Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

Mental Health Programs In Areas Of Armed Conflict: The Médecins Sans Frontières Counselling Centres In Bosnia-Hercegovina

111 Kaz de Jong, Rolf J. Kleber & VVVesna Puratic

ental health programmes in complex help is stifled by disagreement on the cultural Memergencies are generally accepted as an relevance and effectiveness of different important component of aid work. However, this interventions in emergency mental health is a relatively recent development and there is a programmes. This article, describing the lack of theory-based practice and little analysis establishment of a training programme and of previous interventions upon which effective, counselling centres during a war, and the appropriate and sustainable programmes can be continuation of these programmes six years on, based. This article describes the theoretical provides a strong case in favour of the framework, objectives, implementation and applicability of these programmes. intervention activities of the mental health KKKeeey Wororordsdsds: Emergency care, trauma, programme of Médecins Sans Frontières (MSF) counselling, mental health, Bosnia- in Bosnia-Hercegovina, 1994-1998. Hercegovina, war stress Approximately 10,000 individuals were helped during this time. The aims of the programmes were to provide culturally-appropriate support, Key issues assist in coping with extreme stress, counteract Until recently, aid agencies working in helplessness, and reinforce protective factors. Ten complex emergencies largely focused counselling centres were established where 70 their efforts on physical help, to the local counsellors and supervisors worked after a neglect of behavioral, mental and social training period of three months. Assistance and problems. The delivery of mental health interventions provided by the counsellors ranged care and psycho-social support in from mass psycho-education, training, individual complex emergencies began in the outreach activities to crisis intervention and brief conflict settings of former Yugoslavia and psychotherapeutic treatment – psychological Rwanda in 1994, where a number of structuring, working on (self) control, training agencies established programmes self-help techniques, reconnecting the experiences focusing primarily on the effects of to one’s emotions and discussing the personal (post)traumatic stress. These programmes meaning of traumatic experiences. put the psychological consequences of Despite general acceptance that war may lead to massive man-made violence on the serious mental health problems, the provision of agenda of the international community.

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The implementation of mental health support for those suffering from vio- programmes in complex emergencies is lence. becoming more and more common. This article describes the theoretical Clinical expertise and research findings framework, the objectives, the imple- from psychology, psychiatry and social mentation procedures and the interven- science are increasingly applied in war tion activities of the mental health pro- conditions, refugee settings and situations 2 gramme of Médecins Sans Frontières affected by natural disasters. It is now (MSF) in Bosnia-Hercegovina, 1994- generally accepted that mental health 1998. The various implications of emer- programmes offer a relevant and much gency mental health programmes and needed contribution to the alleviation of their usefulness are addressed in the dis- the suffering of people in war and disaster cussion. stricken areas (e.g. Ajdukovic, 1997). In line with this quickly growing interest key issues require attention. One of these War in former YYYugoslavia issues is whether Western conceptual Before the war, Yugoslavia was a social- frameworks on psychological stress and ist federation in south-east Europe where mental disorders can be transferred to diverse social, economic and ethnic different areas of the world (Kleber, groups lived peacefully together. In Figley & Gersons, 1995; Summerfield, 1991, war started. The reasons behind 1995). A second issue is the striking the war complicated. Among the main scarcity of thorough and theory-based reasons were: economic decline, descriptions of concrete mental health increasing nationalism, disillusionment programmes in war-stricken areas: no with communism and authoritarian thorough examination of these leadership (e.g. Malcolm, 1994; Mooren programmes have been published to & Kleber, 1999). date. Consequently the area of mental health interventions in war stricken areas The Yugoslavian republic of Bosnia- is characterized by many myths, incorrect Hercegovina offered a home to three expectations and invalid criticisms. This major ethnic groups (Croats, Serbs and lack of theory-based practice led the Muslims or Bosnjaks). After the World Health Organisation to define independence wars in Slovenia and mental health as one of the six applied Croatia, it officially acknowledged its research priorities in complex independence on April 6, 1992. Civil emergencies (WHO, 1998). war broke out the next day. During 1992, the Bosnian-Serbs were able to conquer In order to develop sound and a main part of Bosnia-Hercegovina appropriate support programmes, an (Detrez, 1996). At the same time military examination of the central principles and groups of Bosnian Croats fought with the concrete activities of mental health Bosnian Serbs as well as with Muslim interventions in conflict settings is units. relevant. Such an analysis will bring the academic discussion to a practical level For more than three years the capital, and will contribute to appropriate Sarajevo, was besieged by the Bosnian-

15 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

Serb forces. This city of roughly 350,000 sleeping problems. This added additional inhabitants (UNCHR, 1993) became stress to the already overburdened health target for shell fire from the surrounding system. mountains. Moreover, small areas of the A 1994 UNICEF report concluded that town were occupied by the Bosnian-Serb 60% of children in Sarajevo suffered Army. From these areas the town was from traumatic-stress related symptoms. held at gunpoint through sniper fire. Household surveys in Sarajevo Primary resources – food, water, gas and conducted by MSF (Jalovcic & Davids, electricity – were manipulated. Short 1993; Van der Kam, 1993) revealed that cease-fires were often broken by in 9% of households at least one person violations on innocent civilians. needed psychological help that was not After a mortar attack in February 1994 available. It has been estimated that on the Sarajevo market that left 68 more than 700,000 persons in both people dead and many more injured, Bosnia-Hercegovina and Croatia UN troops tried to maintain peace suffered from severe psychic trauma and between the different parties in and a further 700,000 suffered from trauma around the city. After the fall of the responses that would qualify them for Muslim enclaves of Srebrenica and Zepa professional help under peace conditions and another mortar attack on the (Jensen and Kosuta, 1995). Sarajevo market in 1995, the pressure This increased demand for care was not for international interference increased met by the (mental) health services. All and NATO began air strikes. Finally, the health facilities had suffered because of peace agreement of Dayton, Ohio the war. Some institutions were officially put an end to the war at the destroyed, others were under continuous end of 1995. shell or gunfire: medical professionals The 1994 mortar attack in Sarajevo and were killed, had fled the country or were the resulting uneasy UN armistice were employed by the army. Furthermore, the the impetus for increasing the pre-war conditions of the mental health international aid effort. In March 1994, system, dating back to the communistic urgent medical needs in Sarajevo were era, showed deficiencies. It was primarily assessed. As expected, war-related needs focused on hospital care and psycho- accounted for a high increase of medical pharmacological treatment; hardly any problems. At all levels of the health modern outpatient mental health care system medical staff complained about was available. Preventive mental health an increasing workload from the number activities (e.g. psycho-education) and of undiagnosed, non-specific complaints counselling services were scarce. (headaches, stomach problems, generalized body pain etc.). Frustrations Theoretical framework about unsuccessful medical interventions Theoretical framework were expressed. Large numbers of An increase in health care capacity and patients returned regularly to the health knowledge was urgently needed. Health centres. Many expressed psychological authorities and Médecins Sans Frontières complaints such as hyperarousal, jointly agreed to increase primary flashbacks, nightmares, anxiety and mental health care capacity with a focus

