RapidMentalHealthandPsychosocialSupportAssessment:Needs,Services,andRecommendationsforSupportto

IndividualsAffectedbytheMosulEmergency

December20161.GoalsTheprimary goals of this rapidmental health andpsychosocial support (MHPSS) assessmentwere asfollows:1)TounderstandtheperceivedandidentifiedneedsamongcommunitymemberswhohavelivedunderISISoccupationandwhohavebeeninternallydisplacedduetotheongoingMosulemergency;2)To determine which MHPSS actors are providing services for this population; 3) To sharerecommendations inefforts to strengthen theMHPSS responseasagreaterpartof thehumanitarianresponseforthispopulation.Forquestionsortolearnmoreaboutthisassessment,kindlycontact:ClaireWhitney,InternationalMedicalCorps’ Regional Mental Health and Psychosocial Advisor for the Middle East,cwhitney@InternationalMedicalCorps.org2.MethodologyThe rapidMHPSS situational analysiswas conductedby InternationalMedical Corps’ RegionalMentalHealth andPsychosocialAdvisor (ClaireWhitney)with support fromby InternationalMedical Corps –Iraq’sMHPSSstafffrom15November–6December2016.Theassessmenttoolsusedwereadaptedfromthe WHO/UNHCR (2012) MHPSS Assessment Guide1 and include an assessment of communityexperiences, stressors, needs, andways of coping and help seeking for emotional distress and other

1WHO&UNHCR(2012).“AssessingMentalHealthandPsychosocialNeedsandResources:ToolkitforMajorHumanitarianCrises.”Geneva.http://www.who.int/mental_health/resources/toolkit_mh_emergencies/en/

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mentalhealthrelatedproblems.AmappingofMHPSSactorsandserviceswasundertakenbytheMHPSSsub-WorkingGroupfortheMosulEmergencyduringthisassessmentperiod,andresultsarepresentedinasubsequentsectionbelow.Adeskreviewofcurrentrelevantdocumentsincluded:• OCHAandUNHCRSituationReportsontheMosulemergency• ACFMentalHealthandPsychosocialAssessmentReportsforKhazerandZelikanIDPcamps• IMCinternalmultisectorreportsonMHPSS,health,andprotectionconsiderationsfortheemergency• Variouspublicstatementsfromhumanitarianorganizationsaswellasnewsaccountsonlifeunder

ISISruleandtheimpactofdisplacementInterviews,FocusGroupDiscussions,andSiteVisits:Field visits were conducted to camp and urban settings with displaced populations in Ninewahgovernorateforkeyinformantinterviewsandfocusgroupdiscussionsatthefollowingsites:Khazercamp,Jed’ah camp and town, Hamdaniya Junction, and Gogchaly (eastern Mosul). Interviews and generaldiscussionswerealsoheldwithkeyinformantsandrepresentativesofvariousagenciesandINGOs(e.g.ACF,MSF,HeartlandAlliance),theRedCross/RedCrescent,UNHCR,andIOM.3.Background&Context3.1LifeUnderISISOccupation&DuringArmedConflictinMosulThefollowingexperienceshavebeenreportedbyciviliansfleeingMosulanddocumentedbyjournalistsaswellashumanitarianorganizations,includingmultipleformsofviolence,humanrightsviolations,andlackofaccesstobasicneeds:ExposuretoViolence,Abuse,&ExploitationThisincludesthedirectexperienceand/orwitnessingof:mortarattacks,airstrikes,bombings,landmines,booby-trappedexplosives,andgunfire.ISIShasperpetrateddeliberateattacksagainstcivilians,includingmasssummaryandunlawfulkillings,hangings,beheadings,publicactsofmurderanddisplayofcorpses,torture,sexualviolence,abduction,enslavement,recruitmentanduseofchildreninarmedconflict,aswellastargetingofminoritycommunitiesanddestructionofcivilianinfrastructureandproperty.2ISIShasalsobeenfoundtoexploitciviliansas“humanshields”andforciblyevacuatecivilianstostrategiclocationsinMosul for thispurpose,aswellaskill thosewhoresist.3 ISIShasbeenknowntodeliberately targetminority communities, includingChristians, Yezidis, Shi’a Shebek, and Shi’a Turkmen. The Iraqi armedforces and militias have also been accused of committing atrocities, including unlawful killings andsummaryexecutions,aswellasdisappearances,allegedlyonthegroundsofsecurityconcerns.4

2AmnestyInternational(11November2016).“TheBattleforMosul:TalesofHorrorEmergeasThousandsFleeClashestoOustIS.”https://www.amnesty.org/en/latest/news/2016/11/the-battle-for-mosul-tales-of-horror-emerge-as-thousands-flee-clashes-to-oust-is/3HumanRightsWatch(November,2016).“Iraq:FearedISISUseof‘HumanShields,’Executions”.https://www.hrw.org/print/2961154AmnestyInternational(2016).“‘PunishedforDaesh’sCrimes’–DisplacedIraqisAbusedbyMilitiasandGovernmentForces”.https://www.amnesty.org/en/documents/mde14/4962/2016/en/

