|Year : 2019 | Volume
| Issue : 1 | Page : 3-12
Collective trauma among displaced populations in Northern Iraq: A case study evaluating the therapeutic interventions of the Free Yezidi Foundation
Gail Womersley1, Yesim Arikut-Treece2
1 Assistante-doctorante, Institute of Psychology and Education, University of Neuchatel, Neuchatel, Switzerland
2 Clinical Psychologist, Free Yezidi Foundation, Amsterdam, The Netherlands
|Date of Web Publication||28-Jun-2019|
Institute of Psychology and Education, University of Neuchatel, 1 Espace Louis-Agassiz, CH2000 Neuchatel
Source of Support: None, Conflict of Interest: None
Yezidism arguably remains one of the most oppressed religions in Iraq, with the population historically confronted by many attempts at genocide. These atrocities have left many survivors displaced and affected by trauma, yet little research has been conducted on experiences of trauma among this population. In the context of an internal evaluation of the Free Yezidi Foundation’s mental health intervention in the Kurdistan Region of Iraq, 200 Yezidi women were screened at the beginning and end of a six-month mental health intervention using the World Health Organization (WHO)-5 well-being scale and the Harvard Trauma Questionnaire (HTQ). Qualitative data were obtained from sixteen focus group discussions (FGDs) among service users of the project as well as six in-depth qualitative interviews conducted with members of the project team. The results of the WHO-5 indicate a 74% increase in self-reported well-being among service users who completed the programme. According to the results of the HTQ, the baseline prevalence rate of posttraumatic stress disorder was 81.25%, which decreased to 45% upon completion of the programme. A qualitative analysis of interviews and FGDs highlighted that a significant impact on mental health were collective, multiple losses and separations (including family members who sought refuge abroad), the fact that not all Yezidi held in captivity have returned, fear of ongoing attacks and daily stressors related to poor living conditions. The results highlight the substantial impact of the political, legal and sociocultural environment on both the prevalence of trauma as well as processes of psychosocial rehabilitation. The implications for interventions include utilising socioecological frameworks for research and practice, engaging in advocacy and establishing agendas for mental health practice and psychosocial support that emphasises individual and collective self-determination.
Key implications for practice
- Utilising eco-social frameworks for research and practice
- Engaging in political advocacy as part of MHPSS interventions
- Establishing agendas for mental health practice that emphasise individual and collective self-determination
- Addressing the social, cultural and political perspectives of trauma as part of MHPSS interventions
- Implementing interdisciplinary approaches to rehabilitation from trauma.
|How to cite this article:|
Womersley G, Arikut-Treece Y. Collective trauma among displaced populations in Northern Iraq: A case study evaluating the therapeutic interventions of the Free Yezidi Foundation. Intervention 2019;17:3-12
|How to cite this URL:|
Womersley G, Arikut-Treece Y. Collective trauma among displaced populations in Northern Iraq: A case study evaluating the therapeutic interventions of the Free Yezidi Foundation. Intervention [serial online] 2019 [cited 2019 Jul 17];17:3-12. Available from: http://www.interventionjournal.org/text.asp?2019/17/1/3/250810
| Background|| |
Yezidism arguably remains one of the most oppressed religions in Iraq, with the population historically confronted by many attempts at genocide (Ceri, Özlü-Erkilic, Özer, Yalcin, Popow, & Akkaya-Kalayci, 2016; Mohammadi, 2016). In the summer of 2014, fighters tore into Kurdish northern Iraq and committed attacks against the Yezidi under the black banner of Islamic State. They took more than 7000 people hostage, killing around 5000, mainly men (Mohammadi, 2016). Although men were mostly killed, women and girls were kidnapped, taken a hostage, raped and used or traded as sex slaves. For many, these catastrophic events lasted for months. These atrocities have left many survivors displaced and affected by trauma. Furthermore, the deep-rooted trauma is collective: 3500 women and 1200 children are still held captive by Islamic State. ‘Mass killings, and the mass graves that follow, mean that most individuals are not sure whether loved ones are alive or dead’ (p. 410). Indeed, recent research on socioecological mental health and psychosocial support (MHPSS) interventions suggests that individuals may suffer from posttraumatic stress through the impact of the disaster on their community, even if not directly exposed (Wind & Komproe, 2018). Little research has been conducted on experiences of trauma among this population, yet one study estimates the prevalence of post-traumatic stress disorder (PTSD) among Yezidis seeking refuge in Turkey at 43% (Tekin et al., 2016), with women being more frequently affected than men. A few more studies confirm this alarmingly high prevalence of trauma among the Yezidi population (Ceri et al., 2016; Gerdau, Kizilhan, & Noll-Hussong, 2017; Nasıroğlu & Çeri, 2016).
According to Mohammadi (2016), the Yezidi community in particular is facing ‘not just the individual recent trauma related to the 2014 attacks, but a historical trauma too − they faced genocide 73 times during the Ottoman Empire’ (p. 410). This research highlights both the historic and collective nature of the trauma to which the Yezidi population has been exposed, related to historic and ongoing oppression and exposure to violence, as well as identity-related trauma among displaced populations attempting to integrate into host communities (Gerdau et al., 2017; Groen, Richters, Laban, & Devillé, 2018). It is not only individuals facing traumatic events but entire Yezidi communities. Eagle (2014) refers to notions of collective or historic traumatisation, whereby whole groups of people carry a sense of common persecution or victimisation:
‘[Historical and collective] trauma may be understood to be transmitted intergenerationally via both conscious and unconscious mechanisms, such that those of generations post those directly victimized nevertheless carry the experience of trauma within themselves. In some respects identity and collective trauma come to be intertwined. Such conceptualizations of trauma may encompass a somewhat broader definition of traumatic stressors including not only relations of oppression that threaten actual survival of the group, but also more ideological forces that threaten the eradication of cultural or group identity. In this framework racism, xenophobia or fundamentalisms based on oppression may be understood to produce collective traumatisation’ (p. 13).
