Teaching clinicians working with victims of violence in Iraq
Dr Sameena Akbar 
When I first travelled to Duhok in northern Iraq, I had been invited to teach clinicians working with survivors of ISIS violence.
Many of the people they were supporting had lived through experiences almost impossible to comprehend – captivity, torture, displacement and the loss of family members. Some were survivors of systematic sexual violence. Others had witnessed atrocities or fled their homes with little more than the clothes they were wearing.
The clinicians themselves carried a heavy emotional burden. What they asked for was practical training in trauma-focused cognitive behavioural therapy (CBT) – tools that could help them support people living with the psychological aftermath of war.
In the UK, where I work as a cognitive behavioural psychotherapist and clinical trainer, much of my work involves treating refugees and asylum seekers with post-traumatic stress disorder (PTSD). In northern Iraq, the scale of trauma is particularly stark among the Yazidi community. They were persecuted by ISIS after it took over the region in 2014. Thousands of Yazidis were killed, abducted and enslaved. Many women were subjected to sexual violence and forced captivity, and many survivors continue to live with the psychological consequences years later.
One of the initiatives created to address this need was a master’s-level psychotherapy training programme based at the university in Duhok. The programme was established by a German psychotherapist of Yazidi origin, who recognised that sustainable mental health care required building expertise locally. Rather than relying solely on international aid workers, the aim was to train a new generation of therapists who could support their own communities. My role was to contribute to that programme by delivering training in trauma-focused CBT, including a technique known as imagery rescripting.
For many people with PTSD, traumatic memories do not behave like ordinary memories. Instead, they return as vivid images or flashbacks that make it feel as though the event is happening again. A smell, a sound or a particular situation can suddenly trigger overwhelming fear or shame. Imagery rescripting works by helping people revisit traumatic memories in a safe, carefully structured way. With the support of a therapist, the person gradually reimagines aspects of the memory – introducing safety, protection or escape into the scene. For someone who was powerless during the original event, this process allows the mind to reinterpret what happened. The goal is not to erase the past, but to change how the memory is stored and experienced, so it no longer carries the same emotional intensity.
The science behind imagery rescripting is robust. When we imagine something vividly enough, the brain responds as if it were real. This means that imagining a different ending to a traumatic moment can allow the brain to process the memory in a new way. But this is not simply a matter of telling someone to imagine a happier outcome. That would be preposterous. There is a careful therapeutic process behind it – explaining the science, helping people understand how traumatic memories function, and guiding them step by step through the exercise so that it feels safe rather than overwhelming. When done well, the results can be striking.
This approach has proved particularly meaningful in work with Yazidi women who survived sexual violence and captivity. Some describe feeling physically contaminated by their experiences even years later – as though the violence done to them has somehow remained on or inside their bodies.
The work of Regina Steil in Germany has helped develop imagery-based techniques designed to address exactly these kinds of experiences. Her method – Cognitive Restructuring and Imagery Modification (CRIM) – focuses on helping survivors process traumatic memories while directly challenging the shame and self-blame that so often follow sexual violence.
In practice, this can involve working with the memory itself, helping the person imagine protection arriving, or picturing themselves responding differently or introducing compassion and support into moments where they were previously alone and powerless. Over time, this can fundamentally alter how the memory is experienced. Instead of seeing themselves only through the lens of what was done to them, some women begin to reclaim a sense of dignity and strength. Flashbacks become less intense. Nightmares less frequent. The past remains part of their story, but it no longer dominates their present in the same way.
Imagery rescripting can reduce the grip of traumatic memories and allow women to re-engage with everyday life – relationships, parenting, education and work. One thing I am careful about when talking about trauma and shame is not to frame it as something that belongs only to ‘other’ cultures. It is very easy, from a Western perspective, to assume that stigma around sexual violence is somehow worse in more conservative or religious societies. But that is far too simplistic.
Survivors of sexual violence are shamed everywhere. In our own societies people may question what victims were wearing, whether they had been drinking or why they were in a particular place. The details may differ, but the dynamic is recognisable. What we must avoid is creating a narrative of “us and them”, where we imagine that psychological suffering somehow works differently depending on geography. Every person’s experience is shaped by a complex mix of personal history, family, community and culture.
One of the strengths of CBT is that it focuses on understanding the individual in front of you rather than making sweeping assumptions about groups of people. But the therapy itself is only one part of the picture. What makes this work possible is the dedication of the local psychotherapists delivering it.
Many of the clinicians I taught are themselves members of the communities they serve. Some provide therapy in clinics, community centres or outreach settings. Others work in displacement camps. Sessions may take place in modest conditions with limited resources. There are no specialist trauma centres or large clinical teams. But what these therapists bring is something far more important – cultural understanding, language and the ability to build trust. Trust is particularly important when working with survivors who have experienced such profound violations.
Therapy often begins slowly – conversations about safety, daily routines and ways to manage anxiety. Once a therapeutic relationship has developed clinicians begin trauma-focused techniques such as imagery rescripting. And when they do, it can be transformative. From the outside, the scale of the violence experienced by survivors of ISIS can make psychological recovery seem almost unimaginable. Yet the idea that people are beyond help is simply wrong.
Trauma therapy repeatedly shows that the human mind has an extraordinary capacity to heal. Of course, therapy techniques do not exist in isolation from the cultural and social environments in which they are used. Therapists need to work sensitively within those frameworks while still drawing on evidence-based approaches. This is why building local psychological expertise is so important. Short-term international interventions can be valuable, but long-term recovery depends on training clinicians who understand the language, culture and lived experience of their communities.
Programmes such as the course in Duhok represent an important step in that direction. Trauma-focused CBT is one of the most effective treatments we currently have for post-traumatic stress disorder. Decades of research show that structured psychological therapies can help people process traumatic memories, reduce symptoms such as flashbacks and hypervigilance, and rebuild a sense of control over their lives. But trauma treatment is not only about therapy techniques or individual sessions. It is also about recognising the resilience that already exists within communities affected by violence.
The clinicians I met in Duhok were deeply committed to helping people move beyond survival towards recovery. They wanted to offer more than crisis support. They wanted to create real opportunities for healing. Techniques such as imagery rescripting may sound technical, but in practice they represent something profoundly human – the possibility of helping someone reclaim a story that trauma has taken from them. For survivors of extreme violence, that can be a crucial step in rebuilding their lives. And for those of us working in mental health, it is a reminder that effective therapy is not simply about reducing symptoms. At its best, it is about restoring something trauma can destroy – a sense of safety, dignity and hope.
Dr Sameena Akbar is a Chartered Clinical Psychologist at the Woodfield Trauma Service