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LackofAccesstoFood,Water,&OtherResourcesManyciviliansaredeprivedofaccesstofoodandwater,andlivedmanydaysfacinghungerandthirst.Mostciviliansareunabletoworkandhavenothadessentialincomeoraccesstobasicresources,resultingin many living in positions of poverty. There have been ongoing electricity shortages, and in earlyDecember,thewatersupplywascutacrosseasternMosulduetoarmedfighting,whichwillpresumablyforcemoredisplacementincomingweeksalongwithadvancesofIraqiandcoalitionarmedforces.StrictRules&RestrictionsCivilianslivingunderISISruleareforcedtoadheretostrictrules,includingShari’alawaswellasadditionalrulesandrestrictions.Womenarerequiredtowearveryconservativeattire;menarerequiredtowearbeards.Communicationfromtheoutsideworldisprohibited,andcellphonesandSIMcardsarestrictlyprohibited.Rulesareenforcedbyviolentintimidation;ifrulesarebroken,thereissystematicpunishment(e.g.publiclashings).Strictpolicieswereespeciallyputinplaceforchildren,detailedbelow.Disruption&ExploitationoftheSchoolSystemAfter ISIStookoverMosul, they introducedanewcurriculumintoschoolsthat incorporatesextremistideology and violent teachings for boys, and a policy of keeping girls confined to the home.Multiplereports indicateamanipulationoftheeducationsystemto indoctrinatechildrenandtoprovidemoralandreligiousjustificationformurderandviolence,andapresumedobjectivetoturnthemintofighters.Thiswascorroboratedinfocusgroupdiscussionsconductedforthisassessment,withexamplesprovidedofhowweaponswereusedtoteachmathematics,aswellas lessonsonhowtomakebombs,killandbeheadothers,andteachingthatkillingispermissible.Mostchildrenweretakenoutofschoolbytheirparents,whetherduetofearofbrainwashing,orforeconomicreasons.5Asaresult,itisestimatedthatoveramillionchildrenhavebeenoutofschoolorforcedtolearnfromISISoverthepast2.5years.6RecruitmentofChildrenasChildSoldiersISIShas systematically recruitedand trained children tobe soldiersof the Islamic State (“Cubsof theCaliphate”),oftenthroughdirectcoercionsuchasabductions,aswellasthroughindirecttacticssuchasintimidation.Therecruitmentprocessincludesthetargetingoforphansaswellasethnicminorities(e.g.Yazidis,Turkmen,andShebek).7Thesocializationprocessmay includeconditioningthat involvesbeingexposedtoviolence,taughtnottoquestionthegroup’sauthority,andbecomingkillersthemselves.BoysaretaughtfromtherigidISIScurriculumandattend‘jihadi’trainingcampswhichpurportedly includesshooting,weaponry,andmartialarts,aswellashowtoplantbombsandIEDs,andassigningrolessuchassoldiers,executioners,suicidebombers,spies,andpreachers.Girlsaretaughthowtobesupportivewivesandmothers,aswellastaskssuchascookingandcleaning.8Theseexperienceshaveprofoundimpactsontheirhealthydevelopmentonpsychosocial,mentalhealth,protection,andeducationlevels.

5AmnestyInternational(11November2016).“TheBattleforMosul:TalesofHorrorEmergeasThousandsFleeClashestoOustIS.”https://www.amnesty.org/en/latest/news/2016/11/the-battle-for-mosul-tales-of-horror-emerge-as-thousands-flee-clashes-to-oust-is6SavetheChildren(11November2016).“OveraMillionChildrenLivingUnderISISinIraqHaveMissedOutonEducation”.http://www.savethechildren.org.uk/2016-11/over-million-children-living-under-isis-iraq-have-missed-out-education-save-children7IraqiInstitutionforDevelopment(28June,2016).“EstablishExtremismIdeasinChildrenthroughEducation,Influences,andPsychologicalChanges.”https://issuu.com/benoitemartin/docs/establish_extremism_ideas_in_childr8Quilliam(March,2016).“TheChildrenoftheIslamicState.”https://www.quilliamfoundation.org/wp/wp-content/uploads/publications/free/the-children-of-islamic-state.pdf

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AnadditionalconsiderationisthatboysfleeingMosulintoKurdish-controlledterritoryarebeingdetainedatajuvenilecenterforindefiniteperiods,evenaftertheypassaninitialsecuritycheck,forpossibletiestoISIS,accordingtoakeyinformantwithanINGOprovidinglegalassistanceandMHPSSsupport.Manyaredetainedforweekswhileauthoritiesconductfurthersecurityscreenings,anditisnotknownwheretheymaygoifandwhentheyarereleased.3.2Displacement

MultipleDisplacements&FamilySeparationManyciviliansfromthegreaterMosulareahaveexperiencedmultipledisplacements;oncefindingrefugesomewhere,findingthemselvesatriskagainanddeterminingitwasnecessarytofleeagain.Often,therehasbeenalackofpredictabilityastowhentheremightbeanopportunitytoflee,andfamilymembershavehadtomakedifficultdecisionstosavethemselveswithoutknowingwhatthefatewouldbeoftheirloved ones. Additionally, thousands ofmen and boys fleeing ISIS territory have been rounded up bysecurityforcesormilitiasduetosuspicionsoflinkstoISIS.11Duringtheseperiodsofdisplacement,manyfamilymembershavebeenseparated,resultinginnumerousunaccompaniedchildren(withanestimated154 registered12).Key informantshavealso reportedprotection concerns for childrenwhohavebeennewlyorphanedandseparatedfromfamily.9UNHCR(15December2016).IraqSituation:UNHCRFlashUpdate.http://reliefweb.int/sites/reliefweb.int/files/resources/20161215%20UNHCR%20Iraq%20Flash%20Update.pdf10OCHA(11December2016).Iraq:MosulHumanitarianResponse.SituationReportNo.11.http://reliefweb.int/sites/reliefweb.int/files/resources/Situation%20Report_11_Mosul_11%20December2016_FINAL.pdf11AmnestyInternational(2016).“‘PunishedforDaesh’sCrimes’–DisplacedIraqisAbusedbyMilitiasandGovernmentForces.”https://www.amnesty.org/en/documents/mde14/4962/2016/en/12OCHA(11December2016).