She suggests that people may be traumatised at multiple levels across generations − including collective/social, personal/physical and role identity levels. This point is no more pertinent to bear in mind than in the case of historically oppressed and displaced populations such as the Yezidi, often faced with a plethora of traumatic events on a collective level. Considering trauma thus as a process, elements of temporality are highlighted, as is the continual interaction of the person with their environment in a given social and historical context. What is highlighted is the significance of the sociopolitical context and power dynamics at play in influencing the mental health of entire populations.
Culturally informed manifestations of trauma
Over the past few decades, a plethora of research has highlighted the importance of the sociocultural environment for the way in which individuals, and indeed entire communities, experience trauma (Bracken, Giller, & Summerfield, 1997; Eagle & Kaminer, 2013; Marsella, Friedman, & Spain, 1993; Nickerson, Bryant, Brooks, Steel, Silove, & Chen, 2011; Nickerson, Cloitre, Bryant, Schnyder, Morina, & Schick, 2016; Summerfield, 1996; Tang, 2007; Tankink & Richters, 2007; Wilson & Drožđek, 2007). Such research argues that PTSD as a diagnosis is too heavily focused on a Western understanding of illness as situated within an individual, neglecting the social or political context. As stated by Jenkins (1996):
‘Because traumatic experience can also be conceptualized collectively, person-centred accounts alone are insufficient to an understanding of traumatic reactions. In addition to the social and psycho-cultural dynamics surrounding any traumatic response, the collective nature of trauma may be related to … the political ethos characterizing an entire society’ (p.177).
Not only are traumatic events experienced collectively, the psychological impact and manifestation of such trauma is similarly thought to be informed by the sociocultural context. The burgeoning field of cultural psychiatry highlights how cultural variations in ways of life and social contexts shape the embodied experience of trauma (Kirmayer & Ramstead, 2016). This research demonstrates how particular symptoms or behavioural expressions of distress vary with cultural knowledge, beliefs and interpretations (Kleinman, 1978) and that individuals interpret and respond to their own symptoms with culturally varied coping strategies that may influence the experience of trauma (Ryder, Ban, & Chentsova-Dutton, 2011). The work of Kirmayer et al. (2000) for example, demonstrates how the experience of trauma is always preceded by and embedded in cultural systems of meanings and practices, which influence modes of attention and interpretive frames or models. Cultural models may be organised in many ways, including collective symbols, images or representations and forms of cooperative activity. In other words, experience of trauma is an intersubjective, temporal, dynamic process shaped by culture (Kirmayer & Ramstead, 2016; Kirmayer, 2001; Kirmayer & Minas, 2000). This approach goes beyond a reductionist focus on ‘cultural differences’, wherein ‘culture’ is perceived a reified, crystallised concept and viewed as a potential barrier to be overcome in a process of psychiatric classification (Watters, 2001). Instead, it focuses on ever-changing cultural and social systems, which determine the various forms of an individual subjective experience of illness, an experience inevitably in constant flux (Ratcliff & Rossi, 2015; Womersley & Kloetzer, 2018).
Among the Yezidi community in particular, Ceri et al. (2016) note a variety of culturally informed idioms of distress drawn on by Yezidis to express their emotional distress:
‘The term “Ferman” is an expression for destruction and holocaust and reminds them of massacres against Yazidis; it means at once genocide and trauma. Every Yazidi knows the word “Ferman” because the term passes on from one generation to the next. In the context of the terror attacks by ISIS, the term “Ferman” regained a massive impact for Yazidis. It evokes feelings of mourning and fright. Two further idioms of distress are “nefsî” (arab. psyche), which is used synonymously for all mental disorders and traumas, and “liver burned” (cigera min shewiti), which means emotional suffering’ (p.146).
What this literature suggests is that culturally informed beliefs and idioms play an essential role in meaning expressions of distress across cultures and that a degree of ethnocentricity is inherent in Western understanding of trauma responses and traumatic events (Marsella, Friedman, Gerrity, & Scurfield, 1996; Nicolas, Wheatley, & Guillaume, 2015; Wilson, 2007).
If we’re not localising trauma on an individual but rather a community level, what are the practical implications for MHPSS interventions? What is being done efficiently and what needs to change? How can interventions consider the underlying sources of collective trauma in a way which reflects ‘local histories and systemic issues of politics, identity and community’ (Kirmayer, Kienzler, Afana, & Pedersen, 2010, p. 14)?
Towards culturally informed trauma interventions
The under-utilisation and mistrust of mainstream mental health services by ethnic minorities in general has been well documented (Bigfoot & Schmidt, 2010; Mattar, 2011; Watters, 2001) and may be in part due to the variations in culturally informed healing practices and perceptions of mental health services (Karageorge, Rhodes, Gray, & Papadopoulos, 2016). Research conducted among displaced populations by Karageorge et al. (2016) identified the following barriers to the acceptability and validity of mental health services: (1) mistrust or uncertainty of intentions/expectations, (2) having more immediate (practical) concerns than talk, (3) difficulty discussing trauma and (4) the inadequate cultural competence of health professionals. A recent desk review released by the World Health Organization (WHO) and the United Nations High Commissioner for Refugees (UNHCR), the United Nations Refugee Agency, has argued that the development of effective MHPSS programmes requires knowledge of existing health systems and sociocultural context, and that familiarising international humanitarian practitioners with local culture and contextualising programmes is essential to minimise risk of harm, maximise benefit and optimise efficient use of resources (Greene et al., 2017). Developments in theories of identity, culture and traumatology have enriched cross-cultural understanding of mental health dynamics and case conceptualisation, informing the development of intervention models which aim to address cumulative trauma dynamics as well collective identity and culture-specific traumas (Groen et al., 2018; Kira, 2010).
