Human Rights Committee of AFTA sponsors collaboration between Kosova and US mental health professionals: Kosovar Family Professional Education Collaborative (KFPEC)

By Corky Becker, John Sargent, and John Rolland

History

The history of Kosova is long and complex. Though Serbians have long referred to this territory as Kosovo, we use the word Kosova, honoring the language of the Kosovars, the Albanians who live there and who, in the years prior to 1999, accounted for ninety percent of the population. Albanians are descended from the Illyrian people who migrated to the Southwest Balkan region before 1000 AD. Serbs, who are Slavs, also migrated into the Balkans at about the same time. The Serbs distingush themselves from Croats (who are also Slavs) through their connection to the Orthodox Eastern Church and their use of the Cyrillic rather than Roman alphabet. Kosova has been considered by Serbs to be the heart of Old Serbia, harkening back to the height of Serbia's glory in Kosova from the year 1159 until its defeat by the Ottoman Turks in 1389. The Ottoman Empire ruled Kosova, and much of the rest of the Balkan region, for over 500 years following the Battle of Kosova in 1389. By 1459, Serbia was reduced to vassal status, completely overrun by the Ottomans. Kosovo became the symbol of the Serbian quest for nationhood. Under Turkish rule, Islam became the predominant religion of Albania. Serbians, however, remained Eastern Orthodox.

Following the fall of the Ottoman Empire in 1912, Kosova became part of Yugoslavia. This country experienced severe conflict, hardship and violence during World War II. Following the War, Tito (who had led the Communist Partisans during the war) assumed leadership of all Yugoslavia. He created several somewhat autonomous regions under his control, of which Kosova was one. Kosova was established as an Albanian region, under the jurisdiction of Serbia, an attempt to appease both Albanians and Serbs.

From 1945 through 1989, Kosovar Albanians experienced the same access to education, employment, and political power available to all in Yugoslavia. After a huge Serbian rally in 1989, on the fields where the Turks defeated the Serbs in 1389, Milosevic declared that Serbs would rule Kosova. Serbian authority became quickly and firmly established, and the free access to education, work, and political power that the Albanian Kosovars had previously enjoyed was first limited, then prevented, a de facto situation of apartheid.

This continued over the next ten years and fostered the growth of the Kosova Liberation Army, which sought to return human rights to the Kosovars. In 1998 and early 1999, the Serbian Army and paramilitary pursued a strategy of ethnic cleansing against Kosovar Albanians aimed at removing them from their homes and from the region. This strategy included selected massacres and executions, burning and looting homes and driving the population from the region and across the borders into Albania and Macedonia.

The goal of this strategy was to create the experience of terror in the Kosovar Albanians at the idea of returning to their homes. The US and Europe decided to intervene in April 1999; NATO air strikes precipitated the withdrawal of the Serbian Army from the region. Many Kosovar Albanians returned to Kosova. Many Kosovar refugees have been displaced from their villages to the city of Pristina, where some live in Serbian evacuated apartments. Some refugees are in temporary shelters in the towns throughout Kosova. Many people wait for their homes to be rebuilt. Some have no hope to return to their homes because of the destruction to their villages.

A United Nations protectorate currently governs Kosova, and NATO ground forces maintain peace. Serbian leaders including Milosevic have been indicted as international war criminals and remain at large and in power in Serbia. The future for Kosova and the Kosovar Albanians remains uncertain.

