In recent years Islamic terrorism has manifested itself with an unexpectedly destructive force. Even though in most cases it started locally, it has spread its terror over the whole world. In August 2014, when troops of the self-proclaimed “Islamic State” invaded areas of northern Iraq, they turned on the long-established religious minorities in the area with tremendous brutality, especially toward the Yazidi religious minority. Huge numbers of men were executed, and women and children were abducted and subjected to sexual violence. In an attempt at systematic destruction of the Yazidi community, the religious minority was to be eliminated and the will of the victims broken. The medical and mental health issues of the resulting from the combined subjective, collective, and cultural traumas, last not least followed by the migrant and refugee crisis, are extraordinary and need new and wise concepts of integrated medical care.
The Yazidi claim to be members of one of the world's oldest religions and make references to Mithraism and its relationship to Yarsan and Zarathrustra (Kreyenbroek and Rashow 2005). The Yazidi have reported massacres since the Arab invasion of the Near and Middle East in 637 AD, and the enforced Islamization continues to the present day. As a result of the pressure of being forced to convert to Islam, they retreated to mountainous areas and had only limited contact with other groups. Their religion was passed down orally from one generation to another by priests. Therefore, the history of the Yazidi is an “oral history” (Kizilhan 2014). There have traditionally been very few documents about the Yazidis written by themselves, although that has started to change in the last fifty years (Omarkhali 2017).
The Yazidis generally assume that their origins are in the Mithraic religion, which dates back to the fourteenth century BC, and have developed an independent religion since that time. Up to the seventh century AD, there is no mention in historical sources of the term Yazidi. Around the turn of the seventh century, Muslim clerics and historians started using the term Yazidi (Al-Damalgi 1949: 139).
When the Ottoman Empire collapsed, many Yazidis fled, along with the Armenians, to present-day Armenia and lived there in the Caucasus regions of the former Soviet Union. At the end of the First World War and the founding of Turkey in 1923, the Yazidi homeland was partitioned. Since then, the Yazidi have been living in Turkey, Iraq, Syria, and the former Soviet Union. The Yazidi settlement area historically was located in today's Turkey, Iraq, and Syria. Until the fifteenth century, Yazidis also lived in Iran. Yazidis also lived in Caucasus regions such as Armenia and Georgia.
Until 2007 the Yazidi narrative spoke of seventy-two ferman, which for the Yazidis is synonymous for massacre or genocide. In 2007 a bomb attack by Al-Qaeda killed over 311 Yazidis, which was seen as the seventy-third ferman, and the genocide by the Islamic State (IS) in 2014 as the seventy-fourth ferman. Based on historical data, there are actually thirty-eight known massacres of the Yazidis in the last eight hundred years. According to conservative estimates, around 1.8 million Yazidis have been forced to convert, and around 1.2 million Yazidis have been killed to date (Kizilhan and Noll-Hussong 2017; Gerdau, Kizilhan, and Noll-Hussong 2017). Numerous fatwas have “legitimized” their killing, looting, abduction, and, since their religion was not recognized, their forcible conversion to Islam. The Islamic State also uses such spurious arguments to carry out genocide against the Yazidi (Kizilhan and Othman 2012).
Since the attack by the IS at the beginning of August 2014, more than ten thousand Yazidi have been killed, thousands of families held hostage in their villages, and, if they did not convert to Islam, murdered. Over fifty-eight hundred young girls have been abducted, raped, sold on Arab markets, enslaved, or killed. Over three-hundred thousand fled to the Kurdish region (Kizilhan and Wenzel 2020).
The aim of the IS was not only to take over Yazidi territory and confiscate their belongings. Their goal was the systematic extermination of the Yazidis. This was already classified as genocide by the United Nations (UN) in 2016 and later by the European Union and other countries such as Germany and the Netherlands.
My Approach to the Topic
I, myself, have been researching trauma in extreme situations such as wars, flight, and displacement for almost thirty years. At the same time, my team and I have been treating traumatized people from various war zones around the world in a transcultural psychosomatic-psychotherapeutic department in a clinic in Germany since 1999.
When the IS occupied large parts of Syria and Iraq and images of beheadings, escapes, and expulsions went around the world, many people asked who the Yazidis were. Until then, they were hardly known to the world public. Since I had already published a lot about the Yazidis and was known as an expert in this field, I was asked by the state government of Baden-Württemberg to inform a government member about the Yazidis and how we can help. At the same time, I received numerous calls from survivors from Kurdistan, Iraq, and Shingal asking for help. So it was an extremely stressful situation to witness “live” how people escape and their relatives are killed or taken hostage.