As noted by Wind and Komproe (2018), researchers and practitioners have called for interventions which incorporate the socioecological perspective into their design. Their research reveals the links between the individual process that determines disaster mental health and the social community one lives in − highlighting the necessity of interventions to consider the shared context on mental health outcomes. For communities affected by genocide in particular, literature from Rwanda (Anne Pearlman, 2013; Kanyangara, Rimé, Philippot, & Yzerbyt, 2007; King, 2011; Staub, Pearlman, Gubin, & Hagengimana, 2005), Guatemala (Marín Beristain, Paez, & González, 2000) and Bosnia (Ba & LeFrangois, 2011; Clark, 2008; Denborough, 2011) all highlight the profound impact of public rituals of mourning and remembrance in healing from collective and historic trauma. In Rwanda, this involved engaging in Gacaga tribunals (Kanyangara et al., 2007; King, 2011), and in Guatemala, this involved collective sharing, commemorative activities and funeral rites for the Mayas − including symbolically identifying and punishing those responsible (Marín Beristain et al., 2000). In Bosnia, collective healing was shown to revolve around the principles of the three ‘Rs’ − retributive justice, restorative justice and reconciliation, as mediated for example by the International Criminal Tribunal for the former Yugoslavia (Clark, 2008).
One striking example of collective healing may be drawn from our experience of working with the Yezidi population: when the highly traumatised girls and women returned from Islamic State (ISIS) captivity, the spiritual leader of the community welcomed them back. The symbolic gesture was intended to lift the shame, which so often accompanies survivors of trauma (Maercker & Horn, 2013). This precious act seems to have enabled the women to be accepted back within the community. Some of the released hostages performed a purifying ceremony at Lalish, considered the holiest temple of the Yezidi faith. These healing interventions were enacted on a collective level − drawing on cultural and symbolic resources known to the community. One could argue that without these interventions, the released hostages would risk further traumatisation because of subsequent guilt, shame and social stigma − the rupture with the community is in itself traumatic. Within this context, individual trauma-focused therapy as typically prescribed within a Western model would be simply insufficient at best, harmful at worst.
The Free Yezidi Foundation
The Free Yezidi Foundation (FYF) women’s centre is situated in the Duhok province of the Kurdistan Region of Iraq. This centre offers psychological interventions for women who suffered in captivity and eventually escaped, as well as those who were never captured but were displaced by attacks and whose entire families are now homeless and jobless. The centre, inside the Khange IDP camp, serves all the women in the camp, including women who have escaped ISIS captivity. The facility at present features a counselling/recreation room, an art corner, a computer laboratory, a classroom area (for teaching English, Kurdish and Yezidi culture and history), a sewing room and an outdoor garden. The project collaborates with over twenty non-governmental and governmental actors in Kurdistan to coordinate MHPSS responses. In Khanke camp itself, Samaritan’s Purse coordinates the Grace Healing Centre which is focused on recovery from trauma. Jiyan Foundation and Ashti are similarly partners active in Khanke doing psychosocial work for trauma survivors. Furthermore, FYF is also active in global advocacy for genocide recognition and more resources to Yezidi survivors. The trauma programme is funded by UNTF to End Violence Against Women.
An essential part of the programme focuses on addressing the significantly high levels of trauma in the community. This specific MHPSS intervention, informed by the mental health pyramid alluded to in the Inter-Agency Standing Committee (IASC) guidelines,1 targets three levels of interventions − the level of the individual, the level of the group (of service users) and the level of the wider community. Broadly, the intervention is informed by empirically validated trauma treatment interventions, which include principles of psychoeducation, and stabilisation techniques based on trauma processing therapies such as Eye Movement Desensitization and Reprocessing (EMDR) Therapy (Eichfeld et al., 2018). This includes pilot projects implementing group EMDR (GTEP, Group Traumatic Episode Protocol) therapy under the clinical supervision of international experts. Individual and group therapy is offered by the project psychologists. Intake interviews are held with each service user to allocate them to appropriate groups or to refer them to individual therapy according to their specific mental health needs. Group sessions draw on techniques of emotional regulation, grounding and stabilisation tools and skills − and are complemented by further extra activities, such as art, exercises, games, role playing, singing and dancing. Furthermore, thirteen service users have been trained as lay counsellors to provide psychological first and second aid, and work under the supervision of the project psychologist. Part of this community work includes facilitating psychoeducation workshops to raise the community’s awareness on trauma and its impact on psychological well-being, and conducting community sensitisation/awareness sessions. For example, with the input of the lay counsellors, cultural mediators and the art teacher, a toolbox was created, which included pictures and text (in Arabic and Kurdish), demonstrating reactions to trauma and loss as well as basic stabilisation techniques.
| Research methods|| |
The aim of this research was to identify and highlight the mental health needs of the displaced Yezidi population of Northern Iraq, to evaluate the FYF intervention programme, as well as to enrich advocacy campaigns for their humane treatment by state and non-governmental organisations alike. Principally, an evaluation of the project was conducted in February 2018 among an incoming cohort of service users (pre-test/baseline assessment), and again in June 2018 upon the cohort of service users graduating from a 6-month programme (post-test assessment). The aim was to assess the effectiveness, relevance, efficiency, sustainability and impact of the project.