As of December 15, 2016, there are anestimated96,864 individualswhohavebeeninternally displaced from Mosul andsurroundingareassincethemilitaryoffensivebegan on 17 October. While the flow ofciviliansoutofMosulcontinuesathighrates(e.g. 14,000 the week of 11 December), asignificant proportion of individuals arealready returning to theirhomevillages thathave been recently liberated (e.g. 9,5000 toShurathesameweek).Approximately84%ofindividualsdisplacedarecurrentlyshelteredincamps and emergency sites.9 As many as 1millionciviliansarebelievedtobetrappedinMosul, living under dire conditions of war,includingwaterandelectricityshortages.10

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DifficultConditionsinCampsThevastmajorityofcivilianswhohavebeeninternallydisplacedduetotheMosulemergencyareresidingincamps,withtheremaininginemergencysitesandurbanareas.Atthetimeoftheassessment,campswere not adequately prepared to protect individuals from cold winter conditions, including limiteddistributionsofwarmclothesandblankets,heatersandsufficientkerosene,andadequatewarmwater.Furthermore,MHPSSassessmentsconductedbyACFinKhazerandZelikancampsindicatedhighlevelsofpsychologicaldistress (66%and70%respectivelyof interviewedcamp residents)aswell as significantdifficulties practicing coping techniques.13 The results of IMC’sMHPSS assessment include a detaileddescriptionofchallengesfacedbythoselivingincamps,whichisoutlinedbelow.ExposuretoEnvironmentalHealthHazardsInadditiontothosefleeingMosulwithseriouswar-relatedinjuries,civiliansinandaroundQayyarahhavebeensubjectedtosignificantenvironmentalhealthrisksduetoburningoilwellsandthethicksmokethatenveloped these communities after ISIS blew up over a dozen wells once Iraqi-led forces began anoffensive inAugust 2016.While themajorityof fireshave sincebeenextinguished, civilians in campsnearbystillliveunderthesecarcinogenicfumesandhavesufferedfromrespiratory-relatedcomplications.Additionally, ISISsetfiretoasulfurplant inMishraq inSeptember2016;sulfurdioxidefumesarealsohighlytoxicandcausesevererespiratorydifficulties.

3.3MentalHealthPoliciesandStrategiesinIraqIraqhasaNationalMentalHealthCouncilthatwasestablishedin2004tooverseethedevelopmentofamentalhealthpolicyandimplementationplan,addressingthefollowingpoints:developingcommunitymentalhealthservicesandamentalhealthcomponentinprimaryhealthcare;downsizinglargementalhospitals; human resources and financing; advocacy and awareness-raising; quality improvement andmonitoringsystem;humanrightsprotectionofusers;andequityofaccesstomentalhealthservicesacrossdifferentgroups.14Thereisnospecificbudgetallocationformentalhealthservices.Intermsofmentalhealth legislation,adraftmentalhealthactwasdeveloped in2013and isbeing reviewedby relevantauthorities at the Baghdad/central government level. There is no legislative support for people withmentaldisorders,andthere isadearthof formalcoordinationandcollaborationwithdepartmentsoragenciesoutsideoftheMinistryofHealth.Thereisamentalhealthpolicythatwasdevelopedin2014thatisavailableandpartiallyimplemented,includinganongoinginitiativefortheintegrationofmentalhealthintoprimaryhealthcareandrelatedtrainingandcapacity-buildingformedicalstaff.Nevertheless,mental health service provision is very low, and the treatment gap for the management of mentaldisorders is estimated at 94%.15 The composition of the mental health workforce (rate per 100,000population)isasfollows:0.4%psychiatrists,0.1%othermedicaldoctorstrainedinmentalhealth,1.5%nursestrainedinmentalhealth,0.1%psychologists,and0.2%socialworkers.16AccordingtoInternationalMedicalCorps’MHPSSteam’spreviousdiscussionswiththeDepartmentofHealthinNinewahandhealthstaffoperatinginclinicsnearMosul,therewere10psychiatristsworkinginMosulpriortothestartofthewar;thereisnomeansofconfirmingthecurrentnumberofmentalhealthprofessionalsatthistime.

13ACF(2016).“MosulResponse:MentalHealthandCarePractices”reportsforKhazer&Zelikancamps.14WHO-AIMS(2006).MentalHealthSysteminIraq.http://www.who.int/mental_health/evidence/iraq_who_aims_report.pdf15WHO(2014).ConflictandHumanitarianCrisisinIraq:PublicHealthRiskAssessmentandInterventions.http://who.int/hac/crises/irq/iraq_phra_24october2014.pdf16WHO(2014).MentalHealthAtlasCountryProfile:Iraq.http://www.who.int/mental_health/evidence/atlas/profiles-2014/irq.pdf

