Iraq Mends a System to Treat Trauma
Eros Hoagland for The New York Times
Mohammed Ziara, 11, is taking part in therapy sessions at the Sara Center for Trauma in Basra, Iraq's first multidisciplinary clinic for post-traumatic stress disorder.
By JOHN LELAND
Published: January 30, 2010
BASRA, Iraq During quiet moments, Fadel Khadum Adel, a former soldier, often hears someone speaking his name into his right ear. The voice is a welcome one, usually that of his mother or father, but when he looks there is no one there.
Fadel Khadum Adel, a former soldier whose ear was cut off for desertion in 1987, is only now getting effective trauma therapy.
Mr. Adel, 43, turned his head to reveal a gnarled stub of an ear the rest was forcibly amputated, without anesthesia, under Saddam Hussein, as punishment for his desertion from the army in 1987 during the Iran- Iraq war.
Mr. Adel has heard the voices, and worse, ever since.
“I’ve gone to doctors and they just say, ‘What’s your problem?’ ” he said, his features heavy and inexpressive. “I say, I’m depressed. They gave me medicines. But the medicines gave me hallucinations. So what I need is to talk.”
Iraq’s mental health care system was once advanced for the region, but by 2006 fewer than 100 psychiatrists remained in a population of about 30 million, and almost no psychologists. Patients were isolated in understaffed institutions, apart from their families and communities.
But now the government has embarked on an ambitious program to rebuild its ruined mental health care system in a country experiencing more than its share of traumas and stress. It will be built on a network of clinics that are team-oriented, with an emphasis on outpatient care and respect for patients’ rights a radical departure from the existing system of institutional care focused on drugs and electroconvulsive therapy, often given without seeking a patient’s consent.
On a recent afternoon, Mr. Adel sat with a community health doctor at the Sara Center for Trauma, the nation’s first multidisciplinary clinic for post-traumatic stress disorder. The center, which opened Dec. 18, includes a psychiatrist, a community health doctor, a gynecologist and a social worker, all working jointly.
“This is the first time we’ve had anything like this,” said Dr. Akeel al-Sabbagh, the center’s consultant psychiatrist. “In Iraq, the psychiatrist is like a dictator. Even my colleagues now, they say, ‘Why would you talk to a nurse?’ In the U.S.A. we saw the nurse, psychiatrist, psychologist and social worker all talk together about the patient.”
In 2008, six teams from Iraq spent a month at facilities in the United States, each concentrating on a different area of care. More teams are scheduled to make the same trip this year, with financing from Iraq’s Ministry of Health and the United States Substance Abuse and Mental Health Services Administration.
But rebuilding an effective mental health system will take years. In the meantime, primary care doctors are being trained to recognize and treat basic disorders.
Last year, 360 primary-care doctors took two-week crash courses in depression, anxiety, psychosis and other afflictions, using a curriculum developed in London for Nigeria. “This is a turning point in mental health services in Iraq, integrating treatment into primary care,” said Dr. Sabah Sadik, chairman of the Middle Eastern International Division of the Royal College of Psychiatrists, who is coordinating the program.
For Mr. Adel, the change has meant a new start.
As a soldier in the war against Iran, Mr. Adel ran away in 1987 after his brother was killed. He was quickly captured and punished with the amputation of his ear.
“I started crying and shouting,” Mr. Adel said of the pain. “We were put in a small room, hundreds of prisoners, with no space to sleep. We had to defecate and urinate in the same room. I started to hallucinate from fever.” When he got out of prison after a year and a half, he became depressed and lost his balance when he walked.
“I never wanted treatment,” he said, meaning antidepressant drugs. “I wanted to talk.”
But until he discovered the Sara Center last month, he never encountered professionals who offered therapy in addition to medication. Since then he has been enrolled in a program called cognitive processing therapy, which is devised to help trauma victims manage their haunting memories.
“To be honest, I’ve only seen this in movies,” he said. “I didn’t know what it was. They told me that whatever I said was a secret between us, and I could talk freely. I haven’t had this treatment in my life.”
His recovery will not be easy. Even after Mr. Hussein’s execution, he said, he felt only sadness. “Because they didn’t torture him,” he said. “They were supposed to cut off his ear and stomp on him. His death was a gift to him.”
Though Iraq’s minister of health, a psychiatrist, supports the multidisciplinary program, Dr. Sabbagh said he had met resistance from peers. At meetings in Baghdad at the mental health council, he said: “When I talk about psychotherapy and dealing with the patient, some of our colleagues say this is a waste of time. When I ask for money to train my staff, they say, ‘This is a waste of time, why not give this money for drugs?’ ”
Some American methods proved unsuitable for Iraq, Dr. Sabbagh added. At one center in Battle Creek, Mich., the director greeted the Sara team with therapy dogs, which Iraqis consider unclean or dangerous.
“We were afraid,” Dr. Sabbagh said. “The dogs are standing up, and one of our colleagues is falling down.”
In a room at the Sara Center, Mohammed Ziara, 11, played a violent video game called Street Fighter. Last year, his father got into a quarrel with neighbors, and the police came to arrest him. The boy assumed the worst.
“On TV, whenever the police take someone away, they torture or kill him,” he said. “I was afraid he’d be killed.” Even after his father returned home, Mohammed had nightmares and performed poorly in school. When teachers hit him for his mistakes, he became afraid to go to school.
At the Sara Center, a social worker, Nidhal Baden Sultan, had him talk about the night of the arrest and talked to his parents and teachers to explore how his relationships were contributing to his trauma.
ldquo;We told his teachers to treat him kindly,” Ms. Sultan said. After two sessions, Mohammed said he was starting to feel better, no longer afraid to go to school.
Much of the center’s work consists of this kind of community outreach. Staff members hold sessions for teachers, clerics, police officers and other public figures about the need for mental health care, which carries a stigma here. Dr. Sabbagh said many of his patients first went to faith healers, who often tried to beat the genies out of them with sticks. One man arrived at Dr. Sabbagh’s practice with two broken collarbones.
On a recent day, the center attracted a few patients suffering from trauma, but most had unrelated problems: a mother with a hyperactive 4-year-old, a man depressed after a failed relationship.
Dr. Sabbagh was philosophical for psychotherapy, people had no place else to go. Iraq’s immodest goal is to make entire country rethink its approach to mental health, from patients’ rights to modes of treatment. Getting people in the door, even the wrong door, is a start.