Programme evaluation design
In the context of this evaluation, Yezidi women, service users of the FYF, were screened before starting and after completing the programme using the WHO-5 well-being scale − among the most widely used questionnaires assessing subjective psychological well-being with demonstrated clinimetric validity (Topp, Østergaard, Søndergaard, & Bech, 2015). For further quantitative data on the prevalence of trauma among the population, the Harvard Trauma Questionnaire (HTQ) was used due its recognised cultural sensitivity in assessing highly traumatised populations (Mollica, Caspi-Yavin, Bollini, Truong, Tor, & Lavelle, 1992; Mollica, McInnes, Poole, & Tor, 1998; Shoeb, Weinstein, & Mollica, 2007). It has been validated for assessing PTSD in Iraqi refugees in particular (Shoeb et al., 2007). PTSD was defined according to a scoring algorithm previously described by the Harvard Refugee Trauma Group on the basis of DSM-IV diagnostic criteria (American Psychiatric Association, 1994; Mollica et al., 1992). A client satisfaction questionnaire was completed by service users in individual psychotherapy upon completion of the programme in June.
Qualitative data were obtained from sixteen focus group discussions (FGDs) among service users of the project (the current as well as previous cohort of women attending) as well as six in-depth qualitative interviews conducted with members of the project team. These FGDs were based on semi-structured interview questionnaires focused on assessing experiences of trauma within the community, perceptions of mental health as well as experiences of the project. FGDs were conducted by the primary author with the assistance of a translator. With the informed, written consent of the participants, interviews and FGDs were recorded and transcribed.
Mixed-method results including both quantitative and qualitative data were triangulated to explore
- baseline prevalence rates of trauma,
- culturally informed subjective experiences of trauma within this specific socio-political context, and
- lessons learnt from the implementation of this psychotherapeutic intervention.
| Results|| |
Prevalence rates of trauma
Service users of the FYF were screened pre- and post-programme using the WHO-5. Out of 200 women attending the programme, 170 completed the pre-test and 113 the post-test. The lower number of women completing the post-test was due to the logistical challenges of having all participants available for testing in the particular week of evaluation. The average pre-test score was 12.35 (49%, n = 170), and the average post-test score was 22.56 (90.24%, n = 113). This represents an 83% increase in self-reported well-being among service users who have completed the programme. The pre-test score was found to be lower in comparison to general population studies conducted in Denmark, where the mean score was found to be 14 (Bech, Olsen, Kjoller, & Rasmussen, 2003; Ellervik, Kvetny, Christensen, Vestergaard, & Bech, 2014), yet substantially higher upon completion of the programme.
When WHO-5 is used for the screening of depression, a cut-off score of ≤10 is used (Topp et al., 2015). At baseline, 45% of participants in this sample fell below this cut-off score, meeting diagnostic criteria for depression upon entering the programme [[Table 1]].
Harvard Trauma Questionnaire
Service users were screened using the HTQ upon entering the project and again upon graduating from the programme. The baseline prevalence rate of PTSD was 81.25%, with an average score of 2.81. Upon completing the programme, the prevalence rate of PTSD was 45%, with an average score of 2.4. This represents a decrease in service users meeting diagnostic criteria for PTSD of 45%. Despite this, the symptoms decreased on average by only 15%. This suggests that there may be a sub-population who continued to meet the diagnostic criteria for PTSD (without any reduction in symptoms) and who continued to need psychotherapeutic support [[Table 2]].
It is interesting to note that, despite a clear reduction in symptoms of trauma globally, there was an increase in symptoms related to question 14 of 19% (feeling as if you don’t have a future). This may not necessarily relate directly to symptoms of PTSD but could be more related to the ongoing sociopolitical and economic environment in which the population finds themselves, including poor material living conditions and prospects for the future.
There was similarly a 12% increase in self-reported ‘recurrent thoughts or memories of the most hurtful or terrifying events’. Given the overall reduction in post-traumatic symptoms, this is an anomaly. A full understanding of the reason for this increase is beyond the scope of this paper. It would be interesting to explore the reason behind this through qualitative interviews. As has been suggested in literature on refugee mental health (Steel, Dunlavy, Harding, & Theorell, 2017), one hypothesis could be the reduction in dissociative symptoms associated with trauma leading to service users being more able to think about or remember the events − the relatively safer space of the camp in general, and the project in particular, allowing them to confront these thoughts and memories.
The most significant improvement in symptoms was a 41% decrease in having trouble sleeping, and a 33% decrease in having difficulty concentrating. The overall decrease in symptoms may be attributed to a variety of factors − including as a reflection of the efficacy of the MHPSS intervention in reducing symptoms, as well as the simple fact of time having passed because the traumatic events experienced by the population as they were forced to flee their homes.
The client satisfaction questionnaire revealed a 91% level of satisfaction with the project, across the following domains:
- overall satisfaction
- satisfaction with access
- perception of outcomes
- satisfaction with participating in treatment planning
- satisfaction with quality and appropriateness of the service
- social connectedness
- improved functioning.
