Trauma-Informed Services for Iraq
Visit to Philadelphia, October 4-6, 2010
Last week, the Center for Nonviolence and Social Justice played host to eight mental health workers from two separate regions of Iraq. The visit was a training initiative sponsored jointly by the Iraq Ministry of Health and the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services. Sandra Bloom, Associate Professor of Health Management and Policy in the School of Public Health was asked to arrange the visit by SAMHSA because the goal of the project is to help to establish trauma-informed mental health services in Iraq (www.sanctuaryweb.com). SAMHSA thought the visitors could benefit by seeing all that is being done in Philadelphia to address the post-traumatic needs of vulnerable men, women and children.
The visitors from Iraq constituted two teams. One team, located in Baquba, Diyala Governorate was comprised of a psychiatrist, Dr. Hammod; a general practitioner in psychiatry, Dr. Razzaq; a social worker, Mr. Aday; and a psychiatric nurse, Mr. Rasul. Their objective is to help children and adolescents deal with the trauma they have experienced in their war-torn country. The second team from Sulaymaniyah, Kurdistan is focusing on integrating trauma services into primary care by placing small mental health teams into twelve primary health centers. They are dealing with the more recent effects of war as well as the attempted genocide of the Kurdish people under Saddam Hussein’s regime. Their team was comprised of two psychiatrists, Dr. Tawfeeq and Dr. Hama, and Mr. Raheem and Mr. Osman, psychiatric nurse.
The visit extended from Monday morning until Wednesday afternoon. On Monday morning, a kick-off meeting was arranged attended by Dr. Arthur Evans, Director of the Department of Behavioral Health and Mental Retardation Services (DBH/MRS); Anne Marie Ambrose, Commissioner of the Philadelphia Department of Human Services (DHS); Carol Tracy, Executive Director if the Women’s Law Project; Dr. John Rich, Chair of Health Management and Policy of the School of Public Health at Drexel University, Dr. Ted Corbin, Director of the Healing Hurt People Program; Dr. Bloom, Linda Rich, Dionne Delgado, Tony Thompson, Leigh Jamison, Ann Wilson, Solomon Evans, and Beverly Haas, all members of the Center for Nonviolence and Social Justice, as well as Joe Foderaro, LCSW and RuthAnn Ryan, MSN who both run the S.E.L.F. Psychoeducational Groups for Healing Hurt People. The Center for Nonviolence and Social Justice (www.cnvsj.org) also has three interns with us this year, Richard Baccare from Bryn Mawr School of Social Work, Rachel Compton and Rebecca Newman both from School of Social Policy and Practice at the University of Pennsylvania. The interns were extremely helpful serving as chaperones for the visitors as they visited programs throughout the city. Susan Salasin from the Center for Mental Health Services of SAMHSA and Joan Gillece, Director of the National Center for Trauma-Informed Care that is part of SAMHSA also attended the three-day visit.
On Monday morning, after a community meeting during which introductions were made, Ms Salasin reviewed the project and its purpose. Dr. Rich then briefly shared some overall impressions about the issue of violence and trauma as a public health problem in Philadelphia. Dr. Corbin explained the initiatives that the Center for Nonviolence and Social Justice has started in responding to assaults, particularly in men who are treated at Hahnemann and children seen at St. Christopher’s Hospital for Children via an emergency room based program, Healing Hurt People, and the interface with primary care. Dr. Evans explained the trauma initiatives that DBH/MRS is engaged in to improve service delivery of trauma-informed treatment in Philadelphia, while Ms. Ambrose discussed the challenges the city faces around child welfare in the face of a high levels of poverty and trauma experienced by the families in our city and the steps DHS is taking to become trauma-informed and to interface collaboratively with the Philadelphia School District. Ms. Tracy described the initiatives taken by the Philadelphia Police Department to address the needs of domestic violence and rape victims.
After a general discussion, the group divided into their separate teams, beginning a rigorous day and a half of visiting programs throughout the city. The group from Kurdistan spent the afternoon at the Healing Hurt People program at Hahnemann Hospital, were interviewed by Maiken Scott from NPR, and attended that afternoon’s S.E.L.F. Psychoeducational Group, a component of the Healing Hurt People program. There they heard directly from the men who attend the group about the issue of violence in our urban environment. The group from Diyala spent the afternoon with Children’s Crisis Treatment Center (CCTC), talking together over lunch and then visiting a number of the CCTC programs for traumatized children and families.
On Tuesday, the visitors had an even busier day. The group from Kurdistan first visited Women Organized Against Rape, and then came back to the School of Public Health to attend the weekly case review for the Healing Hurt People program. After lunch, they were welcomed at the Hispanic Community Center, where views were exchanged about things like assessment tools and treatment approaches for trauma survivors. They ended the day with a visit to Menergy, one of the city’s few resources for men who engage in domestic violence against their partners.
Meanwhile, the visitors from Diyala were also following a busy schedule. In the morning they went to visit Women Against Abuse, the only shelter in Philadelphia for victims of domestic violence. In the afternoon, the team met with the staff at Jane Addams Place, a shelter for homeless families that is part of the Lutheran Settlement House and which is also a member organization of the Sanctuary Network. At the end of the day they were hosted by Resources for Human Development and the mental health professionals dealing with veterans.