Report on Collaborative Project

During AFTA's annual meeting, the Human Rights Forum heard a presentation from Corky Becker, John Sargent and John Rolland about the Kosovar Family Professional Education Collaborative (KFPEC). The Collaborative is an initiative of Stevan Weine, MD from the University of Illinois-Chicago, and John Rolland, MD, at the Chicago Center for Family Health, which is affiliated with the University of Chicago. They have collaborated on a major grant from the National Institute of Mental Health as part of their effort to support research into the mental health consequences of torture. The projects, CAFES & TAFES: offer family education and support for the Bosnian and Kosovar refugee families in Chicago. The project is unique in its use of trained paraprofessional group facilitators to lead multi-family groups with Bosnian and Kosovar refugee families. Stevan Weine approached Ferid Agani, MD, Associate Director of Clinical Services at the University of Prishtina and Mental Health Assistant to the WHO, to propose collaboration between a group of mental health professionals from Kosova and the United States. The emphasis of this collaboration is to bring resilience-based family-focused education and training to the psychiatrists and other mental health and health professionals in Prishtina, to make a long-term commitment to collaboration, which involves training and writing, and to do this with the support of several university sponsors. The goal of the collaboration is to bring strength and resilience-based family therapy to Kosova. We hope to understand the strengths and challenges of the Kosova family, to tell the story of their struggles, and to foster professional training and clinical practices that draw from their strengths and cohesion.

The three co-leaders of the KFPEC are Ferid Agani MD, Stevan M. Weine MD, and John Rolland MD. The overall aim of this project is to enhance the capacities of Kosovar professionals to draw upon the existing and untapped strengths and resources of Kosovar families to better address their mental health and health service needs in the wake of trauma and loss. The Project has the following aims:

1. To strengthen our collaboration with professionals and paraprofessionals in Kosova.
2. To build professionals and paraprofessionals knowledge and technical expertise in the general area of family through seminars, workshops, and visits to homes and communities, using a resilience-based family approach throughout
3. To provide advanced more intensive training in specific family interventions with smaller groups of identified professionals and para-professionals in Kosova.
4. To evaluate the impact of training and participation in this collaborative effort from Kosovar and international perspectives and to use that data as a basis for articulating a model of education in international family work.
5. To disseminate information. The Kosovar professionals will write reports on family topics for distribution in Kosova. The American professionals will write a training manual for local professionals who are working with widespread family trauma; this manual will describe a model of education that can be adapted to other settings and cultures coping with trauma and loss. Currently, no such manual has ever been produced.

The first visit one week visit took place between April 29 to May 8, 2000, with a team of five AFTA members including John Rolland, MD, John Sargent, MD, Director of Research and Education at the Menninger Clinic, James Griffith, MD, director of psychiatry residency training at George Washington University, Jack Saul, PhD, director of the International Trauma Program at New York University, Corky Becker, PhD, faculty at the Family Institute of Cambridge and a founding associate at the Public Conversations Project, and our non AFTA colleague, Stevan Weine, MD. Van Griffith was also an important member of our team. He was involved with every aspect of the trip.

Our visit was characterized by sharp contrasts. All our Kosovar colleagues and the many families we met treated us with utmost warmth and appreciation. At the same time, the devastation we encountered was staggering. There are over 250,000 families in need, and currently, only twenty psychiatrists and three psychologists available to serve the entire population. Health and mental health professionals have until this point been dealing with the many NGO organizations with very mixed feelings and results. As surprising as this may seem, we are the first professional-to-professional organizational collaboration they have engaged in. We can not underscore enough the importance of this to them, as well as that of making an ongoing commitment. We came to see more fully how this project is consistent with the UN Declaration of Human Rights, which affirms that all people have a right to health and mental health care. More than that, in order to make this project happen, we've had to become an actual, organized, collaborative international team with our Kosovar colleagues, and do so while listening to and respecting the most pressing needs of Kosovar colleagues and families. We have begun to understand more fully our role in the context of the overall long-term goal - the development or reform of health and mental health services in Kosova. The centrality of the Kosovar family in all aspects of life in Kosovar culture affirms the importance of the family as the unit of care, and signals a real opportunity for our collaborative to play a significant role in professional training and services development. Also, too often international groups (especially NGOs) make an initial effort, but fail to make an ongoing commitment that is essential for a project to take hold and be successful over the long-term. All involved agree that this will be approached as a multi-year project in order to succeed. We spent three days on site visits, three days of training (including lectures with Kosovar colleagues). We spent two days doing workshops centered on live family interviews, with discussion and collaboration with Kosovar psychiatry faculty residents, interns and other interested health professionals. While we were there, we had very successful meetings with the President of their Academy of Arts and Sciences, the University President and Dean of the Medical School, and the Mental Health Coordinator for WHO in Kosova. They are in full support of this collaborative project and will be facilitative of our efforts. There was a preliminary discussion of the University of Prishtina, the Academy of Arts and Sciences, and KFPEC sponsoring a multi-disciplinary conference on the Kosovar family in Kosova within the next one to two years.