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on traumatic stress. Specific knowledge shortage of basic resources. on the provision of mental health care It was essential that the mental health under war conditions was, however, programme both increased individual scarce. Ideas from a perspective of awareness against learned helplessness coping with traumatic stress (Kleber & and stimulated cultural self help and Brom, 1992; Lazarus, 1981) were used protective mechanisms (e.g. De Vries, as a guiding framework. Furthermore, 1996).Crucial within the mental health the programme was developed ad hoc programme were, therefore, not only an from local knowledge and specific advice appeal on individual responsibility and from abroad. The intervention model an ongoing awareness against learned that formed the basis of the programme helplessness, but also the stimulation of is described below. It was based on the cultural self help and community pro- following four central principles. tective mechanisms (e.g. De Vries, 1996). 1. Culturally-appropriate support. Pre-war 2. A perspective of coping with extreme stress. Sarajevo had a rather cosmopolitan and People in war are confronted with many European cultural climate. It was also severe experiences of helplessness and traditionally the furthest outpost of the disruption. Individuals have to adjust to Islamic religion in Europe, and within a series of circumstances that are beyond the population there was a genuine their control and understanding. Mate- tolerance towards different ethnic groups rial belongings are destroyed, friends and and religions. All four major religious family are lost, fundamental assumptions groups were present – Islamic, of control and certainty, as well as basic Orthodox, Christian and Jewish. Most beliefs in the future and in the benevo- inhabitants were only vaguely aware of lence of other people are shattered their ethnic background. The (Janoff-Bulman, 1992; Kleber & Brom, cosmopolitan feeling created through the 1992), often beyond repair. War is not a diversity of people was for a long time singular traumatic event but a whole se- Sarajevo’s pride. Though both envied quence of drastic events and prolonged and regarded as arrogant by other parts hardships. It is a combination of so-called of Bosnia, Sarajevo was a symbol of type I and type II traumas (Terr, 1991). tolerance. With the war came loss of cultural identity, the humiliation of being Research (e.g. Bramsen, 1996) has shown controlled from outside and the that nearly all war victims experience dependency of a divided international intrusive recollections, recurrent night- community undermined the self esteem mares, and sudden feelings of reliving of the inhabitants. The culturally tight the event. These responses are combined networks of families and friends broke with increased arousal, avoidances of down as the exodus of original town stimuli associated with the trauma, and inhabitants and the influx of rural numbing. Through the oscillation be- newcomers drastically changed the tween intrusions and avoidances the in- community of Sarajevo (UNHCR, tegration of the traumatic experience is 1993). The social disintegration realized, as established by cognitive contributed to the high levels of chronic processing models (e.g. Creamer, 1995). and traumatic stress caused by the daily Physical symptoms like headaches, stom- violence, the many losses, and the ach pains and back pains are often part 17 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

of this process, and frequently result in and healthy ways of adapting to extreme visits to the health service. stress. As cognitive theories (e.g. Horowitz, 1986) have explained, the Post-traumatic stress disorder (PTSD) is general processes to integrate the frequently used in connection to traumatic experience should be, in traumatic events. The concept is well- principle, regarded as normal responses. fitted to describe the serious and The mental health programme described prolonged disturbances of individuals in this article was, therefore, not specifi- confronted with major life events. The cally focused on psychopathology. distinctive criteria of PTSD (DSM-IV; APA, 1994) are (1) an extreme stressor, 3. Counteracting helplessness. Adaptation to (2) intrusive and recurrent symptoms, (3) traumatic stress is not an isolated process avoidance and numbing symptoms, (4) (Lazarus, 1981). Many factors influence symptoms of hyperarousal, and (5) that this process in positive (protective factors) symptoms of criteria 2, 3, and 4 should or negative (risk factors) ways. It is the be present at least one month. The interaction between these factors that concept is also included in the determines, together with the traumatic International Classification of Diseases situation itself, the overall outcome of (ICD-10) of the World Health the coping process (McFarlane & Yehuda, Organization (1992). PTSD is strongly 1996). In the case of the inhabitants of associated with dissociation and Sarajevo, risk factors were omnipresent. somatization (McFarlane, Atchinson, Adaptation to stress is facilitated when Rafalowicz & Papay, 1994; Van der Kolk the individual believes he or she is in et al., 1996). control during and after the event However, an analysis of human (Kleber & Brom, 1992). An impression responses to extreme and catastrophic of mastery, whether subjective or not, is experiences solely in terms of PTSD has important (Thompson, 1991). Trapped serious shortcomings. First, not all in a city without the possibility of disorders after traumatic events can be creating a meaningful daily activity described in terms of PTSD – it is not caused feelings of helplessness and the only possible disorder after traumatic frustrations. Daily confrontation with events, even according to the DSM direct or indirect (witnessing, noises, system. Co-morbidity has been found to stories, etc.) violence and its be more prominent in trauma patients consequences (death, graveyards in the than was originally assumed (Kleber, city, destroyed buildings) created a 1997). Secondly, and more important, situation of chronic stress. The longer the it has been found that many people do siege lasted, the more people became not develop mental disorders at all exhausted. Both mental and physical (Kleber & Brom, 1992). Although nearly resources became depleted. The citizens all people confronted with war will suffer often compared the circumstances in from various negative responses (such as Sarajevo with a large concentration camp nightmares, fears, startling reactions and governed from the surrounding hills. The despair), it does not mean that they all citizens felt isolated and abandoned by will develop mental disorders. An em- the outside world. Food and other hu- phasis on PTSD overlooks the normal manitarian aid could not compensate for