Finally, the government decided to bring one thousand traumatized women who were in the hands of the IS to Germany for medical and psychological treatment. I was the appointed medical-psychological leader of the project and traveled with a team to the Kurdistan region of Iraq to find the women, examine them, and bring them to Germany. In total, we brought eleven hundred women and their children to Germany in 2015. After successful treatment and care, the women and their children have integrated well and speak excellent German, many women have completed training and are working, others have married and now have children of their own, and some of the children who are now adults have graduated from high school and are studying.
In the Kurdistan Region of Iraq (KRI) in 2014, there were no licensed psychotherapists, only 26 clinical psychologists and a few psychiatrists in a population of 5.5 million people. Therefore, we founded an institute for psychotherapy and psychotraumatology at the University of Duhok with the support of the German government, where since 2017 we have been training psychologists, social workers, and doctors in a master's degree course to become psychotherapists according to European standards. Both the students and the psychotherapists work in refugee camps with severely traumatized people. The therapists speak the refugees’ native language and know their culture and religion, and at the same time we have licensed psychotherapists, which previously did not exist in this form in Iraq. We also conduct studies to better understand the forms of individual, collective, and transgenerational trauma and to develop new treatment methods that help more effectively.
Collective Traumata and Traumatization across Generations
The genocide of the Yazidis by the IS and the current traumatization have reactivated the collective memory of the genocides and massacres of their ancestors. They experience a double or multiple traumatization and conclude that they cannot defend themselves and will, again and again, be the victims of Islamic terror. The distance between Yazidis and Muslims has become significantly greater. Fearing their Muslim fellow countrymen, the Yazidis do not say anything in public, but they do not trust Muslims because once more they are subject to a collective massacre in the name of Islam just as they were in the eighteenth or nineteenth centuries.
We see similar types of behavior as in those who experienced the Holocaust (Bar-On et al. 1998). They are unsure and tense, worry that their children cannot survive, and have feelings of being powerless and helpless.
For example, from August 3, 2014, onward, the IS began terrorizing Yazidi villages and soon gained control of the area. The Iraqi army and the Kurdish Peshmerga retreated, and the people were helpless, at the mercy of Islamic State terror. People were herded into buildings such as schools and town halls and their jewelry and valuables confiscated. The IS then separated the men from the women. Many men were executed immediately. More than 150 women whom I interviewed reported that in the village of Kocho, for example, more than 413 men were executed on August 15, 2015. After that, the older women, women with children, married women without children, and young boys and girls between eight and fourteen years were forced into groups and taken to various locations. Older women and women with children were interned in mass accommodations or in villages, near Tel Afar or Mosul for instance, where the Shiites had previously lived. They were guarded by IS fighters, humiliated, beaten, and raped. Every evening not only IS fighters but also male civilians from Syria, Saudi Arabia, Egypt, Qatar, Tunisia, and other countries turned up because they wanted to buy the women and take them away with them (Cetorelli et al. 2017).
Women are being forced to convert to Islam and to pray in Arabic every day, even though they only speak Kurdish. Children are being drilled and exploited, similar to African child soldiers. They are being brought up to be brutal, even toward their own families. In camps they are trained to beat other children, to crucify them, or to bury them alive if they do not adhere to IS demands. Those who are not sent to fight serve as the emirs’ lackeys or as guards or spies in the villages or camps where Yazidi or other religious minorities are held captive (Kizilhan and Noll-Hussong 2017).
This led to the fact that with the beginning of the genocide on August 3, 2014, the Yazidi remembered not only their own individual and collective traumas, since all without exception were targets of extermination, but also the narrative of the historical traumas of their ancestors.
Through narrative, the genocides from one generation to another connected with fear and insecurity have been passed on via stories, songs, and prayers. As soon as a Yazidi hears the word ferman, or genocide, memories of historical genocides are evoked. It was with this background that the Yazidi experienced the 2014 genocide at the hands of the IS as a continuation of their collective traumatization (Kizilhan 2014; Kreyenbroek and Rashow 2005). These collective experiences, which are part of the collective memory of the Yazidis, must be considered from a political, social, and therapeutic point of view.
Treatment and Care
The treatment regimens for individual, collective, and transgenerational trauma are closely interrelated; indeed, treatment may span generations and requires a culture-sensitive approach (Adorjan et al. 2017). The concept of post-traumatic stress disorder (PTSD) can be applied to all ethnic groups. Yet the different notions of health and/or illness as well as cultural or medical treatment traditions when dealing with traumatic experiences require various concepts or therapeutic modifications (Nasiroglu and Ceri 2016).