We had daily collaborative leadership group meetings to plan training and writing activities for the coming year. The writing group met every day to begin a writing project, including a paper written for local news publication, and the beginning of a paper for international publication.

The collaborative leadership group included the six of us, and twelve Kosovar colleagues. We divided into two groups, one to discuss, develop, and implement a plan for the initial phase of training over the next year, and one to develop, implement, and oversee writing projects. Each of these groups met for one hour a day, and collectively for an afternoon at the end of our visit. The Training Group, which included John Sargent, John Rolland, and Jack Saul, developed the following plan. Based on the training needs, we decided that the next four training visits would have the following foci with issues of trauma addressed throughout:

1. Family Assessment and Treatment Planning
2. Brief Treatment Models and Techniques
3. Family Intervention: Child and Adolescent Mental Health, Issues of Substance Abuse
4. Family Intervention: Chronic Mental and Physical Illness, Multiple Family Discussion Groups

Our Kosovar colleagues decided to form two core training groups, each with six members and six "assistants," that would meet weekly for one and a half hours to discuss some core readings we brought for translation, have a family case presentation, follow-up on previously discussed cases, and reflect on personal reactions to doing family-based work. The two groups made plans to meet together on a monthly basis for a case presentation and discussion. Each group appointed a leader who would communicate with a counterpart from our team (John R. and Jack S.) on a bi-weekly basis by e-mail or phone. These groups have been meeting since our visit.

The writing group met four times. In the first meeting we agreed to write a short piece to be published in a newsletter to introduce our project in Kosova. The foci of our concerns were: "What is the strength of the Kosovar family? Why should we care about the family? As health professionals how can we be useful to families?"

During the last meeting we planned the writing that the group would do over the next few months. James Griffith and Shqipe Ukshini from Kosova will write up their cases, and will meet with their teams to discuss their writing. They will send the writing to the other team to be discussed. Two people from each team will write a response to the other's team's writing. The two responses will concern a question, which raises cultural or theoretical issues. The result will be two additional perspectives on each case. Each team will read and discuss the case and commentaries of the other team to create a final draft for publication in an international journal. This piece will be the first published article written about the Kosovar family by collaboration between US and Kosovar professionals.

The Kosovar therapists' view of the Kosovar family is that for hundreds of years up to the present, Kosovar families have been known for their strength and cohesion. They sustain strength under the harshest conditions by drawing upon traditional cultural values of closeness, warmth, understanding, and love expressed within each family. In Kosovar families, all members of the family have an important role. Men protect and provide for the family, interfacing with the world outside the family. The women provide emotional and physical care and support for the family, taking care of the world inside the family. Everyone has an important place in their children's lives, and each child develops a strong identity and value system. Even under the harshest conditions, the family system usually remains structured and predictable, offering some counter-balance for external chaos and unpredictability The following are three separate pieces written by three people from the writing group. The members of the writing group include: Zana Dobrishi, Shqipe Ukshini, Mimoza Shahini, James Griffith, Jusef Ulaj, Corky Becker, Valdet Bajraktari, Van Griffith, and Steve Weine

Everyone in the G. Kosovar family has a place. Everyone belongs to the family and to the family's homeland, alive or dead, here or abroad. Everyone matters, and everyone is counted and counted on. Everyone knows where each person is and what each person is doing. When cooking or planting everyone moves together fluidly in a complementary pattern, each person picking up what the previous person left off. An organic whole is created by each person's willing participation in the predictable, traditional work of living. A hidden treasure in the family is their adaptability to who fills in each of the absented roles. Although the grief about loss is immeasurable, the ability to fill in the roles that are vacated by loss and change are remarkable.