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the disbelief that the civilized, interna- communication with others, contact with tional community did not react stronger the media and various forms of advice to the siege of Sarajevo and ethnic and support. cleansing of Bosnian citizens. The mental health programme was, Objectives therefore, concentrated on the enhance- The overall objective of the programme ment of control for the inhabitants of was to provide support for those suffering Sarajevo and to counteract patterns of from war-related mental health learned helplessness (Peterson & difficulties and to prevent severe Seligman, 1983). psychopathology through the 4. Reinforcement of protective factors. The re- establishment of primary mental health silience of people, even in the horren- services. The theoretical framework dous war circumstances in a shattered described above formed the basis for and demolished country, should not be these programmes. underestimated. The personal strengths Selecting and training local counsellors and social resources of people should to help their own people ensured the have a place in mental health pro- cultural relevance of the programme. grammes. The services had to be easily accessible Social cohesion was under severe pres- to everyone in the general population sure in Sarajevo during war. Old social in need (excluding, for instance, networks disappeared but were not re- psychiatric patients who were referred to placed, due to large differences between health centres or hospitals). Counselling urban and rural population. The ongo- centres were established in Sarajevo and ing lack of safety further hampered so- cities in central Bosnia. To increase cial interactions. Restoring social net- output and assure future sustainability works and stimulating social support can these centres were integrated in to the facilitate coping with traumatic stress. existing health care system. The Social networks (Eitinger, 1964; establishment of community based Rachman, 1978) and social support primary mental health care conformed (Davidson, 1984; Maddison & Walker, with existing government plans to reform 1967) play a positive role in health and the health care system from hospital adjustment (Sarason & Sarason, 1985) based care into primary health care. Co- even to the extent of reducing mortality operation with the health authorities associated with stress (Berkman & Syme, helped promote and encourage the 1979). Activities were organized to sup- acceptance of the centres. Furthermore, port the vulnerable, to protect the weak, to assist the general population in their to create a pleasant atmosphere (e.g. win- normal coping process after extreme ter festivals) and to preserve dignity. The stressors psycho-education was organized mental health programme encouraged on individual, group and community the resilience of war-stricken individu- level. Lastly, the protective factors were als and groups, regardless of ethnicity, reinforced through various health care religion or political background, and interventions: crisis intervention, brief raised a voice for these people through counselling therapy, individual and community outreach.

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Implementation traumatic stress. Eleven Dutch experts in psychotrauma, general psychiatry and Following an initial assessment, the MSF clinical psychology volunteered to pro- mental health programme began in 3 vide the training in Sarajevo . March 1994. At that time Sarajevo was besieged for two years. Many people Since knowledge had to be applicable, were at risk of developing war-stress re- the method of ‘learning by doing’ was lated disturbances and a substantial used during the training (Pretty, Guijt, group of citizens already suffered from Scoones & Thompson, 1995; Weinstein, some kind of mental difficulties. 1995). This method was in contrast with the existing culture of giving lectures and 1. Selection of counsellors. Trained counsel- it took time for participants to get used lors should provide primary mental to this form of learning. The curriculum health care to traumatized people. was organized along an explicit Bosnian people of various professional framework; topics were related to stress (teachers, nurses, social workers) and and coping psychology, traumatic stress academic (psychiatrists, clinical psycholo- studies, psychopathology, social gists, general practitioner) fields were psychiatry, counselling skills and specific selected to attend the training course in subjects (e.g. family dynamics). Skills like Sarajevo. The selection of counsellors listening, interviewing, confronting and was based on educational background, structuring were considered to be highly experience and availability. Ethnicity was relevant. During the training both not a selection criterion. trauma experts and participants adapted 2. In-depth training. Training was consid- intervention techniques to the local ered crucial in the project. Since 1994, culture. three intensive courses have been given: The three-month training course was full- two during the seige in Sarajevo (1994, time for those not specialized in mental 1995) and one in central Bosnia (1996). health. Psychiatrists, clinical psycholo- Each training course lasted three months. gists and general practitioners attended In total 100 persons were trained. Of the course three afternoons a week. The these, seventy were employed by MSF mornings were used for teaching and in the counselling centres. The rest were training, the afternoons for group sessions trained at the request of other organisa- (often of a therapeutic nature at the tions. beginning) and practical work. A training The organisation of the course during period within a counselling centre was the siege was extremely difficult. Move- not possible after the first training course. ment both in and out of the city was The two following training courses dangerous due to the hazardous travel included a practical period of three circumstances and the presence of snip- months for participants within existing 4 ers. All course material had to be trans- centres . ported in by MSF staff, consultants and All participants who completed both the trainers. Original plans to involve only training course and the practical period local staff were frustrated by the ‘brain- received an international certificate drain’ as people left the city, coupled with signed by national and international the general absence of knowledge on

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5 health authorities . The certificate was Co-operation with the health authorities recognised by the local authorities as a was crucial; they supported the sign of quality training. An external programme by giving advice, providing evaluation found the curriculum and space, referring patients and enrolling execution of the course to be effective their staff in the training programme. and appropriate (Etherington, 1996). 4. Local capacity building. In the MSF To continue the educational process, counselling centres multidisciplinary weekly group meetings were organized teams were formed, bringing together after the training course. During these specialists such as general practitioners, meetings staff presented cases, discussed clinical psychologists, psychiatrists, and organizational issues, practised professionals such as social workers, counselling techniques and used psycho-pedagogues (teachers with a debriefing techniques to prevent background in educational psychology) secondary traumatization resulting from and psychiatric nurses. their daily work. Training on the job was provided by local consultants, Many specialists, professionals and professional co-ordinators, MSF co- (para-)medical workers had left Sarajevo. ordinators and expert trainers. Employing remaining specialists for our programme could therefore have 3. Establishment of counselling centres. After undermined the regular health system. the first training course (1994) five After discussion with the health counselling centres were established in authorities it was decided to employ different parts of Sarajevo. In 1995, a specialists working in the health system sixth was opened. Counselling centres only after working hours. Since specialists were established in or near existing in Sarajevo work in 24-hour shifts, it was health centres around the city. After the possible to staff all centres with sufficient Dayton peace agreement one centre was specialist supervision. moved to a health centre located in former Bosnian-Serbian territory in Each centre was staffed with one Sarajevo (Vogosca). It primarily received supervisor, one consultant (academic Muslim refugees from the Bosnian-Serb specialist), one team leader and three republic. At the request of the authorities counsellors. Each centre was an the project was extended to Central independent, functional unit responsible Bosnia at the beginning of 1996. In this for implementing the activities and area, populated by Muslims and tailoring them to the needs of the Bosnian-Croats, four counselling centres community. Supervisors were (in the cities of Zenica, Travnik and responsible for the overall professional Vitez) including four mobile teams were quality and daily affairs. Team leaders established. Although the co-operation were in charge in the absence of the su- between Bosnian-Muslims and Bosnian- pervisor. Consultants supervised and Croats was recent and not always self- trained the counsellors. A director bore evident, employees showed great overall responsibility for all the centres. willingness to overcome their past dif- A separate professional coordinator was ferences and to participate. in charge of controlling the quality of the work, supervising the teams, and sup-

