A Tale of Two Countries: Building A Mental Health System in Iraq, Part 2


“The best of times, the worst of times…”

A rich, well-resourced country of over 300 million people – a beacon of hope and democracy around the world. Alas, also the world leader in incarcerating people. What have we done wrong?

A country decimated by years of neglect by its leader – worse, by the systematic rape of its resources by that leader. Thirty years during which, reportedly, 97% of the country's expenditures went to the military.

As promised in my last blog posting, this blog will focus on a visit by four Iraqi mental health professionals brought to the US to study forensic mental health services. As of this writing, they have been here for four weeks, with two more ahead of us. What have we shown them?

Upon arrival, they had the opportunity to spend a few days touring in DC while they accommodated to our time zone. Then, SAMHSA arranged for a “convening conference,” during which the forensic team and the five other Iraqi teams (two focusing on trauma, two on child mental health, and one on substance abuse) met with folks from the various host sites, shared their hopes for the visit, had a discussion on human rights, participated in an Anti-Stigma Workshop, and then dispersed to their host sites.

In the first week, our new Iraqi friends were introduced to the forensic mental health system in Maryland. We held a series of meetings over two days, during which they met various decision-makers and thought-leaders from the mental health and criminal justice systems in Maryland, had a tour of the Clifton T. Perkins Hospital Center (the maximum security hospital in Maryland), followed by a three day forensic training provided by the state Office of Forensic Services for new forensic evaluators.

During the second week, we spent two more days at Perkins, as well as a full day at the Patuxent Institution, a state correctional facility with a long history of focusing on offenders using a variety of treatment and rehabilitative approaches. In the third week, we branched out a bit, accommodating the interest of our visitors in community-based services. We spent a day at Springfield Hospital Center, where I work, and two days visiting community programs – the Arundel Lodge program in Annapolis and the Forensic Assertive Community Treatment Team (FACTT) offered by People Encouraging People, Inc., in Baltimore. In addition, we spent two days observing mental health courts in the district courts of Baltimore and Prince George's County.

While I cannot speak directly to what they have learned, the questions they ask and the discussions we have had are eye opening. As I wrote in my last posting, the 32 million people in Iraq are served by about 120 psychiatrists. There are two psychiatric hospitals for the entire country. Both are located in or near Baghdad. Al-Rashad Hospital, where the visiting team works, is a 1200 bed long-term hospital, with about 250 beds set aside as a highly secure forensic unit. The clinical staff there includes 10 psychiatrists, 125 nursing staff, 4 social workers, and 6 psychologists. There are no designated rehabilitation staff, such as occupational or activity or expressive arts therapists, though many of the other clinicians provide an array of psychiatric and rehabilitative treatments, including some absolutely amazing expressive arts therapies. For example, one of our visitors, a nurse, writes poetry and plays, which the patients perform.

Compare this to my hospital, which has about 270 patients, who are treated by 25 psychiatrists, 336 nurses, 26 social workers, 14 psychologists, and 68 rehabilitative staff. If they were staffed commensurate to my hospital, they would have 111 psychiatrists, almost 1500 nursing staff, 113 social workers, 62 psychologists, and 300 rehabilitation staff. We have over 3 times the number of staff, to serve a caseload that less than one-quarter of that at Al-Rashad. And we think we struggle to do more with less. Of course, when bad things happen, one of the first proposed causes is inadequate staffing – see this story regarding a recent tragedy at Clifton T. Perkins Hospital. Even our staffing levels, as rich as they seem when compared to Iraq, are still pretty poor when focusing on public sector services for court-involved people with mental illnesses.

Also lacking in Iraq is any formal system of community-based services for people with mental illness. When a patient is treated to the point where she can leave the hospital, she is given a month supply of medication and told to follow up at Al-Rashad or a hospital closer to her hometown. Patients are discharged home with their families – there are no supportive or residential rehabilitation programs, no group homes, no assisted living facilities, no alternatives. There are no day programs, no ACT programs, no collaborative mental health-criminal justice programs – there is no conditional release of any kind. And yet, they manage to discharge people back into their communities, somehow or other. It is truly humbling.

In my next posting, I will discuss the closure of the visit, including the work that we have been able to initiate with them regarding what aspects of our system they might rationally consider borrowing. If nothing else, this visit has made me question aspects of our system I had considered to be gospel: viewed through the eyes of our visitors, I have had cause to question just about everything – why, after all, do we do it they way we do?

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/

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