Service users suggested including more income-generating activities (e.g. being able to have a bakery or hairdresser on site), as well as certificates to professionalise their skills and competencies. This reflects the findings of Mitschke, Praetorius, Kelly, Small, and Kim (2017), who found that refugee participants in a mental health intervention programme expressed a number of challenges related to language and literacy, access to health care and social services, and the need for advocacy as it relates to employment. The authors argue that the recognition of Maslow (1954) hierarchy of needs is an important one for determining how to best address the mental health issues faced by recently resettled displaced populations. In their study, as has been highlighted elsewhere, refugees’ mental health needs were circumvented by more practical issues such as access to employment, housing and other necessities. These needs are similarly reflected in the mental health needs pyramid defined by the IASC for MHPSS mentioned above. As is the case of this study, the authors highlighted the need for language and literacy education as a primary concern.
Experiences of trauma
A thematic analysis was conducted of interview transcripts from sixteen FGDs held with service users from the previous and incoming cohort, as well as six interviews conducted with members of staff. Direct quotes from transcripts of these interviews and FGD are presented under the following identified themes:
- Impact of events
- Manifestations of trauma
- Collective trauma
- Culturally informed idioms of distress
- Perceptions of mental health services
- Positive testimonies from service users
- Service users’ suggestions and feedback for the project.
The impact of events
The Yezidi community’s experiences are characterised by a context of complex trauma. Trauma was related to not only exposure to human rights violations and other atrocities in 2014, but compounded variables related to
- multiple losses (home, family members, possessions, socioeconomic status),
- fear of ongoing attacks,
- breakdown of the family unit (due to loss, separation and family members seeking refuge abroad),
- gender roles being threatened due to men losing employment opportunities,
- poor living conditions in the camps (including cramped living quarters),
- feeling ‘trapped’ in the camps,
- uncertain futures,
- ethnic discrimination.
The following quotes highlight some ways in which service users described their current situation:
‘Years are lost from our lives.
In general, we are still, we’re just scared about the future and what will happen, so it’s all in our mind. They’re saying that the same thing will happen again because they say "you are a minority" and usually there is no one, for example, to protect you’.
‘The trauma is bigger than the time with ISIS, because, maybe you are not − you just want to be at home, not going alone, you just don’t want to see a friend. It’s like from social person to person who is avoiding everything. In each way. Like the day is one trauma, during ISIS it’s trauma, after ISIS also it’s trauma and it’s been like four years, we’ve been here in the tents, it’s a big trauma here, obviously’.
Manifestations of trauma
Nightmares and insomnia were the most common symptoms reported in the FGD. Many reported feeling scared, jumpy or alert − particularly at night. Increased aggression was also noted − with augmented propensity towards conflict in the family (e.g. fighting with husbands, or shouting at the children). Trauma also manifested physically (psychosomatic symptoms). In every single FGD, mention was made of family members with heart problems or ‘fainting spells’ starting after the attacks and displacement. Other physical difficulties reported included celiac disease, asthma and constant headaches.
These manifestations are illustrated in the following quotes:
‘Even in dreams, we just want to see our homes in dreams.
I’m always thinking about another genocide.
I get really angry when someone says something that’s not the right thing, it makes me really upset.
When it becomes dark I feel like we’re going to have to run another time, to escape.
All these come to me, for example seeing dead people − all of these all things come to my mind, when I just want to go to bed or shower. I am very nervous all the time’.
Throughout the FGD and interviews, trauma was commonly referred to on a collective level. In other words, when describing the psychological impact of events on themselves as individuals, many would refer to the impact of events on ‘us’ as a Yezidi community. Many referred to the Yezidi community as close-knit community from which it was difficult to exit or enter (we are a circle, you can’t go out and find someone or bring someone inside). The suffering of one member of the community was expressed as suffering from all, with many referring to a collective ‘we’ as opposed to individual ‘I’. Notably, even those not directly exposed to the conflict reported experiencing symptoms of trauma.
The collective trauma, as indicated by the pronoun ‘we’, is illustrated in the following quotes:
‘We’re forced to be thinking too much about relatives − not only thinking about ourselves… Yezidi are kidnapped every day.
We think about relatives, so it’s very difficult because of this, so it’s always very new, that’s why it’s very difficult.
When every single [kidnapped hostage] comes back, we can feel better.
We are thinking about the past and the future at the same time.
From my family, nobody’s kidnapped but, I feel like all the whole community − when they’re kidnapped I feel as if they’re part of me’.
Culturally informed idioms of distress
The service users drew on a variety of culturally informed idioms of distress to describe the ways in which they experience trauma, as illustrated in the following direct quotes:
‘We are scared, they are always in our hearts and minds these things.
Our mind is not comfortable.
It’s still in our all minds what they did.
My very spirit changes. I have difficulty sleeping at night, I’m thinking and thinking and thinking.
I’m an old person because of these things that happened to me.
I’m thinking a lot.
It’s like it’s not stopping. It’s always there’.
The vast majority of the idioms of distress were centred on the notion of ‘thinking too much’. As noted in the literature on transcultural psychiatry, such idioms of distress include more than just ideas about the cause of an illness; they also incorporate ideas about estimating the severity of illness, appropriate treatment and the meaning of the illness. In other words, it reflects a process of sense making situated within a specific sociocultural context (Harvey, 2007; Kleinman, 1978; Maier & Straub, 2011), which should be taken into consideration by the programme design of any MHPSS intervention.