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4.AssessmentResults4.1CurrentProblemsandStressorsAmongtheAffectedPopulationKeyinformants,includinghealthandmentalhealthserviceprovidersworkingwithaffectedpopulationsinNinewahaswellasfocusgroupparticipants(adultfemalesandmalesinKhazerandJed’ahcamps)wereasked about theproblems andongoing challenges affecting communitymemberswho lived inMosulunderISISruleandweredisplacedtocampandurbansettings.Theresultsaresummarizedintwotablesbelow,basedontheinformationgatheredaswellasfromdirectobservation.Thefirsttablepresentsalistofsignsandsymptomsofdistressamongciviliansrecentlyexposedtowar-relatedviolence;thesecondtablepresentsalistofcurrentproblemsandstressorsamongcivilianslivingincampsettings.Signs&SymptomsofAcuteDistressamongCiviliansRecentlyExposedtoWar-RelatedViolence:For individuals who have just survivedmortar attacks, airstrikes, car bombings, or other war-relatedviolence and have been transported by the Iraqi forces to humanitarian organizations with firstrespondersprovidingimmediatecare,thefollowingsignsandsymptomsofacutedistresswereidentifiedandreportedbyfirstresponders:

Ø ShockØ DerealizationØ DissociationØ AnxietyØ FearØ GriefØ Crying

OngoingProblems&StressorsamongCampCommunityMembers:Generally

• Familyseparation:amajorityofpeoplehavebeenseparatedfromtheirfamilymembersatvariousstages of displacement, especiallywhen fleeingMosul and not having all familymemberswiththem,aswellaswhenmalesaretakenforextendedsecurityscreeningsordetention,orwhenlovedonesaretakentoothergovernoratesformedicaltreatment.

• Limitedtonocommunicationwithlovedones:cutofffromcommunicationwithfamilymembersleftbehindinMosulwhohavewithnoabilitytousephonesunderISISrule;limitedcommunicationwith loved ones elsewhere as many in the camp do not have cell phones, and/or cannotcommunicatewithfamilywhohavebeentakenelsewhere(e.g.toErbil)formedicaltreatment.

• Lackofaccesstobasicneeds:severelylimitedornoavailabilityofcleandrinkingwater,meansofkeepingwarm inwinter (e.g.warm clothes; blankets; sufficient heaterswith needed kerosene;sufficienthotwaterinshowers).

• Financialdifficulties: extremely limitedanddiminishing financial resources; inability toworkorearnanincome.

• Stressofmultipledisplacements:manyindividualsandfamilieshavebeendisplacedseveraltimes;asaresult,multiplelossesandstressors.

• Lossofhomeandpossessions:concernabouthavinglosteverything,orwonderingiftheirhouseisstillstanding.

“Wedon’tmindlivingwithoutfood,withoutwater,withoutshelter,aslongaswecouldbereunitedwithourfamilies,”awomanexplainedinKhazercamp

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• Barrierstogrieveproperlywhenalovedonedies:often,familyseparationpreventsindividualsfromhavingtheopportunitytoensuretraditionalritualsareconductedortobewithlovedonesduringtimesofbereavement.

• Securityconcerns:senseofuneasewithcampsettingwithsomanystrangers,includingfearthatsome individualsaffiliatedwithor sympathetic to ISISmaybeamong them,aswellas somanystrangerswhotheyfeeltheycannottrust.

• Lackofdignity:feelinglikethecampconditionsareunacceptableandhumiliating;feelingliketheyarebeingtreatedlikeanimals.

• Lackofcomfort:inconvenientsharingtents,WCs,andshowerareaswithlimitedprivacy.• Senseoffrustrationandongoingdespair:feelingthattheyleftoneformofhardshipforanother;

desiretoreturnhome• Senseofabandonment: feeling like theyhavebeenabandonedby thegovernment; frustration

withthepoliticalsystemandtheongoingwarforyears.• Uncertaintyaboutthefuture:senseoffeelingstuck/detainedwithnoclarityaboutwhenorwhere

theymightgonext,orhowtohavethemeansneededtomoveforward.• Burden of caring for multiple family members: many have traveled with extended family,

especiallyincaseswherekeyfamilymemberswereleftbehindandtheybroughtthechildrenandmustlookafterthemaswellinsuchdifficultconditions.

• Boredom:sensethatthereisnothingtodo;noelectricity,nothingtodotopassthetime,e.g.work,education,vocationaltraining,entertainment,etc.

AdditionalStressorsinKhazerCamp(aclosedcampthatpeoplearenotallowedtoleave):• Perceptionoflivingasaprisoner:senseofhavingtransitionedfromanopen-airprisonoflifeunder

ISIStoaclosedprisonofadetentioncenter;nofreedomofmovement.• Senseofinjustice:feelingliketheyhavebeenaccusedofbeingguiltyofacrimeandthattheyare

beingpunished,eventhoughttheyfeltliketheyhavebeenthevictims.• Absenceofamosque:nospacetopray,ortohearthecallstoprayer,ortoknowthedirectionof

Meccainordertoknowinwhichdirectiontopray.AdditionalStressorsinJed’ahCamp(acampnearQayarah,whereoilwellsarestillburning)• Unhealthyandunsanitaryconditions:livingunderpollutionandcarcinogenicfumesfromburning

oilwells;garbageincamp;dirtyWCs;concernsofcatchingdiseases.• Lackofaccesstosufficienthealthservices:despitethenumberofcampcommunitymemberswho

are sick, especially those with chronic disease and/or who require medications, there areinsufficienthealthservicesandmedicationsavailable,andmustwaitalongtimetoreceiveservices.

• Sense of unjust and unpredictable non-food item distributions: stress caused by ongoingperceptions thatdistributionsarebeingconducted inanunfairor insufficientmanner,andthatthere are not enough supplies for equal distribution. Concerns about potential corruptionwithdistributions;concernsthatcampmanagementisn’torganizingbetter.