21 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

porting counsellors suffering from sec- therapeutic groups in which participants ondary traumatisation. debriefed each other, shared experiences and emotions, gave support and at- The input from foreign experts was kept tempted to integrate their traumatic ex- to a minimum to stimulate local man- periences. All members of the group agement. MSF played a coaching and experienced themselves what they were supportive role. This strategy was cho- going to ask of their clients. The mix of sen to increase self-esteem – building being client, member of a group and something new, running their own busi- helper was beneficial. After three months ness, initiating new activities to help their the group spirit among all participants own people, being responsible for the was strong. These groups continued as daily affairs and the quality of their serv- part of the weekly group meetings. ices. These endeavours would serve as a model for other citizens and authorities. The professional co-ordinator was as- Despite the existing circumstances and signed to give support or organise help the experiences with the communistic for the helpers. Ongoing education system which did not promote self-man- (workshops) and team building activities agement, the principles of a ‘learning proved to be effective in the battle organisation’, such as openness, team against vicarious traumatisation. learning and focus on increasing capac- ity (Senge, 1990; Swieringa & Wierdsma, 1992), were applied in training, daily Interventions and activities management and activities within the A community based mental health pro- centres. To facilitate the local ownership gramme should direct its activities at sev- of the programme and the process of eral levels: the individual, the commu- self-management decisions, both the lo- nity and vulnerable groups. The forms cal management team and the counsel- of assistance provided by the centres lors were encouraged to take their own were manifold. They ranged from psy- decisions, to bear responsibility for mis- cho-education and media sessions to cri- takes made and to create solutions. sis intervention and brief treatment. In Daily project management was handed the period between Autumn 1994 and over to the national staff in May 1995. January 1998 approximately 10,000 in- MSF stayed to provide coaching by ex- dividuals were helped. perts, management support, and finan- 1. Psycho-education of specific groups. Psycho- cial and logistical continuity. This input education is an effective tool to alleviate became more distant over time. In early (post) traumatic stress responses in large 1998, the centres were handed over to numbers of the population and to sup- the developmental aid agency HealthNet port the normal coping process (Brom International. & Kleber, 1989; Herman, 1992; 5. Helping the helpers. Most counsellors had Mitchell & Dyregrov, 1993). The cen- encountered traumatic events themselves tres organized psycho-education sessions during war. Their work also predisposed and psychosocial activities for vulnerable them to secondary traumatisation groups (school children, refugees, eld- (Figley, 1995). During the training course erly, etc.). Ten sessions of basic psycho- this issue was addressed through small education were offered, specific context- 22 Volume 1, Number 1

related issues were raised and basic psy- 3. Training for specific groups. The concepts chosocial needs were addressed. The of traumatic stress were not well known availability of information on war stress among health staff in Sarajevo. provided an incentive for people to Therefore, training programmes were come, express their worries, share their designed for the recognition of traumatic feelings and give each other support. stress, symptoms and disturbances, ways of helping, and possibilities for referral. 2. Psycho-education of the general public. The Training was given to nurses in health aim of psycho-education was to create centres and hospitals, professionals and an environment in which individual specialists working in emergency rooms acknowledgement of war-related and first aid services, and general emotional problems was facilitated. To practitioners. Police officers, fire reach the large group of people suffering fighters, the staff of orphanages, and from war-related stress in the besieged teachers were also trained. cities mass media were used. Radio Bosnia i Hercegovina (radio BiH) 4. Individual outreach. Intervention allowed MSF counsellors to broadcast a programmes for victimized people are programme one hour a week. Radio BiH often of an active or ‘outreach’ nature. was received all over Bosnia (including Many studies into victim support (for Bosnian-Serb and Bosnian-Croat areas). example, Maguire & Corbett, 1987; Van The radio programme was broadcast der Ploeg & Kleijn, 1989) have shown from January 1995 until January 1998. that this kind of health care is useful. A subsequent survey showed that it was Risk groups are better reached in this wellknown among the population of way. Disturbances have been found to Sarajevo. arise especially among victims who The radio programmes explained the would rather avoid (professional) notion of traumatic stress, the normality assistance (Weisaeth, 1989). An outreach of the responses, the various reactions, approach aims to avoid an association the principle of self-help, the provision between assistance and personal of support to others and the possibilities weakness. for professional help. To stimulate The mental health programme provided curiosity and increase direct support the support in various forms: companionship broadcast was formatted as a live, call- with people in similar circumstances, in programme linked to themes for emotional (e.g. talking, activities, specific groups (e.g. internally displaced remarks), cognitive (e.g. advice, informa- persons, widows, elderly, orphans, ex- tion), outspoken acknowledge-ment of soldiers, workers in factories etc.). These what has been suffered, and the devel- specific vulnerable groups of people suf- opment of ceremonies and memorial fering from traumatic stress are easily rituals. The socially withdrawn, the de- forgotten and marginalized (Op den pressed, and the elderly were supported Velde et al., 1993; Scurfield, 1993). through basic social support and coun- Advocacy, acknowledgement of suffering selling. The establishing of links to the and raising awareness for those not able surrounding social network was a high to speak for themselves were important 6 priority in creating sustainable support. components of the radio programme . These outreach activities also provided