When the men in the village were blocked from employment in 1990 by the Serbian sanctions against Albanian men working, sons and fathers went to Germany to work, sending money home to provide for their families. Without this work the family would have had no income. When the mother of the two small children was unable to care for them because of a brain injury, the husband's mother provided love and attention for her son's children. When Albanian children were not allowed to go to school the grandmother educated and played with the children. "The woman is the umbrella for the family," the uncle told us. "The Albanian woman is the one who takes care of the family and the children. This is sacred." Women are able to provide "emotional and physical support" because of the tremendous respect and appreciation of the men who protect and provide for them. This division of roles and clarity about expectations has helped the Kosovar people survive centuries of discrimination and oppression. The hidden resource is the adaptability in the face of loss, displacement and assault. The capacity to shift roles when tragedy demands change and continue the work of the family demonstrates a hidden resource: flexibility and adaptability in the face of dramatic change from displacement, attack and tragic loss. The knowledge of belonging to each other and the land has helped them survive. Without a sense of place, belonging and family we are all threatened. With the ability to shift who fills important prescribed roles there is remarkable survival in dire circumstances.

In another family, a mother had listened to the gunshots as her husband, two sons, and two grandsons were murdered in the yard of their farm home. Now she and her surviving family members talked with us in their home. "What has kept your family strong?" the interviewer asked. The surviving son in the family responded, "We are all believers. One of the strengths of our family is from God. . . . Having something to believe has helped very much."

"What do you do to keep faith strong?" the interviewer asked.

"I see my mother as the "spring of strength," he responded. "To see someone who has lost five family members- it gives us strength just to see her. We must think about the future and what we can accomplish. This is what keeps us strong. What will happen to him (pointing to his five year old nephew) if I am not here? If he sees me strong, he will be strong. If I am weak, he will become weaker than me."

"What do you hope your nephew will learn about the family as he grows up?" the interviewer asked.

"The moment when he will be independent and helping others and the family- for him, it will be like seeing his father and grandfather and uncles alive again."

In the face of horror and loss, this family had found strength and resilience in its relationships and a shared commitment to their children.

In a third family, a mother had lost two sons and two daughters, together with her husband, in a massacre. To this day, their bodies have not been found. Only a sign exists where they are not yet buried. When first meeting with the surviving family members, the Kosovar psychologist remembered thinking: "For the world this war is finished, but in the souls of its victims it continues. For them, there is just one time- the past. For them, there is no future. It is expressed in their eyes, their faces, and their postures." During family meetings, the mother-in-law began expressing her sense of responsibility as grandmother for keeping the family going. The mother-in-law and aunts began to show more interest and closeness toward their daughter-in-laws' children. Their common strength was care for the children and their love for their lost loved ones. Understanding and care among the women increased, as family roles and obligations were reasserted.

We have only begun to learn about Kosovar families. We look forward to learning more with our Kosovar colleagues about how to bring practical family-based skills to Kosova.

Corky Becker, PhD is on the faculty of the Family Institute of Cambridge, a senior associate of the Public Conversations Projects, and a consultant to the Harvard Law School course on negotiation. She consults and teaches family therapy and dialogue. She has a private practice in Watertown, Ma.

John Sargent, MD is a child and adolescent psychiatrist and family therapist and is the Pfeiffer/Adams Professor of Psychiatry and the Director of Education and Research at the Menninger Clinic. He also is the Deputy Director of the Eastern European Child Abuse Prevention and Treatment Project sponsored by the Childer's Mental Health Alliance and the Soros Foundation. This project has included extensive teaching and program development in Eastern Europe, the Balkans and the Former Soviet Union.

John Rolland, MD, current Chair of the AFTA Human Rights Committee, is Professor of Psychiatry and co-director of the Center for Family Health at the University of Chicago and its affiliated post-graduate family therapy training institute, the Chicago Center for Family Health.