IdentifiedSignsofMentalHealth&PsychosocialDistress• Fear:pervasivesenseofconcernanddiscomfortregardingtheirsafetyandthesafetyoflovedones• Anxiety/worry:bothfromfearaswellasuncertaintyaboutthefuture;nopeaceofmind• Feeling“tired”:exhaustionanddistressonpsychological,physical,andmentallevels• Anger:irritable;losingtemper• Loss,bereavement,andgrief:includingtraumaticandambiguousloss• Physicalcomplaints:fatigue;bodyaches;lackofappetite

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• Decreasedself-care,e.g.caringforappearances• Violent behavior:17 taking out anger in violentways, often toward loved ones (e.g.men being

violenttowardswivesand/orchildren;womenbeingviolenttowardschildren)

Women Men

• Security and dignity concerns: need forlatrinestohaveproperlightingforsafetyaswell as partitions for privacy and dignity;needforotherstoaccompanytolatrines

• Specialconsiderationsforwomenwhonolonger have their husbands for support:needs for those separated from theirhusbands,whomtheyreliedonforsupport,protection,andincome,aswellaswidows

• Challenges of supporting familymembersduring these difficult circumstances, andworryforchildren’swellbeing

Additional Signs of Mental Health &PsychosocialDistress• Crying• Attemptstohidedistress

• Financial stressors: need for employment/income-generatingopportunities

• Burdenofnotbeingabletoprovideforfamily:senseofhelplessnessandfrustrationthattheycannot support their family and have notfulfilledtheirroleastheheadofhousehold

Additional SignsofMentalHealth&PsychosocialDistress• Frustration:stronglyexpressingdiscontent• Aggression:violentbehavior;quicktofight• Changeinsleepinghabits:difficultysleeping,or

sleepingmorethanusual• Difficulty concentrating: lack of focus in

discussions;consumedwiththoughts

ConcernsforChildren

• Education-relatedconcerns:amajorityofchildrendidnotattendschoolfor2.5years;forboyswhowhodid attend school, theywere subjected to the ISIS curriculumwhich included very violentteachings.Inthecampsetting,concernsthateducationopportunitiesaresuboptimal.

• Childrenrecruitedby ISIS:concernforboystrainedtobesoldiersandotherchildren(boysandgirls)whowererecruitedandindoctrinatedbyISIS,andexposedtoandparticipatedinviolence.

• Unaccompaniedminorsandorphanedchildren:noknownsupportforthesechildren.IdentifiedSignsofMentalHealthandPsychosocialDistress• Actingout:disobeyingandnotlisteningtoparents• Frustration:exhibitingstrongdiscontentwiththecurrentsituationandchallenges• Aggressivebehavior:fightingoftenwithothers(neighbors,friends);especiallyamongboys• Hyperactivebehavior:hardtositstill• Internalizingbehavior:quiet,talkingless;socialwithdrawal• Fear&crying:especiallylinkedwiththesoundsofshelling18

17OnlymentionedinfocusgroupdiscussionsinJed’ahcamp(bothinmale&femalegroups)18OnlymentionedinfocusgroupdiscussionsinJed’ahcamp,wherethesoundofshellingisregularlyheardnearby

“Idon’thaveanythingexcepttheclothesonmyback…CanIcallmyselfamanwhen

Ihaveonly250dinarsinmypocket?”askedamaninKhazercamp

“Ifyoulookatyourchildrenwhoareunhappy,youwillbeunhappyaswell,”sharedamotherinJed’ahcamp.

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Additionalstressorsobservedduringfieldvisitsandindiscussionwithkeyinformantspertainstofamilyseparationfromtheinjuredordeceased.WhenindividualsrequireambulancetransferfromNinewahintoErbilforacutemedicalreasons,theobservedpolicyisthatonlyfemalefamilymembersareallowedtoaccompanylovedones,duetosecurityconcernsaboutmales.Keyinformantsarticulatedthattheredoesnotseemtobeasysteminplacetofacilitatecommunicationwithfamilymembersoutsidethehospitaltogiveupdatesonthewellbeingofthosewhoarehospitalized.Furthermore,theredoesnotseemtobeaclearpolicyregardingthemanagementofdeadbodies.TheonlyidentifiedprocedureisthatbodiesaretransportedtoErbilHospitalforautopsies;itisunclearwhathappensthereafter,andtowhatextentlovedonesareinformedofanyprocedures.Aftersufferingthelossofalovedone,theuncertaintyaboutdeadbodymanagementandimplicationsforrelatedritualssuchasburialshasbeenseentointensifyemotionaldistress.At-RiskCommunityMembersThefollowingpeopleinthecommunityhavebeenidentifiedtobethemostat-risk:

Ø Children (especially due to limited coping mechanisms, lack of educational opportunities, orunaccompaniedororphanedchildren)

Ø OlderpeopleØ Females(especiallyduetoprotection-relatedconcerns)Ø ThosewhoareseparatedfromtheirfamiliesØ ThosewhowereexposedtoextremeviolenceØ Thesick(especiallythosewithchronicdiseaseanddisabilities,andwholackneededmedications)

CopingwithdistressParticipantsinfocusgroupdiscussionswereaskedtoidentifythevariouswaystheycopewithdifficultiesfaced, as well as their current ability to practice these coping strategies and any challenges faced.Participantswerealsoaskedwhatmightbehelpfultosupporttheircopingabilities. Traditionally CurrentAbilityorChallengesin

usingthisCopingMethodRequestedSupport

forCoping

Generally

Talkingwithandsupportingothers,especiallyingroups

Limited;nocommunityspaces,butpossibletovisitwithrelativesorneighborsintentsorbyshops.Khazer:nofreedomofmovement.