A basic requirement is a secure environment in which the person does not feel the threat of persecution or any other danger. Only this sense of security will allow open dialogue regarding their experiences and acceptance of the treatment and therapists. Even the recognition of cognitions, emotions, the definition of self, individual and collective identity, and the way in which disorders manifest themselves (for example, women increasingly complain of headaches), makes conventional treatment difficult, since there is often no concordance with known diagnostic criteria (Summerfield 2001). Women repeatedly report, in great detail, the burden of their ancestors using the word ferman (equivalent to the Holocaust) (Ceri et al. 2016), and they are not able to make the link between this and their own traumatization, which can lead to a lack of understanding and impatience among physicians and therapists (Solomon 1996).
The collective experiences of terror and abuse, part of the collective memory of the Yazidis, difficult as they may be, may (from a psychotherapeutic point of view) help a Yazidi to come to terms with their individual trauma by strengthening their resilience. Resilience strengthening is of great significance for the treatment of terror survivors.
Psychosocial Care in the Kurdistan Region of Iraq
As mentioned above, on account of the disastrous situation in Iraq and Syria, the Baden-Württemberg state government in Germany decided to bring up to one thousand people to the state for treatment. These are people who are in need of protection, above all young women who have been held captive by the IS (Kizilhan and Noll-Hussong 2017). As a medical and psychological head, I examined the survivors and tried with my team to support them in Germany and the Kurdistan Region of Iraq.
There are necessary steps of care after disasters like war and conflicts: before psychosocial interventions are implemented, it is crucial to bring people to safety, care for basic physical needs, and provide medical first aid (Kizilhan 2021). While this is done, the principles of psychological first aid come into play, which encompass protection from further harm, care for basic needs, the opportunity to talk about the events, and guidance toward helpful coping strategies (IASC 2007). While these steps are relevant for most of the affected people in a crisis region, only some of the survivors will develop a stress or trauma-related mental health problem, or experience aggravation of a preexisting condition related to their resilience and individual resources. The development of further mental illness depends on several pre-, peri-, and post-traumatic risk factors (e.g., the kind of trauma experienced). As described above, because of the severe brutality used by the IS, the number of people affected by lasting mental illnesses is high in the KRI. For people who develop trauma-related sequelae, psychological examination and treatment by trained mental health-care experts is necessary.
Aiming to train local specialists in the KRI and create sustainable structures for psychotherapeutic treatment, the Institute for Psychotherapy and Psychotraumatology (IPP) was founded in 2016 with the help of the German government under my coordination and that of Prof. Dr. M. Hautzinger. Subsequently, the master of advanced studies of psychotherapy and psychotraumatology was established.
Since the IPP's opening, three cohorts have successfully completed the master's program, with a fourth cohort completing the program in 2026. In the meantime, several of the previous graduates have been further trained through a “train the trainer” approach, to assume responsibility for teaching and other institute activities in the future and thus ensure sustainability.
In February 2021 the German Clinic for Psychotherapy, an outpatient clinic belonging to the IPP, was established. There are currently eight graduates of the IPP working there as psychotherapists, treating people from the refugee camps as well as from the city. The treatment is free of cost for the patients, as high fees, beside stigma, constitute a barrier to seeking help. A local community member with similar linguistic and ethnic (Yazidi) background from the community has been installed as a first contact to explain services and answer questions about psychotherapy, further reducing fears and stigma. Since the establishment of the institute, more than fifteen hundred patients have been treated with more than thirty thousand therapy sessions.
Conclusions
To what extent psychotherapeutic trauma management is possible also depends on the way societies deal with the topics of sexuality, violence, and transgenerational stress. Alternative approaches to treatment that have an interdisciplinary and culture-sensitive focus, in which psychiatrist and psychotherapist cooperate with other professionals who have a sufficient knowledge of the patients’ cultural imprint and who take this into account, are particularly important. Ethical standards in coping with trauma and restoring justice in post-conflict regions are indispensable to enable long-term peace. The course for social justice can be set through a just health system. Only programs and legal processes that try to do justice to the survivors and take their needs into account are ethically justifiable.
Human rights and health cannot be separated in psychotherapy with survivors of war and terror. On the basis of ethical principles, new approaches must be generated for psychotherapy in war regions and with survivors of war and terror. The aim will be to make an important contribution to the mental and social reconstruction of countries after mass violence.
In this context, we hope that our work will contribute to increasing awareness of mental illness and its consequences and thus increase the acceptance of psychotherapy in the region. At the same time, the project serves as a model that can be emulated and adapted to other world regions affected by violence. The consequences of violent conflicts (PTSD, depression, feelings of anger and revenge, and many more) can make social coexistence difficult and hinder a peace-building process (Stammel et al. 2017). Psychotherapy can help people cope with these feelings in a productive way, thus representing an important contribution to the reduction of war-related suffering, which, if it remains untreated, can lead to transgenerational transmission of trauma. Psychotherapy therefore poses an important contribution to peace building.
