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Psy en situation humanitaire
dans le cadre de Médecins
Sans Frontières (M.S.F.)

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Pour citer cet article :
Moro MR. Psychiatric Interventions in Crisis Situations : Working in the Former Yugoslavia. The Signal 1994 ; 2(1) : 1-4 (U.S.A.).

 

Psychiatric interventions in crisis situations :
working in the former Yugoslavia

Marie Rose MORO *

I. Necessity, problems and limitations in psychological treatment in humanitarian interventions

For a long time now I have been working with children and their families living in precarious and sometimes tragic situations. Some of the sit­uations are linked to natural disasters, famines, etc., but more often than not they are the results of wars and situations linked to the whims of politics and powers.

A first Médecins Sans Frontières (M.S.F.) (1) mission with mental health professionals took place in Armenia. It set up a treatment center for children and adolescents having suffered from the earthquake of 1988. A second mis­sion took place in Romania with the children in orphanages. And a third with the Bosnian and Croatian refugees and their families in France, then in Croatia. An exploratory mission was carried out in Mozambique during the war that has lasted for many long years. The mission aimed to analyze ar­rangements likely to optimize mother-child relationships in such circum­stances (famine, war, displacements…). A new mission has been undertaken in Palestine for children and adolescents… In varying degrees these missions bring together psychiatrists, psychologists and, depending on needs, educa­tors, nurses, psycho-motricians, etc.

The work however is very different from one continent to another, from one country to another. Present interventions such as those being carried out in the former Yugoslavia are special for the fact that they are happening in Europe, which makes them radically different from previous interventions in, for example, Africa. Because of the geographical and cul­tural proximity, it might be thought that European techniques could be transposed in their entirety, but what we are about to see is that the context must be taken into consideration and understood in its totality. Moreover these interventions are representative of those now faced by humanitarian organizations. Previously it was thought that providing food, treating epi­demics and performing surgical operations were enough. We now know that there are also psychological emergencies and mental suffering that, if left untreated, would become irreversible. This is especially true for babies and children. Yet this working together of specialists in food and medical emer­gencies and those in the mental health realm is not all that clear-cut. There is need for reciprocal adaptation. Doctors sometimes have a hard time under­standing the rationale of mental work. « Shrinks » of every stripe are often lacking in pragmatism and sometimes take their theoretical quarrels into the field with them ! We all know this ! So there is need of an apprenticeship, of reciprocal adaptation on all sides.

Working in Europe means that in countries where we work there are already trained health professionals. And whatever the quality of their training, we have to work with these professionals and not instead of them. In fact it must be said that even in countries without trained professionals there are always people who fulfil a medical role for their people (however they may be called : healers, matrons, etc.), and they must not be shunned. But do we know how to deal with them ? This is one of the major problems in this job. This is what makes me think that these field teams must open up to other professionals : ethno-psychiatrists, for example, or anthropologists or mother-infant specialists or sociologists… We then run up against the prob­lem of decentration and a multiplicity of professions. A doctor’s expertise alone isn’t enough, any more than a psychoanalysts’ or a psychiatrist’s or an anthropologist’s is. In short, it’s a good schooling in modesty !

There’s another snag, too : Time. Every field worker has at one time or another seen professionals from Paris or New York or elsewhere arrive in the field bearing « gifts », usually a good word more than truly effective help. They’ve come to tell the locals or the expatriate professionals who have been living and working with the locals in precarious situations for long months how the job should be done. They look, criticize, film, make judgements out of context, then go away again, leaving behind the daily pain, the necessary adjustments due to material difficulties and human limits. They also some­times leave behind the fear of bombing, of deprivation… On the other hand, field personnel sometimes think it is enough to be on hand to be effective ! Arriving at a proper balance is required, a subtle alchemy between rigor and humanity that has to be renewed ceaselessly.
Now let us turn to the former Yugoslavia.

II. Short presentation of the work being done in the former Yugoslavia

I’d like to stress a few points that seem to me to be especially new and tragic in this situation (2). The conflict is causing an addition and a multiplica­tion of potential trauma.
1 - First of all, in A. Le Brun’s terms (1993), the extreme misfortune of the Croatian, then Bosnian people, victims of the implementation by the Serbs of the first racial State in Europe since the Third Reich. Faced with this disaster, our inability to understand and act. Psychiatric actions are also bogged down by this lack of understanding.
2 - Another disastrous novelty : the concentration-camp life is no longer restricted to Tito’s gulag, Naked Island, but has been extended to a large part of the civilian population. « Everyone becomes a displaced person and equally susceptible to being deported, tortured or executed » (3) (Le Brun, ibid. : 17). Trauma is, so to speak, no longer limited to very localized situations. Real or potential, they now concern a large part of the civilian population. We are smack-dab in the middle of a concentration-camp experience. We were slow in recognizing « the overflow of the concentration-camp world into civilian society, the very movement itself of totalitarianism which consists in changing whole populations into "criminals who have not committed a crime" » (ibid. : 19).
3 - I would stress the fact that with this war people wanted to see, at least in the beginning, a simple little « identity crisis », i.e. freed at last from the Tito yoke, cultural identities clashed. Present-day political, historical, even anthropological studies have shown that it is much more like a « totalitarian crisis » that depends on pseudo-populist theories nourished by theorists (note the place of certain psychiatrists of the former Yugoslavia in building these ideological mountains). A reading that would reduce this war to a simple inter-ethnic conflict is clearly insufficient (Nahoum-Grappe 1993).