Havingacommunityspace

Religion/Prayer Possible,butnotincustomaryways.Khazer:nomosque;nocalltoprayer;unknowndirectionofMeccaforprayer

Havingamosque

Activitiestooccupytime,e.g.watchingTV,listeningtotheradio,sewing,usinglaptop

None;noelectricity;noentertainmentdevices

Havingagenerator

Maintainingandsharinghope;tryingtoputthingsinperspective

Possible;moredifficultforsomethanothers

Educational&vocationalopportunities

Limited;thereareeducationopportunitiesforchildren,butnotforadults;novocationalopportunities

Wouldlikesuchopportunities

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AmongWomen

Familyandhouseholdduties–caringforchildrenandhusband

Difficultgiventheconfinesofatentandcampsetting

Activitiese.g.cooking,sewing Notpossible;nospaceorresources

AmongMen

Working;doingsomethingofvalue

Notpossible;noincome-generatingopportunities;nocashassistance

Requestforemploymentand/orcashassistance

Havingasenseofagencytomakeadifference

Norepresentationinthecamp Havingacampcommittee

AmongChildren

Goingtoschool(education,structure,rules,andvalues)

Informallyincamp;noformalreentryintoschoolsystem

Playing;recreationalactivities Yes,insuboptimalconditions;limitedsafeorcleanspaces

Goingforwalksoroutforpicnics

Notpossible

Enjoyingspecialtreats(e.g.gifts,candy)

Notpossible

4.2MHPSSCoordinationAn MHPSS sub-Working Group for the Mosul Emergency response co-chaired by IOM and IMC waslaunched out of the MHPSS Working Group in Erbil on 15 November 2016 and meets biweekly. Apreliminary basic 4Wsmapping exercisewas completed and disseminated on 2 December 2016, andcontinuestobeupdatedregularlybyIOM.19TheMHPSSWorkingGroupinErbil,co-chairedbyUNHCRandIMC,hasadedicatedpageonmhpss.net20hostedbyUNHCR,andthereisaMosul2016CrisisResponsegroupestablishedforthesharingofMosul-specificresources.214.3ActorsCurrentlyActiveinMentalHealthandPsychosocialSupportInitiativesCurrently,IDPsandhostcommunitieslivinginNinewahreceivementalhealthandpsychosocialsupportservices through community-based service outlets established by both national and internationalorganizations in camp and urban settings. IDPs and host community members access mental healthservicesthroughprimaryhealthclinicsand/ormobilemedicalunitswherethereareintegratedMHPSSserviceswithpsychiatrists,psychologists,and/ormentalhealthcasemanagersprovidingsupport,oratleastwherehealthstaffhavebeentrained inmentalhealth.Psychosocial supportservicesareusuallyprovided through community centers, child friendly spaces andwomen centers.Additionally, theRedCross/RedCrescentMovementhasaninitiativeforRestoringFamilyLinksinIraq22withanofficeinErbilopeningsoontosupporttheMosulemergency.CurrentcoverageofcampandurbanlocationshostingIDPsfromMosulisshownbelow.

19Toobtainacopyofthemapping,contactthesub-WorkingGroupco-chair,IOM:SarahAlgom,salgom@iom.int20http://mhpss.net/groups/regions-and-countries/middle-east/mhpss-in-iraq/mhpss-working-group-in-erbil-kurdistan/21http://mhpss.net/groups/current-mhpss-emergency-responses/iraq-crisis-2014-present-response/mosul-2016-crisis-response22https://familylinks.icrc.org/en/Pages/Countries/Iraq.aspx

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MHPSSLevelofCareZone23 Location Site

TypePsychosocialActivities&SafeSpaces

CommunityPsychosocialSupport&Outreach

PsychosocialTreatment

Interventions

SpecializedMentalHealth

Services

1

Khazer Camp IraqiRedCrescent,Triangle,HI,AlMesalla,IMC*

HI,ACF,AlMesalla,IMC

ACF,AlMesalla,IMC

MSF,ACF,AlMesalla

Hasansham Camp IOM,TdH,HI,WRO,AlMesalla

IOM,TdH,HI,WRO,AlMesalla

IOM,TdH,HI,WRO,AlMesalla

MSF,IOM,TdH,AlMesalla

Debaga Camp IOM,TdH,IMC IOM,TdH,IMC

IOM,TdH,IMC MSF,TdH

2Qaymawa(Zelikan)

Camp ACF ACF MSF,ACF

Nargizlia Camp IOM* IOM* IOM* IOM*

4

Qayyarah-Jad’ah

Camp HAI,WRO,IMC*

HAI,WRO,InterSOS,IMC

HAI,WRO,InterSOS,IMC*

HAI

Jad’ah Urban IMC* IMC* IMC* QayyarahAirstrip

Camp IOM IOM,HAI IOM,HAI IOM,HAI

Qayyarahsub-district

Urban HI* HI* HI* HI*

HajAli Urban IOM* HAI,IOM* HAI,IOM* HAI,IOM*Salahadeen-AlAlam

Urban IMC IMC IMC

*PlannedservicesaremarkedwithanasteriskChallengestotheProvisionofAppropriateMentalHealthandPsychosocialSupportServicesThereisadearthofqualifiedpsychologiststoprovideessentialsupportatbothnon-focusedandadvancedlevels of mental health care provision. This is in part due to the lack of clinical psychology trainingprograms, asmost psychologists have completed educational counseling programs and have not hadexperience receiving clinical training and supervision for addressing mental health needs. Manypsychologistshavenotreceivedtrainingtoenhancetheirknowledgeandskillstoprovidesupportforwar-affected populations, andmay not be familiarwith global guidelines on providingMHPSS services inemergencysettings.Additionally,afewNGOsstatedtheywouldoffersinglesessionswithpsychologists,althoughtheobjectivesandmethodsbeingusedcouldnotbeclarifiedat thetimeof theassessment.Furthermore,therearelimitednumbersofstaffwhoarequalifiedtoprovidepsychosocialsupportandbasiccounseling–whethersocialworkersbytraining,orparaprofessionalswhosecapacityhasbeenbuiltthroughongoingtrainingandclinicalsupervisiontoprovidesupportaspsychosocialworkersormentalhealthcasemanagers.