Perceptions of mental health services
In general, a significant shift in perceptions of mental health services among the Yezidi community appears to have occurred. Whereas before the attacks of 2014, mental health services were seen as being only for people who are ‘crazy’ (with a significant social stigma attached) − this has now changed. Paradoxically, this shift may possibly be related to the alarmingly high levels of trauma in the community, which have led to an easier and more obvious recognition of the need for mental health support. This shift towards a more positive perception of mental health services is illustrated in the following quotes:
‘Before people were thinking it’s shame, for example, if you see a doctor or a psychologist but for now for Yezidi community, it’s become something very general since all of them are affected, it’s something very normal and general for every Yezidi’.
‘They know what is trauma. They know that for example if the kids are traumatized then they have to be treated. It is something psychological; we shouldn’t consider them as crazy or mad.
I have right now, like, about 28 people, 26 waiting list [to see the psychologist], and I think that’s why because right now they understand’.
Positive testimonies of change from service users
All FGDs highlighted the following factors as part of their theory of change:
- The centre representing a physical and emotional safe space
- The staff being respectful, helpful and ‘like family’
- Being occupied helped them forget about traumatic memories of the past
- The centre fostered positive relationships among the community, allowing a space for women to socialise outside of the home
- The sense of empowerment related to being able to read and write.
| Conclusion|| |
The results of this study attest to the alarmingly high rates of trauma among the Yezidi population. Furthermore, they highlight the substantial impact of the political, legal and sociocultural environment on both the prevalence of trauma as well as processes of psychosocial rehabilitation. Indeed, trauma among this population was also shown to be related to collective and historic trauma experienced on a community level. One of the key themes to emerge from this research was the significant emotional impact for the Yezidi community to have members still held hostage, lost or missing. On a collective level, this appears to have resulted in unresolved, ongoing trauma. For many, the uncertainty as to whether or not their loved ones were alive or dead appears to have complicated the mourning process. Some individuals in the project report feeling as though they are ‘frozen’ in this liminal space, unable to start on the important and necessary work of grieving. Hope that loved ones may still be alive is a double-edged sword − keeping many stuck on a perpetual loop of acute and intense pain, unable to proceed along the emotional journey of mourning. Here, we think of the symbolic importance of mass memorials such as the case of countries such as Rwanda and Bosnia, where rituals of mourning have offered some possibility of healing from this complicated, collective grief. The trauma is irrevocably collective, symbolic and political − as are healing mechanisms. If trauma may be experienced collectively, it stands to reason that processes of healing should similarly be facilitated collectively.
This similarly speaks to a need to consider the political context in which the intervention takes place. Consequently, the FYF programme incorporates an advocacy strategy targeting those directly affected (notably enslaved women and girls), as well as the international community. We believe that a sense of justice being served through the social recognition of this suffering (Marková, 2016) is integral to the healing process. Collective and historic trauma does not occur in a sociopolitical vacuum, and neither should intervention strategies. As noted by Yassin, Taha, Ghantous, Atoui, and Forgione (2018), ‘although interventions at the micro and mezzo levels are extremely helpful, radical changes do not occur without implementing support and strategic interventions at the macro level’ (p. 9).
The implications for interventions include utilising eco-social frameworks for research and practice, engaging in advocacy, and establishing agendas for mental health practice that emphasise individual and collective self-determination (Harvey, 2007; Sousa & Marshall, 2017). It is our hope that this paper serves as one contribution to the ongoing effort to develop responsive and effective services for survivors of violence, persecution and human rights abuses. Understanding the impact of dislocation, trauma and loss, of political persecution and human malevolence, and social systems involving abuse, neglect, and ethnic and cultural rejection, is crucial in terms of guiding policy makers and clinicians to assist, and as advocates to address, the social, cultural and political perspectives of trauma. Furthermore, it is fundamental to the success of any mental health or other type of therapeutic intervention among displaced populations. We conclude that attending to the mental health needs of trauma survivors, including interdisciplinary rehabilitation from trauma, is a key part of restoring dignity in the wake of human rights abuses and providing a form of justice for those who suffered harms.
Ethical approval for the study was given by the ethics committee of the Free Yezidi Foundation. The authors declare that they have no competing interests. The requirements of authorship include the writing of the article. The manuscript has been read and approved by all the authors, the requirements for authorship as stated earlier in this document have been met, and each author believes that the manuscript represents honest work. The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
. Washington, DC: American Psychiatric Press Inc.
Ba O. B., LeFrangois B. A. (2011). Healing and recovery. Critical issues in peace and conflict studies: Theory, practice, and pedagogy
. Plymouth: Lexington books (p. 81).
Bech P., Olsen L. R., Kjoller M., Rasmussen N. K. (2003). Measuring well‐being rather than the absence of distress symptoms: a A comparison of the SF‐36 mental health subscale and the WHO‐five well‐being scale. International Journal of Methods in Psychiatric Research
, 12(2), 85-91.
Bigfoot D. S., Schmidt S. R. (2010). Honoring children, mending the circle: cultural Cultural adaptation of trauma‐focused cognitive‐behavioral therapy for American Indian and Alaska Native children. Journal of Clinical Psychology
, 66(8), 847-856.
Bracken P., Giller J. E., Summerfield D. (1997). Rethinking mental health work with survivors of wartime violence and refugees. Journal of Refugee Studies
, 10(4), 431-442.
Ceri V., Özlü-Erkilic Z., Özer Ü., Yalcin M., Popow C., Akkaya-Kalayci T. (2016). Psychiatric symptoms and disorders among Yazidi children and adolescents immediately after forced migration following ISIS attacks. Neuropsychiatrie
, 30(3), 145-150.
Clark J. N. (2008). The three Rs: Retributive justice, restorative justice, and reconciliation. Contemporary Justice Review
, 11(4), 331-350.
