Vol. 11 No. 12 - July, 2009

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Helping heal trauma a world away

Kurdistan community
The class of Kurdistan community mental health workers; Pagoto referred to them as “the most attentive class I’ve ever taught.”

This spring, Sherry Pagoto, PhD, assistant professor of medicine, traveled to Iraq to help lay the groundwork for a study to compare mental health treatment methods for long-term depression and post-traumatic stress disorder among Kurdish survivors of a brutal campaign of genocide directed by former Iraqi President Saddam Hussein in the 1980s; Hussein’s soldiers are believed to have tortured or murdered more than 200,000 men, women and children. The study, based at the Johns Hopkins Bloomberg School of Public Health and funded by the US Agency for International Development (USAID), seeks to determine which treatment approach leads to the best outcomes given the cultural, literacy and resource barriers in the region.

“The mental health care system in Kurdistan is very limited in resources, education and training,” said Pagoto, who led a six-day training session in Suleimaniyah, Iraq, for 15 community mental health workers who traveled from the urban centers and rural villages of Kurdistan. “By collaborating with the community mental health workers, we will have an opportunity to bring these patients the treatment that they need and deserve.”

Kurdistan Pagoto
While in Kurdistan, Pagoto and her colleagues visited the National Museum of the Kurdish Revolution and Victims, including this building, where Kurds were tortured during Saddam Hussein’s regime. “Touring the museum really gave us a sense of the horrors experienced by the patients we were trying to help,” she said.

Four hundred patients will be randomized to one of four tracks of the study: behavioral activation (BA); cognitive processing therapy (CPT), a complex treatment that focuses on the trauma experience; “usual care,” supportive counseling currently being provided by communi ty mental health workers; or wait-list control. Pagoto and co-investi gator Carl Lejuez, PhD, of the University of Maryland trained community mental health workers in BA, a form of psychotherapy developed by Dr. Lejuez that focuses on depression resulting from trauma and the ways patients can develop a fulfilling and enriching life. Another team trained workers in CPT. Both BA and CPT will be compared to supportive counseling and wait-list control, as well as to each other.

In addition to providing muchneeded clinical services, Pagoto said this study addresses interesting scientific and public health questions. “The most interesting question is whether directly addressing trauma in this setting is either necessary or helpful. There is a risk of a patient decompensating in the face of such a difficult process,” Pagoto noted. “In many areas, the community mental health workers simply don’t have the training or the resources to manage the range of psychological responses a patient might have as the result of confronting profound trauma-related memories.”

Community mental health workers

have begun to see patients for a three-month treatment phase, with Pagoto providing weekly supervision remotely from Worcester via Skype.

Community mental health workers have begun to see patients for a threemonth treatment phase, with Pagoto providing weekly supervision remotely from Worcester via Skype. “If BA is superior to CPT, our training team will return to Iraq to train other community mental health workers.”

Pagoto notes that BA is largely focused on helping patients make life changes outside of therapy sessions and obtain support from people in their lives, rather than from the therapist. “We use the ‘teach a man to fish’ metaphor to emphasize to counselors the importance of immediately beginning to work with the patient on strategies that will help them build strong support systems and enriching, meaningful lives outside of therapy.”

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