23ZonesweredesignatedbyUNOCHAtofacilitatethecoordinationoftheMosulemergencyresponse.Atthistime,therearenoknownMHPSSactorsinZone3,duetotheongoingconflictanddifficultyaccessingthisarea.

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5.Summary&Recommendations

5.1 Advocatefortherestorationoffamilylinksandreunification.Themostfrequentlycitedsourceofdistressamongtheaffectedpopulationisfamilyseparationandchallengesrelatedtocommunicatingwithfamily,especiallywhenafamilymemberistakenawayformedicaltreatmentorafteralovedonehaspassedaway.Recommendations:⇒ Encouragediscussionswithkeystakeholderssuchasgovernmentrepresentativesinchargeofor

withinfluenceincampsaswellasvarioushumanitarianactorsontheessenceofpromotingfamilycohesionandcommunicationforindividual,family,andcommunitywellbeing.

⇒ DisseminateinformationtoallserviceprovidersontheRestoringFamilyLinksinitiativeledbytheRedCross/RedCrescentMovement,includinginformationabouthowindividualscanregisterthemselvesormissingfamilymembersintheirdatabaseandhowupdatescanbeobtainedandfamilylinksrestored.

⇒ Advocateforaclearcommunicationpolicybetweenthosereceivinghospitalizationinanothergovernorate,andtheirlovedonesfromwhomtheyareseparated.EncourageorganizationswithstaffinNinewahandErbiltocoordinateineffortstoestablishreliablecommunicationchannels,andensureupdatesaresharedbetweenhealthcareprovidersandfamilymembers.

⇒ Advocateforaclarificationandrightsregardingdeadbodymanagementand involvementoffamiliesindecision-makingprocesses.Ensurelovedonesareinformedoftheseproceduresandanyrightstheymayhaveaboutdecisionsthataremadeforburials.Facilitatefamilymembers’abilitiestoplanandholdburialsandprovideanyneededmeansforthis(e.g.transport,thingsneeded for graveside and any rituals etc.)See IASCGuidelinesAction Sheet 5.3 on facilitatingconditionsforappropriatecommunalcultural,spiritual,andreligioushealingpractices.

⇒ Ensurephonesareavailableatcentrallocationstofacilitatecommunication,giventhemajorityofthosewhofledMosulwerenotallowedtohavephonesorSIMcards.

Basic services and security

Community and family supports

Specialized*Services**

Focused*non2specialized*supports*

Community*and*Family*supports*

Social*considera7ons*in*basic*services*and*security*

Mental'Health'care'by'Mental'Health'specialists'(e.g.'psychiatric'nurses,'psychologists,'psychiatrists).'

Communal'tradi;onal'supports.'Suppor;ve'child>friendly'spaces.'

Basic'emo;onal'and'prac;cal'support'by'community'workers.'

Basic'Mental'Health'care'by'PHC'doctors.'

Ac;va;ng'social'networks'

Advocacy'for'basic'services'that'are'safe,'socially'appropriate'and'that'protect'dignity.'

Global standards outlined in the Inter-Agency Standing Committee (IASC)Guidelines on Mental Health andPsychosocial Support in EmergencySettings (2007) includerecommendations on different levels ofmental health and psychosocialinterventionsusingapyramidapproach,with basic needs and socialconsiderations at the foundation, withincreasingly advanced mental healthservicesmovingupwards. The followingrecommendationsaremadeineffortstoaddress the various MHPSS needs andgaps identified in Iraqpertaining to theMosul humanitarian response, and toenhance the quality andcomprehensivenessofMHPSSservices.

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5.2 EnsureMHPSSprogramsincludeactivitiesthatpromotecommunitycohesionandsocialsupport.Asthegreateststressorcitedbytheaffectedpopulationisfamilyseparationandrelateddifficultiespertaining to limited supports and challenges in practicing coping strategies, there should be anemphasisonpromotingcommunitycohesionandsocialsupportaswellasenablingnaturalsourcesofcopingandfosteringresilienceonindividual,family,andcommunitylevels.Recommendations⇒ ThroughMHPSScoordinationmechanisms,encourageactors ineachcamporurbansettingto

develop community- and group-based activities that could establish or strengthen socialsupport.Thiscouldincludecommunitycenters,group-basedinitiativescenteredonactivities(e.g.sewing, cooking, sports, art), self-help and support groups facilitated by trained MHPSSprofessionals,aswellaseducationalandvocationaltrainingopportunities.

⇒ Advocate for campmanagement to include campcommunitymembers and toencourage thecreation of camp committees to promote the identification of community priorities andempowercommunity-ledinitiatives.

