGO) of interested mental health professionals, the OCTC is training 30 Iraqi Kurds to deliver cognitive behavioral therapy (CBT) to other Kurds. The OCTC, which is both a part of Oxford University and the Oxford branch of the UK’s National Health Service, is a leading trainer in the UK. Conducted in teaching blocks across a calendar year, the training, much of which is done online, includes extensive ongoing supervision for trainees and is already exceeding the OCTC’s expectations.
The first cohort of 30 Kurdistanis – who speak excellent English, have a background in psychology, strong interpersonal skills, and access to clients – should finish their training. What has the experience been like for them so far?
“From day one, the first benefit was getting to know everyone, forming a community. Then, we were exposed to an incredible wealth of knowledge. Initially, we just heard the name ‘Oxford’ and thought the training would be very hard – but no. They’re working with us to make difficult material more approachable. It’s not easy, but they make it easy. The trainers are so kind with us, and we are very grateful to them.”
Efficiently building foundations
The OCTC trainers are delighted with the project so far and are eager to enact the five-year goal of building the foundations of a modern mental health service in a part of the world that desperately needs it. Included in this goal is creating a regulatory framework and a market for psychotherapists in the Kurdistan Region.
The project depends on the services of the European Technology and Training Center, an experienced training organization based across Iraq, to recruit candidates, ensure good trainer-trainee liaison, and to manage relations with the authorities, who have been supportive. The wider team, led by KR-UK-IMPAKT, have worked pro bono so far to help negotiate any cultural issues that emerge.
Online training sharply reduces costs and exposure to security issues while enabling more equitable working arrangements. The project is relatively cheap – at a cost of around £250,000 per annum – targeted, and involves a multi-year commitment of up to five years. Funding for the first two years so far has been provided by a private donor with a long-standing commitment to Iraqi Kurds, particularly those who helped journalists during the difficult times in the early 1990s. The project is seeking funding for years three to five.
The project is eminently replicable, and its project coordinators are ready to bring their experience into other settings.
CBT, a highly effective treatment for most common mental health issues, also provides an entry point to a range of situations and areas of focus.
Initial discussions suggest that a CBT training intervention could prove a useful, targeted tool in Iraq, particularly in areas liberated from ISIS. For instance, CBT training can help the families of missing persons and those searching for or who have found the remains of loved ones. It can also help those suffering from ambiguous loss and traumatic memories.
There can be a wide variability in people’s ability to cope with, and adjust to, the absence or death of someone close to them. This includes a constellation of beliefs: a griever’s thoughts about the circumstances of the death, their feelings about the person who died, their reflections on the relationship with that person, and their assessment of their own ability to survive the loss. Uncertainty adds another complicating dimension to adaptation that needs careful and qualified help.
Taking a step-back, the Yezidi genocide crisis marked an inflection point for the global humanitarian community. ISIS’s rape and torture of women and young girls meant that the victims’ needs were as much psychological as they were physical. The responses of the UN and NGOs in providing food and shelter for the Yezidis were necessary, but insufficient. Many NGOs struggled to find Kurds who had the right language skills, experience, training, and expertise to address the deep trauma that many Yezidis were suffering from and continue to suffer from to this day.
This is ultimately because psychotherapeutic techniques are in their infancy in Kurdistan, Iraq and the Middle East. There is no qualified wellspring of expertise to draw upon from the host community – itself bereft of talking cure therapists.
In short, there is no health without mental health. The OCTC has started to deliver CBT training in the Kurdistan Region with best-in-class UK trainers cheaply and effectively, thus laying the foundations for a comprehensive and resilient system for the treatment of mental health issues in the region and beyond.
Chris Bowers is the former UK Consule General in the Kurdistan Region and has been working on KRI for more than a decade.
Dr. Chinar Osman is a Consultant Neurologist in the NHS in the UK who graduated in London in 2008. She is an honorary lecturer at the University of Southampton and a medical examiner.
