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Issue 1 from P4.Pmd 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. 14 Volume 1, Number 1 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 16 Volume 1, Number 1 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
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