23 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

a model for as a sense of togetherness, environment for the client the social sys- compassion and emotional support to tem surrounding the client (e.g. spouse, others in the neighbourhood. family members) was (if possible) also part of the intervention. 5. Crisis intervention. Immediate assistance was available through crisis intervention. Both individual and group treatments This brief intervention consisted of a were offered. Group interventions were basic intake procedure, combined with preferred, especially for the secondary emotional support and some benefits of sharing and providing mutual psychological structuring of the event as support (Grinker & Spiegel, 1945; well as psycho-education. This lasted for Walker, 1981). Treatment of mildly a maximum of three sessions. When help traumatized people lasted approximately was needed for a longer time the formal 10-15 sessions. The period of treatment intake procedure was followed. was kept short for several reasons. The number of people in need was estimated 6. Treatment. After the formal intake to be substantial (Jalovcic & Davids, procedure (including assessment of 1993; Unicef, 1994), so offering long- complaints and registration) clients were term treatment would reduce the overall offered counselling treatment for a number of beneficiaries. Moreover, it limited period. A central element was to has been found that brief therapy facilitate the expression of thoughts and focusing on trauma-related disorders feelings with regard to war experiences. (such as (P/TSD) is effective (Marmar, Telling the story of the event helps Foy, Kagan & Pynoos, 1993). There was victims to integrate the experience into also a practical reason: the professional their own life (Herman, 1992). Narrative level of the staff limited the number of approaches (‘talking cure’) and other treatment sessions to 10-15; most did not forms of expression, such as drawing, have sufficient experience to deal with play and more collective activities the transference and counter-transference (ceremonies and rituals) can facilitate the established during long lasting, intensive integration. Treatment was based on psychotherapy. For similar reasons principles derived from brief trauma- psychotropic drugs were not prescribed focused therapy (Brom, Kleber & in the centres, in spite of the fact that Defares, 1989; Foa, Hearst-Ikeda & the use and prescription of tranquillisers Perry, 1995). The basic components of was widespread in Sarajevo. treatment were: psycho-education (including family members), psychologi- Therapist and co-therapist did the intake cal structuring of experiences, working and follow-up together. The objective of on control, reconnecting experiences to the intake was to receive client data and emotions, working on integration and get the perspective of the client on the future perspective, and self-help problem. To motivate the client infor- techniques. Examples of intervention mation gathering during intake was com- techniques included: relaxation, guided bined with giving emotional support or meditation, guided communication, practical advice. The team discussed, af- systematic desensitisation, and behav- ter the intake procedure, the client’s case. iour prescription. To increase self-help The consultant supervised the difficult and understanding and to create a safe cases. Clients were registered after each

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session. The decision to end treatment themselves and others in their vulner- was evaluated by the team. able existence. On many occasions the local counsellors declared that helping their own people increased feelings of Discussion worthiness and triggered self-esteem. Emergency mental health care is a new The counsellors regarded the programme area in which many key scientific as well as a tool to regain control and to main- as clinical questions remain. It is not a tain self-respect during war. To start in- self-evident intervention and there are vesting in a post-war health system serv- several significant issues related to its ice amidst a seemingly endless war application. In the last section of this showed a strong sense of future perspec- article we discuss the implications of the tive. Through their work activities and implementation of a comprehensive job discipline the counsellors felt a strong counselling programme in a war-stricken ownership of the programme. Often in area. difficult and dangerous circumstances outreach activities were executed. The choice to implement a mental health programme during a war such as the From a practical point of view an early conflict in former Yugoslavia is relevant start of a programme is an anticipation when terror and violence are found to on the difficult and often disappointing be devastating for both communities and post-war situation in which the popula- individuals. Ideally, such a programme tion will have to face and integrate the should already be applied during the horrors of war and to build a new fu- ongoing hostilities (see also Ajdukovic, ture. Some people will need profes- 1997; Butollo, 1996). Moreover, it sional support for this. A system that is should not be based on a limited per- implemented during war is better spective of trauma recovery, nor on rigid equipped to meet post-war challenges. concepts of symptom reduction, as we A serious drawback of many emergency have explained in our theoretical frame- (mental) health programs is the lack of work. reliable information with regard to the Experimental research in psychology has effects of the interventions. What is the shown that some form of disclosure (e.g. precise impact of violence on the popu- talking about the experience) is helpful, lation? Do the interventions really work? mentally as well as physically Of course, it is extremely difficult to con- (Pennebaker, 1995). During war a duct research in war-stricken areas. There mental health programme may prove to are other priorities and there are ethical be instrumental in improving individual arguments – people in need may be coping mechanisms and thus indirectly offended by being seen as interesting re- increase the capacity to survive. search subjects. Nevertheless, there is a growing need for empirical data for On a community level such a pro- scientific reasons and also for policy making. gramme bears the implicit message of worthiness. We observed in our program The absence of monitoring models ap- that the individual counsellors created propriate for the Sarajevo situation cre- through their work a new meaning for ated a serious challenge. A new system had to be created. From 1995 a thor- 25 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