Wednesday was devoted to a specialized training for the visitors in a trauma-specific technique developed by Dr. Lyndra Bills, a psychiatrist who now works as Associate Medical Director of the Northeast Region for Community Care Behavioral Health. Dr. Bills kindly donated her time to offer Trauma Art Narrative Therapy (TANT) training, a creative narrative cognitive exposure therapy that is beneficial for reducing intrusive symptoms from trauma; integrating verbal and nonverbal aspects of traumatic stress exposure; and providing resolution to traumatic experiences in children and adults, while requiring only paper and markers as tools and some specific training. TANT is designed to help resolve trauma-based symptoms and behaviors in order for traumatized individuals to move on to the next step in their healing (www.learntant.com). The training itself is experiential and the Iraqi visitors readily participated in the activity, in the process sharing a little with us about their own traumatic experiences of the past few years.
Thanks go out to Dr. Evans, Ms. Ambrose, Ms. Tracy; and Dr. Bills; our interns, Rachel Compton, Richard Baccare, Rebecca Newman (who was able to speak some Arabic); Grace Ryder from CCTC, Eda Kauffman at Women Against Abuse, David Roth from Jane Addams Place, David Dan from Resources for Human Development, Carole Johnson at Women Organized Against Rape, Dr. Eduardo Pino of the Hispanic Community Center, Paul Bucovec and Tony Lapp at Menergy; as well as Dionne Delgado and Tony Thompson at Healing Hurt People, and Beverly Haas at the Center for Nonviolence and Social Justice for coordinating all of this.
IRAQI MENTAL HEALTH PROFESSIONALS VISIT PHILADELPHIA
Wednesday, October 6th, 2010
By: Maiken Scott
A delegation of Iraqi mental health professionals is visiting Philadelphia this week to learn more about American approaches to treatment. The six-week session is offered by the federal Substance Abuse and Mental Health Service Administration.
Decades of brutal dictatorship and war have exposed much of Iraq's population to suffering and loss, leaving wounds both physical and mental.
The focus of the delegation's U.S. visit is understanding the impact of trauma. It's a very familiar topic to Dr. Jamal Omar, a psychiatrist in Sulaymaniyah in Iraqi Kurdistan:
Omar: Kurdish people is exposed to trauma for a long time, under Saddam's regime, evil Saddam regime, chemical bombardments and also mass displacement of the people
One of the stops on the delegation's packed Philadelphia schedule is a program called "Healing Hurt People," which works with young people who have been shot or stabbed. The program's research director, clinical psychologist Linda Rich, explains that trauma is a lens that provides a deeper understanding of their clients:
Rich: By being trauma informed, what we really do it take into account that individuals and communities have had distressing and emotionally painful events, chronically and really over the course of their lives and that this impacts their health emotionally and physically.
Traumatic events, says Dr. Sandra Bloom Co-Director of Philadelphia's Center for Nonviolence and Social Justice, alter mechanisms in the brain, like the fight or flight response:
Bloom: Lots of people don't realize that it changes your biology, and the way your brain works, not just emotionally. So people are much more ready after a traumatic event, not because they want to be but because their biology is changed, to respond to minor provocation with a major, often violent response.
This concept will be a tough sell back in his region, says Dr. Jamal Omar. People there focus on physical symptoms such as headaches, or backaches, but don't see a connection between past events and behavior:
Omar: Sometime, some of them tortured for a long time, and then, after that now he is not working, he has not family, no job, nothing. if you try consider this – it's not related to that, they don't know, what is that, trauma.
During the training session, Healing Hurt People staffer Dionne Delgado gives an example of how trauma can affect her clients' behavior:
A lot of them smoke marijuana, which is maladaptive, but when you talk to them they explain it as calming themselves down, it's how they soothe themselves, it's their solution and they say you don't want to have to deal with me if I'm not calm, if I'm agitated, nobody in my family wants to deal with me.
What about clients who refuse treatment after a life-changing injury, asks one of the members of the Iraqi delegation:
Iraqi delegation member: I have an example, people say I don't want to receive medication, I want to die, what do you want from me.
Delgado responds that a first step is to explain to the medical staff that the patient is severely traumatized, and then start with behavioral health interventions. She says often, once patients begin to understand and address their emotional wounds, it changes their outlook on life.
Omar estimates that over 40 percent of people in his region deal with mental health issues. He says one problem is that the suffering has been going on for so long that symptoms like sleeplessness, anger, aggression, or depression feel normal to people. He says raising public awareness about mental health issues will be the first major step.
Omar: For example, we can go through the community, through the teachers, we can teach or tell them awareness about mental health, what are abnormal behaviors among the students, if they found this, they must know, so we we begin slowly slowly.
Another big issue, says Omar, will be to reduce the stigma associated with visiting a psychiatrist or crisis center.
The delegation concludes its Philadelphia visit later on today.