Mental Injuries

December 12, 2012

Mental Injuries © Chris Huby/Le Desk

Psychological Trauma in Iraq, and the Way to Help

Joe Belliveau

The chief doctor in the rehabilitation ward of Fallujah’s main hospital says he prescribes fewer drugs now that Médecins Sans Frontières (MSF) has helped introduce psychological counseling to his recovering patients. Many of the patients in the ward were injured in violent incidents including bomb blasts. A young man, perhaps in his early twenties, had his upper left arm shattered in an explosion about 6 months ago. The metal brace, attached to the bone fragments, pokes out of his arm in 3 different spots. He looks depressed and his father says he’s “anxious” about his future. He has just been referred for his first counseling session and the doctor is optimistic that both his arm and his spirit will recover.

Over the past two years, MSF has helped pioneer a different approach to mental health in Iraq. Complementary to the psychotropic drugs and electro-convulsive therapy used to treat severely mentally ill patients, MSF is working with the Iraqi Ministry of Health (MoH) to introduce mental health counseling. Very often medication is not required for psychological trauma. With the right guidance and teaching of simple coping mechanisms, people can make great gains in dealing with fears and anxiety and restoring their normal day-to-day functionality. The demand for this kind of help – owing to the sheer number of people suffering the effects of violence in its various forms – appears enormous.

There are so many examples. A woman kept coming to the hospital complaining of lower back pain thinking that she had some sort of tumor. The doctors could find nothing so referred her for counseling. Eventually it surfaced that during Ramadan last year her son stepped outside to smoke a cigarette at the day’s end and was blown up. Her grief was so deep it became physical.

Earlier this year, shrapnel from an explosion disfigured and blinded a man in one eye. He was a trader, but withdrew, lost his confidence and felt stigmatized. At home he took out his frustration on his wife and son who are now in counseling.

These types of accounts are common amongst the hundreds of patients that MSF/MoH teams counsel every month (an average of 300 new clients, and more than 800 sessions per month). So far, we have rolled out services in three hospitals in Baghdad and Fallujah and aim to replicate the model in other locations including through primary health care centers. The MoH is committed and MSF has already helped train the next generation of counselors and trainers for three newly identified units. Telephone help-lines have been set up in two areas for patients who want more information or cannot access the counselors in person. Teams of outreach workers are assigned to increase community awareness about the services. And a new evaluation tool has been introduced to measure patients’ progress and improvement. The gap in counseling services in Iraq is conspicuous. The needs are huge, but the positive impact of counseling is also clear.

More than half of all cases are violence related, whether domestic including sexual assault, or witnessing/experiencing a major violent event, often an explosion. Earlier this year, a grenade was lobbed into the area where a man sat with his family. His wife and daughter were killed and his leg was badly damaged. In hospital he refused to be treated or take medication. After two weeks of counseling, he accepted treatment and was soon discharged. A six year old boy is under counseling after repeated sexual abuse. A kindergarten teacher is being counseled after escaping from a kidnapping during which she was physically assaulted. These are the types of mental injuries our counselors are handling every day.

The effects of such psychological trauma can be debilitating, leaving people to suffer from nightmares, fears, depression, apathy or aggression, and in many cases unable to function normally. Mental health counseling is not a magic cure, but it can quickly improve peoples’ symptoms and usually help them become more functional and able to take up their responsibilities. According to data from the tool used to measure patient improvement (SRQ-20), outcomes are very good. Drop-out rates vary significantly between locations, suggesting local factors that may discourage returning patients. However, amongst those discharged, nearly all patients record an improvement in their well-being and functionality. Amongst a sample group of patients earlier this year, for example, 4% of them displayed “light” symptoms, 68% “moderate,” and 28% “severe.” Amongst those discharged in the same month, 78% had “light” symptoms, 22% “moderate” and 0% “severe.” For those who complete counseling, there is a very clear pattern toward improved mental health.

Counseling cannot replace psychiatric medicine, but it can make a big difference in people’s lives.

In all personal accounts, places, names and times have been removed or changed to protect patient confidentiality.


Click here to read about MSF Background/media Briefing: Mental Healthcare in Iraq

Click here to watch the documentry What are your complaints

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