ough monitoring system was imple- aid agency HealthNet International. By mented to register signs and symptoms December 1999 approximately one half of clients of the counselling centres and of the centres had been integrated into the effects of the various interventions. new community-based rehabilitation Standardised questionnaires, such as the centres. It is expected that the other half General Health Questionnaire will be closed or transferred to other or- (Goldberg & Hillier, 1979) and the Im- ganizations that provide specific treat- pact of Event Scale (Horowitz, Wilner ment and training of war-related prob- & Alvarez, 1979) were used, together lems. Appropriately, the Bosnian people with other instruments adapted to the and authorities will decide whether and programme. The extensive monitoring how the mental health care programme system and the collection of data was an will be integrated. acknowledge-ment of the work of the In spite of its popularity and accessibil- counsellors in the besieged areas of ity, the concept of postraumatic stress Bosnia. From the start of the programme disorder (PTSD) should be used with until early 1998 data on approximately care. Many authors and representatives 10,000 people had been collected. of emergency care agencies in former Monitoring tools and preliminary results Yugoslavia have suggested that large are described elsewhere (Kleber, groups of people will suffer from war- Kulenovic, Mooren & Jong, 1999; related PTSD (e.g. Agger, Vuk & Mimica, Mooren, Kleber, Ruvic & Kulenovic, 1995). However, these predictions were 1999). not based on solid research findings. One of the objectives from the onset was There is a danger of equating war stress the integration of the programme in the with post-traumatic stress disorder (e.g. existing health system. Though hesitant Bracken, Giller & Summerfield, 1995, in the beginning, the Bosnian authori- 1997) and for the resulting assumption ties became co-operative and support- that most civilians would suffer from this ive. After the transferral of the day-to- disorder (O‘Brien, 1994). Even so, day management to local people the agencies and nongovernmental counsellors and authorities expressed on organisations involved in emergency many occasions their appreciation for care in Bosnia have often stressed a this sign of respect and the stimulation PTSD perspective on war-related men- of local ownership. Nevertheless, the tal disturbances. This discrepancy is re- formal integration into the post-war markable. It implies at least two rather health system is a slow process with many different conclusions. First, that some uncertainties. Post-war conditions with scientific authors are armchair theorists all the political issues, financial con- are not involved in real and concrete straints and practical problems have fur- mental health care activities in war- ther complicated the speed of integra- stricken areas – it is rather easy to criti- tion. To provide long lasting support for cise large emergency care programmes the programme and secure mental health that are, by definition, not extensively care activities within Bosnia- prepared, but it is quite difficult to pro- Hercegovina, MSF handed over the vide a sound alternative. Second, that mental health project to the development authorities and agencies do not listen to

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critical arguments and only pay atten- psychiatric concepts. The large number tion to seemingly easy explanations. of people visiting the MSF centres is Both arguments are oversimplifications proof of the relevance of the interven- 7 and do not hold true for the programme tion . described in this article. A discussion on the relationship between Trauma is a concept that can appropri- humanitarian aid providers and recipi- ately bridge the gap between the indi- ents should be based on the concept of vidual and the surrounding society respect for the prevailing culture and its (Herman, 1992; Kleber et al., 1995). mental health healing practices and on Trauma threatens the individual’s sense mutual agreement concerning the prob- of self and the predictability of the lems and ways to address them. How- world. Basic beliefs in trust, confidence ever, it is also sensible to set limits. West- and the connectedness with other peo- ern humanitarian ethics, based on the concept of ‘Do No Harm’, should al- ple are shattered (Janoff-Bulman, 1992). low that it is sometimes unavoidable to Helping traumatised people is, in prin- impose foreign concepts. In Bosnia- ciple, a matter of restoring the bond Hercegovina the predominant approach between the individual and the sur- towards mental health was a very tradi- rounding society. This perspective in tional psychiatric one. Adjusting our pro- particular has been used in the mental gramme to this culture would have meant health care activities described in this treating patients by confining them to article. hospital beds and contributing to possi- It is important to avoid imposing psy- ble future drug dependency. An inter- chological and psychiatric concepts that vention based on preventive mental are alien to the culture (e.g. Summerfield, health activities and counselling was pro- 1995). Such a transfer may ultimately be posed, explained and accepted after ex- harmful. Ultimately, however, such cul- tensive discussion. tural sensitivity can lead to doing noth- ing at all. Broadly speaking, any inter- Epilogue vention done by outsiders implicates a meeting and, therefore, confrontation of Few would deny that war may lead to two different cultural worlds. Within this serious mental health problems. Never- meeting, participants exchange opinions, theless, the psychological impact of war views and values. A mutual influence is, experiences has been seriously neglected de facto, always occurring. In this sense in health care and emergency almost all humanitarian aid interventions programmes. The emphasis is on instant are to a certain extent an imposition of medical treatment and assistance. There Western principles upon other cultures. was, and still is, a compelling need to It is important to acknowledge this. The pay more systematic attention to the consideration of one’s own cultural and psychological needs of people in war- ethical influence upon others and a prag- stricken areas (see also De Jong, Ford & matic appreciation of the limitation of Kleber, 1999). this influence in concrete interventions is rational. Within the interventions One of the top priorities for mental described here we have attempted to health or psychosocial programme avoid imposing alien psychological and development is applied research through 27 Intl. J. of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict

careful investigations and evaluations. cial networks, lost resistance, and The starting point, as the World Health mortality: A nine-year follow-up Organization (1998) has proposed, is an study of Alameda county residents. inventory of existing mental health in- American Journal of Epidemiology, (p109- tervention models. Indeed, the extent of 186). the impact of violence on communities Bracken, P.J., Giller, J.E. & Summerfield, and individuals, and the extent of the D. (1995). Psychological responses to effects of special interventions, are cru- war and atrocity: The limitations of cial questions. Only through operational current concepts. Social Science and examinations can these questions be Medicine, 40, (8), (p1073-1082). answered. Findings may also clarify cross-cultural variations and consisten- Bracken, P.J., Giller, J.E. & Summerfield, cies in frequency, symptomatology and D. (1997). Rethinking mental health coping mechanisms (De Girolamo, work with survivors of wartime vio- 1993). lence and refugees. Journal of Refugee Studies, 10, 4, (p431-442). In our experience mental health pro- grammes are commendable. Though Bramsen, I. (1995). The long-term psycho- many people in war and disaster stricken logical adjustment of world war II survivors areas mobilise coping mechanisms by in the Netherlands. Delft: Eburon Press. themselves, some need help. The num- Brom, D., Kleber, R.J. & Defares, P.B. bers may vary depending on risk and (1989). Brief psychotherapy for post- protective factors. The support of adap- traumatic stress disorders. Journal of tation processes, the provision of treat- consulting and clinical psychology, 57, (5), ment to those suffering from severe trau- 607-612. matic stress, and the facilitation of com- munity restoration all carry the implicit Butollo, W.H. (1996). Psychotherapy message that some one cares. This ges- integration for war traumatization: A ture alone may be healing. training project in Central Bosnia. European Psychologist, 1, (p140-146). Creamer, M. (1995). A cognitive process- RRRefefeferererences ing formulation of posttrauma reac- Agger, I., Vuk, S. & Mimica, J. (1995). tions. In: R.J. Kleber, Ch.R. Figley Theory and practice of psychosocial projects & B.P.R. Gersons (Eds.), Beyond trauma: under war conditions in Bosnia-Hercegovina societal and cultural dimensions (p.55-74). and Croatia. Zagreb: ECHO/ECTF. New York: Plenum. Ajdukovic, D. (1997) (Ed.). Trauma recov- Davidson, S. (1984). Human reciproc- ery training: Lessons learned. Zagreb: So- ity among Jewish prisoners of the Nazi ciety for Psychological Assistance. concentration camps (p.555-572). In: Proceedings of the fourth Yad Vashem Inter- APA (1994). Diagnostic and statistical manual national Historical Conference. Jerusalem, of mental disorders. Fourth Edition. Israel: Yad Vashem. Washington, DC: American Psychi- atric Association. De Girolamo, G. (1993). International perspectives in the treatment and Berkman, L.F. & Syme, S.L. (1979). So- prevention of post-traumatic stress 28 Volume 1, Number 1