Denborough D. (2011). Resonance, rich description and social-historical healing: The use of collective narrative practice in Srebrenica. International Journal of Narrative Therapy & Community Work
, 3(27), 27-42.
Eagle G. (2014). From evolution to discourse: Key conceptual debates in the history and study of traumatic stress. Psychology in Society
, 47(1), 1-20.
Eagle G., Kaminer D. (2013). Continuous traumatic stress: Expanding the lexicon of traumatic stress. Peace and Conflict: Journal of Peace Psychology
, 19(2), 85.
Eichfeld C., Farrell D., Mattheß M., Bumke P., Sodemann U., Ean N., Mattheß H. (2018). Trauma stabilisation as a sole treatment intervention for post-traumatic stress disorder in Southeast Asia. Psychiatric Quarterly
. (Sep 28), 1-26.
Ellervik C., Kvetny J., Christensen K. S., Vestergaard M., Bech P. (2014). Prevalence of depression, quality of life and antidepressant treatment in the Danish General Suburban Population Study. Nordic Journal of Psychiatry
, 68(7), 507-512.
Gerdau I., Kizilhan J. I., Noll-Hussong M. (2017). Posttraumatic stress disorder and related disorders among female Yazidi refugees following Islamic state of Iraq and Syria attacks—A case series and mini-review. Frontiers in Psychiatry
, 8, 282.
Greene M. C., Jordans M. J., Kohrt B. A., Ventevogel P., Kirmayer L. J., Hassan G., Tol W. A.. (2017). Addressing culture and context in humanitarian response: preparing Preparing desk reviews to inform mental health and psychosocial support. Conflict and Health
, 11(1), 21.
Groen S. P., Richters A., Laban C. J., Devillé W. L. (2018) Cultural identity among Afghan and Iraqi traumatized refugees: Towards a conceptual framework for mental health care professionals. Culture, Medicine, and Psychiatry
, 42, 69-91.
Harvey M. R. (2007). Towards an ecological understanding of resilience in trauma survivors: Implications for theory, research, and practice. Journal of Aggression, Maltreatment & Trauma
, 14(1-2), 9-32.
Jenkins J. H. (1996). Culture, emotion, and PTSD. In Marsella A. J., Friedman M. J., Gerrity E. T., Scurfield R. M. (Eds.), Ethnocultural aspects of posttraumatic stress disorder: Issues, research, and clinical applications 165-182
. Washington, DC: American Psychological Association.
Kanyangara P., Rimé B., Philippot P., Yzerbyt V. (2007). Collective rituals, emotional climate and intergroup perception: Participation in “Gacaca” tribunals and assimilation of the Rwandan genocide. Journal of Social Issues
, 63(2), 387-403.
Karageorge A., Rhodes P., Gray R., Papadopoulos R. (2016). Refugee and staff experiences of psychotherapeutic services: A qualitative systematic review. Intervention
, 15, 51-69.
King R. U. (2011). Healing psychosocial trauma in the midst of truth commissions: The case of Gacaca in post-genocide Rwanda. Genocide Studies and Prevention
, 6(2), 134-151.
Kira I. A. (2010). Etiology and treatment of post-cumulative traumatic stress disorders in different cultures. Traumatology
, 16(4), 128.
Kirmayer L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: implications Implications for diagnosis and treatment. Journal of Clinical Psychiatry
, 62, 22-30.
Kirmayer L. J., Minas H. (2000). The future of cultural psychiatry: an An international perspective. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie
, 45, 438-446.
Kirmayer L., Ramstead M. J. (2016). Embodiment and Enactment in Cultural Psychiatry. Embodiment, enaction, and culture: Investigating the constitution of the shared world
. Cambridge, MA: MIT Press.
Kirmayer L., Kienzler H., Afana A. H., Pedersen D. (2010). Trauma and disasters in social and cultural context. Principles of Social Psychiatry
, 2, 155-177.
Kleinman A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Social Science & Medicine. Part B: Medical Anthropology
, 12, 85-93.
Maercker A., Horn A. B. (2013). A socio‐interpersonal perspective on PTSD: The case for environments and interpersonal processes. Clinical Psychology & Psychotherapy
, 20(6), 465-481.
Maier T., Straub M. (2011). “My head is like a bag full of rubbish”: Concepts of illness and treatment expectations in traumatized migrants. Qualitative Health Research
, 21(2), 233-248.
Marín Beristain C., Paez D., González J. L. (2000). Rituals, social sharing, silence, emotions and collective memory claims in the case of the Guatemalan genocide. Psicothema
, 12(Suppl), 117-130.
Marková I. (2016). The dialogical mind: Common sense and ethics
. Cambridge: Cambridge University Press.
Marsella A. J., Friedman M. J., Spain E. H. (1993). Ethnocultural aspects of posttraumatic stress disorder. American psychiatric press review of psychiatry
. (vol. 12, pp. 157-181). Washington, DC: American Psychiatric Press, 12, 157-181.
Marsella A., Friedman M., Gerrity E., Scurfield R. (1996). Ethnocultural aspects of posttraumatic stress disorder:
. Washington, DC: American Psychological Association, Washington DC.
Maslow A. H. (1954). The instinctoid nature of basic needs. Journal of Personality
, 22(3), 326-347.
Mattar S. (2011). Educating and training the next generations of traumatologists: Development of cultural competencies. Psychological Trauma: Theory, Research, Practice, and Policy
, 3(3), 258-265.
