During the two years they lived under Islamic State control, residents of Shargat, northern Iraq, lost most things that mattered to them. Husbands and sons were captured or killed. Belongings were burned. Houses were looted and cars stolen. Government salaries went unpaid.
“Sometimes the children were very hungry and we just had to put them to sleep, because there was nothing to eat,” said one female former resident, whose name Devex is withholding for her security. Now, she lives in a displaced camp where she says her family has had to cook and stay warm for the past two months with just one carton of kerosene gas.
Tales of trauma like this are strikingly common among the hundreds of thousands of Iraqis who have lived under ISIS and then often been displaced by military efforts aimed at dislodging the militants. Here, and in Syria, relief workers say nearly everyone they encounter has some level of post-traumatic stress disorder.
“[For] most of the IDPs, their [current] situation and the condition of life they have been facing in Mosul has been very hard, so most of them are really in need of psychological support services,” said Fanny Mraz, Iraq head of mission for Handicap International.
The astounding level of psychological trauma has transformed the relief operation in a way that aid workers say they haven’t seen in other emergencies. Aid groups are developing new strategies to provide usually limited psychological services on a massive scale. They are finding new tactics and allies along the way, and discarding interventions that fail.
Specifically, aid groups are turning to the relatively new concept of Psychological First Aid. Developed over the past decade, the response includes basic rudimentary techniques of listening, providing safe spaces and comfort and assessing future needs, according to a World Health Organization guide drafted in 2011, just ahead of the wave of displacement in the Middle East.
Devex spoke with several groups providing services in northern Iraq for victims of the conflict. Here are a six key takeaways for a psychosocial aid protocol, as it is drafted in real time.
1. Incorporate PFA at all levels of a response.
At the beginning of military operations to liberate Mosul from ISIS last fall, NGOs and United Nations members of the Global Protection Cluster grappled with how to deal with the mental trauma they expected to find among residents and displaced.
“We decided to first set up psychological first aid teams to have very basic, simple but straight to the point system and method,” said Handicap International’s Mosul Field Coordination Maud Bellon. The basic tenant of the PFA was simple: allowing victims to “express themselves and take back control of their lives.”
PFA teams are now popping up in every corner of the response: At initial response points, in schools, among camp volunteers, in health facilities and mobile clinics. The GPC regularly coordinates to ensure that NGOs working in the sector are well distributed between camps and affected populations. Several organizations are also working with urban internally displaced persons.
Handicap International’s programs offer an example of how the service works. As a first intervention, two social workers gather a small group of people together — usually a family or group of families — for a conversation. “We explain that now they are in a safe place, we know that they experienced very traumatic situations, and that now they have the space and the forum to express themselves,” said Bellon. The PFA teams can also hold one-on-one conversations in particularly vulnerable situations, or when beneficiaries request more privacy.
This initial PFA is also vital, aid groups say, for spotting more severe cases of psychological distress and ensuring sufferers have access to care.
The demand for services has surprised even those involved, and the GPC now lists PFA as a “first-line humanitarian response” in the United Nations’ 2017 Humanitarian Response Plan for Iraq.
2. Integrate and rely upon expertise from the local community.
PFA has expanded in Iraq in part because communities themselves demanded it. Their understanding and appreciation of the problem has also been a resource for groups trying to navigate a complex environment.
“It’s a country where you don’t have to convince [people] about the need for psychological support,” said Mraz. “Even the authorities and local and community leaders; one of the first points that they are raising for the people is the trauma.”
Numerous organizations working in PFA described the importance of recruiting social workers directly from the community. “They know the victims, and they can build a rapport” in a way an outsider might not be able to, one aid official told Devex. The person spoke without attribution, to protect his organization’s discrete work in gender-based violence particularly.
In Iraq, local recruitment is also helping address a major deficit in local mental health care services: There are just 70 Iraqi psychiatrists in the entire country. Social workers, however, are far more numerous and many of them current or former government employees. NGOs train these individuals to form the pillar of the PFA response.