disorder. In J. Wilson & B. Raphael Horowitz, M.J., Wilner, N. & Alvarez, W. (Eds.), International handbook of traumatic (1979). Impact of event scale: A stress syndromes (p. 935-946). New measure of subjective stress. Psycho- York: Plenum. somatic Medicine, 41, (p.209-218). De Jong, K., Ford, N. & Kleber, R.J. Jalovcic, D. & Davids, A. (1993). Health, (1999). Mental health care for refu- Water and Heating: A Report of a House- gees from Kosovo: The experience of hold Survey (II). Amsterdam: Médecins Médecins sans Frontières. The Lancet, Sans Frontières. 353, (p.1616-1617). Janoff-Bulman, R. (1992). Shattered As- Detrez, R. (1996). De Sloop Van Joegoslavie. sumptions: Towards a New Psychology of Relaas Van Een Boedelscheiding (The Trauma. New York: Free Press. demolition of Yugoslavia. Account of Jensen, S.B. & Kosuta, M. (1995). The the division of an estate). Antwerpen: present state of the mental health system in Hadewijch. the countries of the former Yugoslavia. Ge- Eitinger, L. (1964). Concentration camp sur- neva: WHO. vivors in Norway and Israel. Oslo: Uni- Kleber, R.J. and Brom, D. (1992). Cop- versity Forlaget. ing with trauma: Theory, prevention and Etherington, C. (1996). MSF Evaluation, treatment. Lisse, The Netherlands: Mental Health Program-Sarajevo, BiH (un- Swets & Zeitlinger. published report). Kleber, R.J., Figley, Ch.R. & Gersons, Figley, C.R. (1995) (Ed.). Compassion fa- B.P.R. (1995) (Eds.). Beyond Trauma: tigue. New York: Brunner/Mazel. Cultural and Societal Dimensions. New York: Plenum. Foa, E.B., Hearst-Ikeda, D. & Perry, K.J. (1995). Evaluation of a brief cogni- Kleber, R.J. (1997). Psychobiology and tive behavioral programme for the clinical management of post-trau- prevention of chronic PTSD in re- matic stress disorder. In: J.A. den Boer cent assault victims. Journal of Consult- (Ed.), Clinical management of anxiety: ing and Clinical Psychology, 63, (p.948- Theory and practical applications (pp. 295- 319). New York: Marcel Dekker Inc. 955). Kleber, R.J., Kulenovic, S., Mooren, Goldberg, D.P. & Hillier, V.F. (1979). A G.T.M. & Jong, K. de (1999). The scaled version of the General Health impact of a mental health program in Bosnia- Questionnaire. Psychological Medicine, Hercegovina: Interventions and evaluations. 24, (p.18-26). Paper presented at the Sixth Euro- Grinker, R., Spiegel, J. (1945). Men un- pean Conference on Traumatic Stress, der stress. New York: McGrawHill. European Society for Traumatic Stress Studies, Istanbul, June 6-8. Herman, J.L. (1992). Trauma and recovery. New York: Basic Books. Lazarus, R.S. (1981). The stress and cop- ing paradigm. In C. Eisdorfer, D. Horowitz, M.J. (1986). Stress response syn- Cohen, A. Kleinman & P. Maxim dromes. San Francisco: Jossey-Bass (Eds.), Models for clinical psychopathology (Second Edition). (pp. 177-214). New York: Spectrum.

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Maddison, D.C. & Walker, W.L. (1967). O‘Brien (1994). What will be the psy- Factors affecting the outcome of con- chiatric consequences of the war in jugal bereavement. British Journal of Bosnia. British Journal of Psychiatry, Psychiatry, 113, 1057-1067. 164, 443-447. Maguire, M. & Corbett, C. (1987) The Op den Velde, W., Falger, R.R.J., effects of crime and the work of victim sup- Hovens, E.H., De Groen, J.H.M., port schemes. Aldershot: Gower. Lasschuit, L.J.L., Van Duin, H. & Malcolm, N. (1994). Bosnia: A short his- Schouten, E.G.W. (1993) In: J.P. tory. London: Papermac. Wilson & B. Raphael (Eds), Interna- tional handbook of traumatic stress syndromes Marmar, C.R., Foy, D., Kagan, B. & (pp. 219-230). New York: Plenum Pynoos, R.S. (1993). An integrated Press. approach for treating post-traumatic stress. American Psychiatric Press Review Pennebaker, J.W. (Ed.) (1995). Emotion, of Psychiatry, 12, (p.239-272). disclosure and health. Washington, D.C: American Psychological Association McFarlane, A.C. & Yehuda, R. (1996). Resilience, vulnerability, and the Peterson, C. & Seligman, M.E.P. (1983) course of posttraumatic reactions. In: Learned Helplessness and Victimiza- B. van der Kolk, A.C. McFarlane & tion. Journal of Social Issues, 39,(2), L. Weisaeth (Eds.), Traumatic stress (pp. 103-116. 155-181). New York: Guilford Press. Pretty, J.N., Guijt, I., Scoones, I. & Mitchell, J. & Dyregrov, A. (1993). Trau- Thompson, J. (1995). A trainer’s guide matic stress in disasters workers and for participatory learning and action. Lon- emergency personel: prevention and don: International Institute for Envi- intervention. In: J.P. Wilson & B. ronment and Development. Raphael (Eds.), International handbook of Rachman, S.J. (1978). Fear and courage. San traumatic stress syndromes (pp. 905-914). New York: Plenum. Francisco: Freeman. Mooren, G.T.M. & Kleber, R.J. (1999). Sarason, I.G. & Sarason, B.R. (Eds) War, trauma, and society: Conse- (1985). Social support: Theory, research and quences of the disintegration of applications. Dordrecht: Martinus former Yugoslavia. In: K. Nader, N. Nijhoff Publishers. Dubrow & B. Hudnall Stamm (Eds.), Scurfield, R.M. (1993). Posttraumatic Honoring differences: Cultural issues in the stress disorder in Vietnam veterans. treatment of trauma and loss (pp. 178- In: J.P Wilson & B. Raphael (Eds), 210). Philadelphia: Brunner/Mazel. International Handbook of Traumatic Stress Mooren, G.T.M., Kleber, R.J., Ruvic, J. Syndromes. New York: Plenum. & Kulenovic, S. (1999). Coping with Senge, P.M. (1990). The fifth discipline: war, loss and migration in survivors of the The art and practise of the learning organi- war in Bosnia-Hercegovina. Paper pre- sation. Doubleday, England sented at the Sixth European Con- ference on Traumatic Stress, Euro- Summerfield, D. (1995). Addressing pean Society for Traumatic Stress human response to war and atrocity: Studies, Istanbul, June 6-8. Major challenges in research and