⇒ SeeIASCGuidelinesActionSheet5.2onfacilitatingcommunityself-helpandsocialsupport5.3 Advocateforpsychosocialconsiderationsincampsettingstopromoteanenvironmentofdignity,

equity,andjustice.Findingsfromfocusgroupdiscussionshaveindicatedacollectiveperceptionofunpredictable and unjust aid distributions, as well as a lack of access to reliable, up-to-dateinformationoncamppoliciesandprocedures,andservicesavailabletothem.Recommendations:⇒ Advocate for delivery of services in a way that promotes psychosocial wellbeing, including

predictability,transparencyandequityinthedistributionofessentialnon-fooditemstoprovidewarmthandprotectionduringwinter.

⇒ Improve information dissemination and access to information pertaining to policies andproceduresthatapplytocampcommunitymembers(e.g.onsecurityandmovementrestrictionsand aid distributions) aswell as a list of the various services available in the camp, includinginformation onwhere,when, and how to access these services. This information can also becentralizedincommunitycentersonbulletinboardsand/orviahandouts.

5.4 PromotetheProvisionofQualityandAppropriateMHPSSServicesandReferrals.

TheassessmentshowedthatfirstrespondersinMosulandKhazercamparefacedwithindividualswhohaveexperienced significantandpotentially traumatic stressors, someofwhomare showingacutesignsofpsychologicaldistress.IASCMHPSSGuidelinesrecommendtrainingforfirstrespondersin Psychological First Aid to ensure they have the skills to provide basic support, communicateeffectively,connectpeopletoneededservices,andpracticeself-care.Furthermore,thereisoftenalackoftrainingandcapacityinbestpracticesandguidelinesforlocalMHPSSstaffinIraq.⇒ Ensure first responders receive training in Psychological First Aid, with an adapted training

curriculumto includeadditionalcomponentsonrecognizingsignsofdistress,shock,andgrief,andexamplesofhowtodemonstrategroundingtechniques,deliverupsettingnews(e.g.aboutthelossofalovedone),andprovidebasicsupportforthosewhohavejustexperiencedloss.

⇒ Organize ongoing training, supervision, and capacity-building initiatives for MHPSS serviceproviderstopromotebestpracticesfortheprovisionofsupporttoconflict-affectedpopulationswhomayhaveexperiencedsignificanttraumaticevents,loss,andpsychologicaldistress.MHPSSactorscouldconsidercollaborationforjointtrainingandcapacity-buildinginitiatives.

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⇒ Asdomesticandgender-basedviolencewerereportedasasignificantconcernbyfocusgroupparticipants, ensure MHPSS staff are trained on best practices of supporting survivors ofviolenceandmakingreferralsforprotectionservicesincollaborationwithprotectionactors.

⇒ Establishandstrengthenreferralpathwaysbetweenhumanitarianactorstopromotecommunityaccess to comprehensive services spanning mental health and psychosocial support, health,protection,andsocialservices.EnsurecontinuedMHPSSrepresentationatHealthandProtectionCoordinationGroupmeetingsandasharingofmappingandreferralpoliciesandprocedures.

⇒ Develop and disseminate MHPSS-related Information, Education, and Communicationmaterials,suchasonstressresponsesfollowingdistressingevents,aswellasonpositivecopingmechanisms. See IASC Guidelines Action Sheet 8.2 on providing access to information aboutpositivecopingmethods.

5.5 AdvocateforspecialprogramsforformerchildsoldiersandotherchildrenrecruitedbyISIS.Former

Mosul residents who participated in focus group discussions, as well as other key informants,expressed significant concern for children who were recruited and indoctrinated by ISIS.Comprehensive programming will be needed to address psychosocial, mental health, protection,legal,andeducationneedsofthesechildren.Recommendations:⇒ Family reunification and community reintegration should be prioritized, as well as the

identificationofchildrenwhoareinneedofmentalhealthandpsychosocialsupportservices.⇒ Key recommendationsmade for former ISIS child soldiersby theQuilliamFoundationand the

RoméoDalllaireChildSoldiersInitiativeincludethefollowingcomponents:deradicalization,re-education, reintegration,andcommunityoutreach, aswellasensuringappropriateaccess tosupport,protection,education,andlegalservices.24

⇒ Recommendations pertaining to the promotion of psychosocial adjustment and socialreintegrationofformerchildsoldiersonagloballevelincludetheneedforholistic,integratedsystems of care for all war-affected youth, outlined by Psychology Beyond Borders and theResearchProgramonChildrenandGlobalAdversityattheHarvardSchoolofPublicHealth.25

⇒ MHPSSactorsshouldreviewbestpracticesofdisarmament,demobilization,andreintegration(DDR)programsthathavepreviouslybeenimplementedglobally,todeterminetheuniversalityofbestpracticesinidentifyingandmeetingtheneedsofformerchildsoldiers.Additionaleffortswill need to be ensured for the contextual and cultural adaptation of recommendedprogramminginIraq,aswellasforsecuringneededfundingandsupportforsuchinitiatives.

InternationalMedicalCorps1313LSt,NW,Suite220Washington,DC20005Phone:+1202.828.5155Web:https://internationalmedicalcorps.org/mentalhealth

24Quilliam(March,2016).“TheChildrenoftheIslamicState.”https://www.quilliamfoundation.org/wp/wp-content/uploads/publications/free/the-children-of-islamic-state.pdf25PsychologyBeyondBorders(2008).“PsychosocialAdjustmentandSocialReintegrationofChildrenAssociatedwithArmedForcesandArmedGroups:TheStateoftheFieldandFutureDirections.”https://www.essex.ac.uk/armedcon/story_id/CAAFAG.pdf