Human Rights Forum

By John Rolland, James Griffith, Corky Becker, and Ellen Pulleyblank-Coffey

This year's forum was devoted to discussion and dialogue about AFTA's central involvement in the Kosovar Family Professional Educational Collaborative (KFPEC). Seven team members presented an overview and recent developments of the project. To bring the experience more vividly to life, we included a slide presentation (James Griffith) and excerpts of a video done by Jack Saul during a recent visit. The discussion was lively, with a lot of excitement and enthusiasm for the development of the project and AFTA's role in it. Also, many attendees shared their own experiences working with trauma and loss in the Americas and other area worldwide.

 The KFPEC is a partnership between American university and professional organizations and mental health clinicians at the University of Prishtina School of Medicine. The KFPEC has sought to counter the effects of genocide and ethnic culturecide by strengthening protective family processes. Rather than provide direct mental health services, it has bolstered the clinical competence of Kosovar mental health professionals in conducting family-centered, community-based, resilience-focused consultations and therapies. This partnership seeks to build a Kosovar mental health system with the family as the key unit for mental health treatment. In this project, AFTA is collaborating with the University of Prishtina, the Center on Genocide, Psychiatry, and Witnessing at the University of Illinois at Chicago, the University of Chicago affiliated Chicago Center for Family Health, and the International Trauma Studies Program of New York University.

Kosova is a land approximately the size of Kentucky, with 1.8 million people, of whom 95% are Kosovar Albanian and 5% are Serbian in ethnicity. The problems faced by its families are multi-fold. A 1999 study by the Centers for Disease Control and Prevention found that 62% of Albanian Kosovars had near encounters with death during the war, and 67% were at some point deprived of food and water (Cardozo et al: JAMA 284:569—578, 2000). 82% fled their homes, most to other countries, and over half witnessed murders or knew someone who was killed. The prevalence rate for Post-Traumatic Disorder was 17%, with high rates of anxiety and somatic symptoms. Beyond these traditional measures, the impact on families throughout the region is monumental. However, there was a paucity of mental health clinicians and resources available to respond to the widespread trauma and loss. The former Yugoslavian government had never developed adequate educational and medical systems, and the Milosovic Serbian government had dismissed Albanian physicians and medical students from the healthcare system in 1992. At the end of the war, there were only 15 psychiatrists, 5 psychologists, and no psychiatric nurses or social workers in Kosova. No psychiatric beds for the chronically mentally ill were located in the country. No outpatient psychiatric services or community mental health system existed.

Dozens of NGOs initiated humanitarian relief, including mental health services, in Kosova following the war. However, the efforts of the KFPEC have been distinguished from other relief efforts by three salient aspects:

1. Focus on Families— We have aided mental health professionals and primary care physicians in gaining the knowledge and skills needed to engage the family as the basic unit for health services. In collaboration with our Kosovar colleagues, methods for family interviewing, assessment, and treatment have been developed for problems that Kosovar families are facing in the context of genocide and loss. Most NGO aid programs there have not defined, conceptualized, or operationalized a family approach to mental health services in any meaningful way.

2. Focus on Resilience— This clinical work builds upon the strengths, skills, and practical wisdom of Kosovar families, rather than diagnosing and treating psychopathology. Mental health training provided by aid organizations has focused primarily upon diagnosing and treating post-traumatic symptoms of individuals.

3. An Educational Collaboration—Our partnership with Kosovar professionals is organized for each administrative, clinical, teaching, and writing activity to be conducted jointly by paired Kosovar and American colleagues. Workshop topics, teaching priorities, and timing of visits are set by the Kosovars. Kosovar and American professionals are developing long-term collegial relationships with international presentations, jointly-authored publications in professional journals, and eventual publication of a clinical text to guide clinicians working with Kosovar families. In contrast, most mental health training by aid organizations has sought to teach American clinical methods to the Kosovars in a top-down fashion.

An important measure of success for the KFPEC has been its extensive engagement of the Kosovar community of mental health clinicians, including its national leadership. Dr. Ferid Agani, co-director of the KFPEC, has recently been named Commissioner of Mental Health and will soon direct the establishment of the new community mental health system. Broadly defined, there are approximately 55 Kosovar mental health professionals and para-professionals. Our didactic lectures at the medical school have attracted as many as 70 attendees at times. After the initial on-site consultation by the AFTA team, 30 psychiatrists, psychologists, primary care physicians, and nurses continued to meet weekly for the following four months, discussing cases and studying family therapy literature together, in preparation for the next visit by the Americans. These clinicians were organized into 16 teams that conducted family-based therapies. By the end of the first year of the project, a core group of approximately 30 clinicians was continuing to meet weekly. Some psychiatry residents have conducted therapies with clinical supervision via the Internet with American faculty. The growing clinical competence and morale of these Kosovar clinicians has been broadly evident from one visit to the next.

How has the AFTA contribution been most helpful? Much has been accomplished by the Kosovars as they gain the skills for working with families in a resilience approach. We have influenced Kosovar clinicians to study how strengths of Kosovar families and culture can be tapped to repair destructive sequelae from ethnic violence. Importantly, we have been able to support Kosovar professionals who were demoralized and overwhelmed at the end of the 1999 war, by witnessing their clinical work, acknowledging the difficulty of its challenges, illuminating its heroic dimensions, and fostering relationships through which the Kosovars can engage in the international professional community. Hopefully, this model of professional collaboration developed in Kosova will be one that can help American mental health professionals establish effective partnerships with mental health educators and clinicians in other third world countries.