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practices and the limitations of west- Walker, J.I. (1981). Group therapy with ern psychiatric models. In: R.J. Vietnam Veterans. International Journal Kleber, Ch.R. Figley & B.P.R. of Group Psychotherapy, 31, 379-389. Gersons (eds.), Beyond trauma: Societal and cultural dimensions (pp.17-30). New Weinstein, (1995). Action Learning: A jour- York: Plenum. ney in discovery and development. London: HarperCollins. Swieringa, J. & Wierdsma, A. (1992). Becoming a learning organisation: Beyond the Weisaeth, L. (1989). Importance of high learning curve. Wokinham, England: response rates in traumatic stress re- Addison-Wesley Publishers. search. Acta Psychiatrica Scandinavica, Terr, L. C. (1991). Childhood traumas: 80, 131-137. An outline and overview. American WHO (1992). International Classification of Journal of Psychiatry, 148, 10-20. Diseases (Tenth Revision: ICD-10). United Nations High Commissioner for Geneva, Switzerland: World Health Refugees (1993). Informational notes on Organization. former Yugoslavia. New York: UNHCR, WHO (1998). Consultation on applied health August. research priorities in complex emergencies. UNICEF (1994). A UNICEF report on war Geneva: World Health Organisation, trauma among children in Sarajevo. Zagreb: Division of Emergency and Humani- Division of Emergency Operations in tarian Action. Former Yugoslavia, UNICEF. 1 The project described in this article has Van der Kam, S. (1993). Report of a house- been supported by grants from the Min- hold survey in Sarajevo. Amsterdam: istry for Foreign Affairs of the Nether- Médecins Sans Frontières. lands, the European Community and Van der Kolk, B.A., Pelcovitz, D., Roth, Médecins Sans Frontières Holland. A. S., Mandel, F.S., McFarlane, A.C. & Richters and A. Pen carried out the first Herman, J.L. (1996). Dissociation, assessments for this programme and were somatization, and affect instrumental in its development. Team- dysregulation: The complexity of work has been essential in this pro- adaptation to trauma. American Jour- gramme. The authors would like to thank nal of Psychiatry, 153, Festschrift Sup- all counsellors, supervisors, staff mem- plement. bers and trainers in this project. 2 Van der Ploeg, H.M. & Kleijn, W.C. Médecins Sans Frontières is an inde- (1989). Being held hostage in The pendent humanitarian organization Netherlands: A study of long-term dedicated to providing medical support after effects, Journal of Traumatic Stress, to populations in health crises. 2, 153-171. 3 These experts were: H. van Berkestijn, Vries, M.W. de (1996). Trauma in cul- R. de Boer, E. Bonsel, M. Diekman, R. tural perspective. In: B.A. van der Kleber, F. Lamers, C. Mittendorff, Y. Kolk, A.C. McFarlane & L. Weisaeth Mulder, T. Mooren, A. Pen, A. Richters (Eds.), Traumatic stress, the overwhelming and G. van der Veer. experience on mind, body and society. New York: Guilford Press.

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4 The level and duration of training de- pend on the extent of existing knowl- edge and expertise amongst local staff, the needs of target population and the phase a crisis may have reached. For in- stance, in other emergency settings such as Macedonia (de Jong et al. 1999), Si- erra Leone (de Jong et al. 2000), Tajikistan and Lebanon crash courses were held of varying length ranging from several days to two months. 5 The Director of the National Public Health Institute Bosnia-Hercegovina, the Director of the Netherlands School for Public health, the Dean of the Medical Faculty, University of Sarajevo, and the Chairman of the Department of Clini- cal & Health Psychology, Utrecht Uni- versity, The Netherlands. 6 Advocacy is not restricted to human rights abuses only. In the Sierra Leone emergency programme staff contributed more directly to the reduction of human suffering through advocacy for basic re- sources required for making food, clean water and shelter. In Sri Lanka it was Kaz de Jong, psychologist, is mental health possible to prevent further traumatisa- advisor of Médecins Sans Frontières tion through advocacy for rights of mi- Holland and was formerly coordinator of nority groups. their counselling centres in Bosnia- 7 Hercegovina. Our other interventions in non-west- ern settings such as Lebanon, Sierra Rolf Kleber, psychologist, is professor of Leone, Indonesia, Colombia and psychotraumatology at Tilburg and Utrecht Tajikistan taught us to balance our west- Universities, The Netherlands, and head ern MSF perspectives with the explana- research of the Institute for Psychotrauma. tory models and language used by ben- Vesna Puratic was coordinator of the eficiaries. It is our experience that na- Médecins Sans Frontières mental health tional staff are well able to act as cross- project in Sarajevo between 1994 and cultural translators and negotiators when 1998 and is now working for HealthNet given the opportunity to do so. International, Sarajevo. Address of correspondence: Prof.dr. R.J. Kleber, Department of Clinical Psychology, Utrecht University, Heidelberglaan 1, 3584 CS Utrecht, The Netherlands.

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