3. Discretion above all else.
In Qayarrah General Hospital’s maternity ward, two female social workers discreetly mix with the flow of doctors, nurses and patients in and out. No one announces they are there, but the women are trained to recognize signs of abuse or GBV. They are a subtle frontline resource.
Women wouldn’t come to a clinic specifically branded as providing psychological support, for example for GBV, aid officials in the hospital said. But in the privacy of the maternity ward, they are often relieved to talk.
Here and across the range of psycho-social services, anonymity and privacy are vital. “The cultural pressure and norms corner people and victims of gender-based violence to feel something is wrong with [them] if they seeks psychological assistance,” said Arez Hussen Ahmed, project manager at Asuda for Combating Violence against Women, one of the first local NGOs to respond to GBV. “Having psychological issues should be perceived like any other health issues.”
Asuda, for example, has developed an “open” counseling service for patients whose social or economic situations may not allow them to seek continuous care. Psychologists offer as much as they can, including forward-looking tools for patients to use on their own.
“Whether a client does not want to come back or because she or he cannot come back — there’s stigma, the husband doesn’t allow it to come back, or the wife doesn’t allow it to come back. We have open meeting sessions, which is usually one session, and we try to give as much assistance as possible in this one session.”
The organization also prioritizes discretion in all its interactions with patients. Community volunteers undertake door-to-door visits to vulnerable neighborhoods in hopes of raising awareness about the issue, and also offering a safe environment for the first conversation.
4. Make it normal.
One organization working to support victims of GBV was struggling to convince women to attend its sessions, until they stumbled upon an idea: Turn it into a makeup class. Many of the women in the affected community couldn’t afford to buy cosmetics. They saw the gathering as a social opportunity and access to a rarely available luxury.
Normalizing psychosocial support can help lift the stigma sometimes attached to it, and encourage even the most reluctant to seek help. Videos, acting, humor and fun are powerful tools when used with nuance.
Advocates say community awareness is also vital. “We engage men and boys in combating violence against girls and women,” said Ahmed. “We try to bring them on board and get them involved. A lot of time we tend to forget, violence by whom.”
5. Ensure visitors and the media are sensitive to vulnerability.
In the initial media frenzy of the Mosul campaign, a number of victims of trauma were essentially retraumatized by their encounters with the press, according to several aid groups who spoke to Devex.
In the most dramatic cases, journalists posted photos of victims on social media without their consent, and relatives still in ISIS-held areas were penalized — and in one case, killed. More banal encounters also caused harm, where questions from the media forced victims to relive violent or traumatic encounters.
The GPC was so alarmed at the level of possible misconduct that they drafted media guidelines that members of the press must now read before entering a displaced camp. “Many persons including GBV survivors and children who have spoken ‘on the record’ have later faced a range of problems resulting from being identified, including reprisal, attacks and community rejection,” the guidelines caution.
“Journalists should be guided to prevent any form of psychological trauma to any of the GBV or VAC [violence against children] survivors that are being interviewed and strictly requested to respect their privacy, culture and beliefs.”
6. Remember the host community.
Those who are displaced may be the most visible victims of trauma, but the communities that receive them have also often experienced conflict, economic difficulty or violence.
Treating everyone is not just a matter of fairness; it’s a necessity for community cohesion going forward. After conflict recedes from Iraq, many advocates and civil society organizations here are already planning for the hard work of restitching a divided social fabric.
“These people have suffered. They have gone through so many atrocities. Also the host communities, they have been beaten by husbands and brothers, had their freedoms deprived by them, so these are all victims of GBV and it’s happening to them because they are a minority,” said Ahmed.
Asuda’s goal, he said, is to help clients see the suffering they’ve faced as a turning point and an opportunity to move forward: “To make them individuals that are not only recovered but will fight to make sure that the same thing will not happen to their children.”