 The project has continued to grow and flourish. We have achieved the goals we developed fifteen months ago, prior to the first visit. As originally planned, five teams have been to Kosova. Everyone from the initial team has returned once or twice, and a total of twelve AFTA members plus Steve Weine and Van Griffith will have participated in the visits by the upcoming sixth visit in early September (Jane Ariel, Corky Becker, James Griffith, Melissa Griffith, Judith Landau, Mabs Mango, Ellen Pulleyblank-Coffey, John Rolland, John Sargent, Jack Saul, Carlos Sluzki, Kaethe Weingarten). At this point, we are still waiting for a final decision regarding our three-year proposal from the Joint Distribution Committee, which has a long history as a major Jewish funder of relief organizations. This proposal would advance and expand the current project through the development of community-based mental health and preventive services. The proposal highlights a resilience-based family approach that draws on the strengths and culture of the Kosovar family. As part of our collaboration, we have come to understand that a primary goal is the development of a health and mental health service delivery system in this war-torn region. We are fortunate to have developed our project in collaboration with the Kosovar mental health leadership. Now, the design and the beginning of implementation of a long-term strategy is being developed. The groundwork of our project's first year has positioned the KFPEC, and specifically a family-centered model, to play a significant role in this process. Also, we are aware that we need funding to sustain and develop the project into the next stage so that it is less dependent on a purely volunteer structure and effort. We are also exploring other funding possibilities.

Typical Visit

In response to the requests of the Kosovar team, each of the trips has been organized around a different topic: the first visit focused on learning about the current experience of Kosovar families in cities, villages and towns. During that visit we developed the topics and overall format for future visits. These included: 1) systemic approaches to understanding families, grief/loss and the initial interview, 2) crisis intervention, trauma and short term therapy, 3) chronic medical and psychiatric problems, and, 4) children, adolescents, and substance abuse and the family. The next visit will focus on developing a community mental health system.

During each visit, the flow of the week was much the same. Before we left, we received a schedule that had been organized by Ferid Agani in consultation with other leaders of the Kosovar team. We arrived in Prishtina after a two day journey, and got settled. We stayed in a bed and breakfast and worked in a nearby hotel. According to the pre-arranged schedule, the next two days were spent making site visits, to towns and villages, to families, schools, clinics, hospitals, and gravesites. Our experience has involved traveling into the countryside to see the effects of war and oppression, and subsequent rebuilding, to visit families, and see the beauty of the land. To get to a Kosovar village we pass razor-wired enclaves of Serbian villages, trapped inside by the current status of the relations between the two ethnic groups. The Kosovar mental health professionals are fearful when they drive past the Serbian villages to reach the Kosovar village.

In the villages, there are dirt roads, mud, houses with out-houses, plastic-covered vegetable gardens, burned buildings, some rebuilding. The schools in the villages have no equipment for hands-on learning. The schools in the cities have no computers, and no athletic equipment. The fields are still mined and dangerous. The children are afraid to play in the fields. As we drive by, we see mass grave mounds, and a new cemetery being built, where colleagues bury their neighbors and fellow soldiers. The children worry about their parents, the men who are idle with no work, the women who grieve the loss of their husbands, sons and fathers.

On each visit, we were asked to return to the village of Slovii in order to get a longitudinal view of the recovery of one community. This included returning to visit the same four families in Slovii during each visit. These families were being seen between these visits by Kosovar mental health teams. On the third day we gave lectures attended by up to 70 people from Prishtina and other cities and towns. We sent outlines of our lectures ahead of time and were paired with a Kosovar colleague who gave a lecture with each of us. Their lectures complemented, elaborated or illustrated the material in our lectures from a Kosovar cultural or experiential perspective. This pairing was one of the crucial aspects of the collaborative process. It was an expression of and fostered a bilateral learning experience. On the last two days we did workshops, which were intended for the "core group" of twelve three-person teams. Each of these teams has been engaged in seeing families over the fifteen months. These teams have met together weekly, and all the teams have met together monthly since the first visit. The workshops were used in a variety of ways, including: demonstration role-play interviews, interviews of live families who came in to be seen by us or with our Kosovar colleagues, discussions regarding integration of the training in a range of contexts, and workshops in which we dialogued about ways to adapt U.S. style interviews to the Kosovar family. The last was an innovation in which we presented an interview format and sample questions, and asked our colleagues the culturally appropriate ways to address families given the various goals of the interview. These exchanges became rich ways of creating a cross-cultural dialogue.

Every day we met in two groups, the writing and training groups. The purpose of the writing group is to help the Kosovar mental health professionals develop training materials, and have a voice of in the international journal community. They are working on a training manual, and one article has been published from this group. The training group discusses cases and training issues and methods used in the project.

After fifteen months of working together, we continue to feel concerned with how recovery from trauma, displacement, sudden urbanization, inundation with westerners via television and the Internet affect relationships in families. Old ways are challenged by loss, grief, trauma, dislocation, and destabilization of the family. Strong values, family roles and rules are under siege by massive change. We wonder how people recover from such trauma and grief without continuing the violent the cycles of hate and retaliation? We continue to search for ways of working together that facilitate recovery and create meaning from the horrific level of trauma and loss, without elevating the cause in which so many died.