Psychiatrists and other professionals from Iraq spent five weeks this fall
observing American practices in school-based mental health, forensics, trauma care,
substance abuse, services for women and children, and chronic psychiatric disability
They learned a lot while in the United States but also taught something to their
The 24 Iraqis in the program were supported by the Iraqi and Iraqi Kurdistan
ministries of health and the U.S. Substance Abuse and Mental Health Services
The Iraqi visitors were divided into six teams, each specializing in a different
area (see Iraqi Forensic
Experts Face Daunting Challenges).
"Everywhere we went, we learned something new," said Rebwar
Ghareeb Hama, M.D., a psychiatrist from Sulaymaniyah in Iraqi Kurdistan, in an
interview. "Especially the greater use of psychotherapy."
In Iraq, mental health care has been carried out historically on a narrow medical
model, by doctors and nurses, with heavy reliance on drugs, he said.
"A community psychiatry model is hard to apply in Iraq for several
reasons," added Jamar Omar Tawfiq, M.B.Ch., also a psychiatrist from
Sulaymaniyah. Just six psychiatrists serve that city of 2 million people.
Tawfiq and Hama were both part of the group studying trauma services in primary
"There is a lack of psychiatrists, psychologists, clinical social
workers, and nurses," Tawfiq told Psychiatric News.
"There is also a great deal of stigma and misunderstanding in the general
population about mental illness."
There are 350 clinics in Iraqi Kurdistan. On their return to Sulaymaniyah, the
psychiatrists and their colleagues will choose 12 geographically dispersed health
centers and teach the primary care staff—usually just one physician, a physician
assistant, and a nurse—more about mental illness and its treatment.
"We will train them in trauma care, teach them to talk to the patient,
ask if they experienced trauma, then develop rapport and educate the patient,"
said Tawfiq. "If a case is severe, the patient will be referred to the
hospital's psychiatric department."
In addition to a shortage of psychiatrists, Iraq also lacks sufficient
nonphysician mental health personnel.
"Our biggest problem is training enough nurses, clinical psychologists,
and clinical social workers to create the multidisciplinary teams we need,"
The Iraqis visiting the Johns Hopkins Bayview campus in east Baltimore
studied school-based mental health systems. Nearly 50 percent of Iraqis are under
age 18, but there are few mental health professionals in community settings to
identify children with special needs or learning disabilities, said Anita Everett,
M.D., director of community and general psychiatry at Bayview and the Iraqis' host
The visitors sat in on Baltimore public-school classrooms, observed
children's mental health services in schools, and talked to principals and other
school officials. Their hosts discussed questions such as how to differentiate
behavioral problems from learning disabilities, attention-deficit/hyperactivity
disorder, or posttraumatic stress disorder.
Eventually, the Iraqis will pass on such knowledge to teachers to help them
identify students who need to be referred for services. They were particularly
intrigued by an after-school program's therapeutic intervention to combat substance
abuse, in which students are bused from their schools to Bayview.
The primary intent of the program was for Iraqis to learn about the most
applicable aspects of U.S. mental health services and how to make use of them back
in their devastated country.
But something else happened as well. The Americans learned a lot from the
"Our staff benefit from exchanges with our guests," said
Everett. "Those discussions help us understand our systems better. We're not
learning techniques, but we are gaining perspective on our services that we get
For one thing, the Iraqis illuminated the fact that much of American
psychiatry is focused on the individual.
"In the U.S., we design programs to make patients more
independent," noted Everett. "Many of our patients are disengaged
from their families by the time they get to the clinic."
But in Iraq, even with all its stresses, family bonds remain stronger and
can serve as a source of support for patients. For example, one group from Mosul
that took part in a similar program in 2008 set up a program in which a family
member becomes a paid member of the patient's care team.
"We can look at how the Iraqis try to provide mental health services
in a resource-poor setting and learn something about how to work in underserved
areas of this country," said the International Medical Corps's Allen Dyer,
M.D., the host for the trauma group in Virginia.
The experience has even sparked some new thoughts on diagnosis and treatment
that might be applicable here.
"Perhaps PTSD is not the right description for the trauma faced by
people in Iraq," said Winnie Mitchell, M.P.A., international officer at
SAMHSA. "We're thinking of calling it OTSD—‘ongoing
traumatic stress disorder’—because the violence continues on and on,
and is not a single event. We face the same thing in the U.S. with domestic
violence, street violence, and the aftermath of combat. Our providers also need to
pay attention to that ongoing experience of trauma."
The Iraqi groups were based at the National Center for Trauma-Informed Care
in Alexandria, Va.; Children's National Medical Center in Washington, D.C.; the
Maryland Department of Health and Mental Hygiene's forensic services division at
Jessup and Sykesville, Md.; INOVA Fairfax Comprehensive Addictions Treatment
Services in Falls Church, Va.; the Johns Hopkins School of Medicine in Baltimore;
and the UCLA Integrated Substance Abuse Programs in Los Angeles.
They also visited sites in Boston and Greenfield, Mass., Milford, Conn.,
Yonkers, N.Y., Philadelphia, and Sacramento, Calif.
"We hope that this exchange will go on to permit the continuing
education of psychiatrists and other mental health professionals," said