Mitschke D. B., Praetorius R. T., Kelly D. R., Small E., Kim Y. K. (2017). Listening to refugees: How traditional mental health interventions may miss the mark. International Social Work
, 60(3), 588-600. doi:10.1177/0020872816648256.
Mohammadi D. (2016). Help for Yazidi survivors of sexual violence. The Lancet Psychiatry
, 3(5), 409-410.
Mollica R., Caspi-Yavin Y., Bollini P., Truong T., Tor S., Lavelle J. (1992). The Harvard Trauma Questionnaire: validating Validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochinese refugees. The Journal of Nervous and Mental Disease
, 180(2), 111-116.
Mollica R., McInnes K., Poole C., Tor S. (1998). Dose--effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. The British Journal of Psychiatry
, 173(6), 482-488.
Nasıroğlu S., Çeri V. (2016). Posttraumatic stress and depression in Yazidi refugees. Neuropsychiatric Disease and Treatment
, 12, 2941.
Nickerson A., Bryant R. A., Brooks R., Steel Z., Silove D., Chen J. (2011). The familial influence of loss and trauma on refugee mental health: a A multilevel path analysis. Journal of Traumatic Stress
, 24(1), 25-33.
Nickerson A., Cloitre M., Bryant R. A., Schnyder U., Morina N., Schick M. (2016). The factor structure of complex posttraumatic stress disorder in traumatized refugees. European Journal of Psychotraumatology
, 7, 33253.
Nicolas G., Wheatley A., Guillaume C. (2015). Does one trauma fit all? Exploring the relevance of PTSD across cultures. International Journal of Culture and Mental Health
, 8 (1), 34-45.
Pearlman L. A. (2013). Restoring self in community: Collective approaches to psychological trauma after genocide. Journal of Social Issues
, 69(1), 111-124.
Ratcliff B. G., Rossi I. (2015). Santé mentale et sociétés plurielles (Mental health and plural societies). Alterstice-Revue Internationale de la Recherche Interculturelle
, 4(2), 3-12.
Ryder A. G., Ban L. M., Chentsova‐Dutton Y. E. (2011). Towards a cultural-clinical psychology. Social and Personality Psychology Compass
, 5(12), 960-975.
Shoeb M., Weinstein H., Mollica R. (2007). The Harvard trauma questionnaire: adapting Adapting a cross-cultural instrument for measuring torture, trauma and posttraumatic stress disorder in Iraqi refugees. International Journal of Social Psychiatry
, 53(5), 447-463.
Sousa C., Marshall D. J. (2017). Political violence and mental health: Effects of neoliberalism and the role of international social work practice. International Social Work
, 60(4), 787-799. doi:10.1177/0020872815574128.
Staub E., Pearlman L. A., Gubin A., Hagengimana A. (2005). Healing, reconciliation, forgiving and the prevention of violence after genocide or mass killing: An intervention and its experimental evaluation in Rwanda. Journal of Social and Clinical Psychology
, 24(3), 297.
Steel J., Dunlavy A., Harding C., Theorell T. 2017 The psychological consequences of pre-emigration trauma and post-migration stress in refugees and immigrants from Africa. Journal of Immigrant and Minority Health
, 19, 523-532.
Summerfield D. (1996). L’impact de la guerre et des atrocités sur les populations civiles: Principes fondamentaux pour les interventions des ONG et une analyse critique des projets sur le traumatisme psychosocial
. London: Overseas Development Institute.
Tang C. S.-k. (2007). Culturally relevant meanings and their implications on therapy for traumatic grief: Lessons learned from a Chinese female client and her fortune-teller
. Voices of trauma
. Boston, MA: Springer, (pp. 127-150).
Tankink M., Richters A. (2007). Silence as a coping strategy: The case of refugee women in the Netherlands from South-Sudan who experienced sexual violence in the context of war
. Voices of trauma
. Boston, MA: Springer, (pp 191-210).
Tekin A., Karadağ H., Süleymanoğlu M., Tekin M., Kayran Y., Alpak G., Şar V. (2016). Prevalence and gender differences in symptomatology of posttraumatic stress disorder and depression among Iraqi Yazidis displaced into Turkey. European Journal of Psychotraumatology
, 7, 28556.
Topp C. W., Østergaard S. D., Søndergaard S., Bech P. (2015). The WHO-5 Well-Being Index: a A systematic review of the literature. Psychotherapy and Psychosomatics
, 84(3), 167-176.
Watters C. (2001). Emerging paradigms in the mental health care of refugees. Social Science & Medicine
, 52(11), 1709-1718.
Wilson J. P. (2007). Reversing cultures: The wounded teaching the healers
. Voices of trauma
. Boston, MA: Springer, (pp. 87-104).
Wilson J. P., Drožđek B. (2007). Are we lost in translations?: Unanswered questions on trauma, culture and posttraumatic syndromes and recommendations for future research. Voices of trauma
Boston, MA: Springer, (pp. 367-386).
Wind T. R., Komproe I. H. (2018). Closing the gap between disaster mental health research and practice: evidence Evidence for socio-ecological mental health interventions through multilevel research. Intervention,
Womersley G., Kloetzer L. (2018). ‘‘This is not paranoia, this is real life": Psychosocial interventions for refugee victims of torture in Athens. Intervention Journal of Mental Health and Psychosocial Support in Conflict Affected Areas
, 16, 95-102.
Yassin N., Taha A. A., Ghantous Z., Atoui M. M., Forgione F. (2018) Evaluating a mental health program for Palestinian refugees in Lebanon. Journal of Immigrant and Minority Health
, 20, 388-398.
[Table 1], [Table 2]