2. The M.S.F. (4) mission

• In France

At the end of October, 1992, in the framework of the international humanitarian action implemented by the United Nations High Commissioner for Refugees, the French government decided to receive three hundred Bosnian civilians, former detainees in the Serb detention camps of Bosnia-Herzegovina, and their families.

A team from Médecins Sans Frontières carried out a medical-psycho­logical assessment mission with these refugees. Their report revealed a whole gamut of exactions committed against the civilian population that come under the legal heading of crimes against humanity. With a great deal of uniformity all the accounts trace an unrelenting fury to destroy and tor­ture, whether it be by the concentration-camp rationale within the bounds of the detention camps or by the terror fomented by armed bands within towns and villages transformed into prisons. Given the seriousness of the ex­actions, M.S.F. decided to make public a first report on the « Process of Ethnic Cleansing in the Kozarac Region » (December 7th, 1992). The aims of the ac­tion were to favor an appropriate treatment and to facilitate the restoration of a mental, anthropological, social and legal space for a population particu­larly tried by the length, multiplicity and intensity of the trauma they had experienced.

There were two main lines to the job :

1- Psychological support for the victims : this meant lending support to the refugees as they came to grips with the problems of terror, mourning, exile and guilt for having survived. Technically the basis of this support work consisted of establishing links between the mental past and present, a link that is prohibited by traumatic violence. This meant enabling them to build an account and encouraging existing resources within their traditions and their history.
 
2- Gathering their eye-witness accounts : in accordance with its humanitar­ian principles M.S.F. undertook to gather information so as to determine the exact nature of the exactions committed in Bosnia-Herzegovina from March, 1992 to the present. Beyond its legal dimension, the interest in gathering eye-witness accounts is that it helps in the therapy by re-instigating the work of linkage and by articulating experience, thus creating links between individual and collective experience.

• Setting up a treatment center in Croatia (Karlovac)

The creation of a psychology-treatment center was undertaken after several assessment missions had been to Croatia.
Nearly 270,000 Bosnian Muslims have been taken in by Croatia to date. Some have settle into refugee camps, but the majority have been housed in private homes out of solidarity.

In early June a three-member team (a doctor, a psychologist and a legal expert) undertook to establish a medical-psychological treatment unit in the Karlovac camp where 400 former detainees and their families (1,600 persons in all) have settled. The Karlovac refugee camp (KTC UNHCR transit camp) is 50 kilometers south of Zagreb and 1 kilometer from the front lines. It is the preferred arrival place of detainees released from Serb detention camps under the ægis of the I.C.R.C. (International Committee of the Red Cross). The refugees have been waiting for transfer abroad for periods varying from three to ten months.

The medical-psychological treatment unit is made up of two locally re­cruited teams (a medical examination and a psychological examination), and an M.S.F. advisory team.

The medical examination is intended to provide initial treatment, fol­low-up of chronic-diseases and management of the pharmacy.
The main work-lines in the psychological examination are the same as with the refugees in France except for certain specifics :
1- work on infant suffering when the mother is so absorbed by absences and mourning that she is unavailable for her infant. The work aims at rebuilding the mother-infant bond that has often become inharmonious.
2- Work of personal rebuilding for adults within groups (rebuilding self-es­teem damaged by the degrading conditions of refugee, torture, rape, etc.).
3- Work with adolescents with a view to providing solutions to the lack of parental and group boundaries and supervision.
4- Work with school-age children’s groups to enable the children to elabo­rate on the trauma experienced.
5- Work with elderly persons with the intention of restoring them to their positions as witnesses to the past, as purveyors of meaning regarding the present situation.
6- Support work with local teams so that the suffering they are faced with does not impede their chances of helping.

The reference model for working sessions is that of short-term ther­apy with care only exceptionally exceeding three months. An assessment of this mission’s results is now being carried out.

Conclusion
 
These psychiatric interventions in the framework of a humanitarian organization derive from an absolute ethical and human necessity. This necessity depends on eye-witness accounts and the fact of being involved in in­human situations whatever their origins. Yet these psychiatric interven­tions run up against epistemological and technical difficulties : a multi-dim­ensional approach has to be taught ; complementarity and de­centration have to be sought, and modesty accepted… They run up against boundaries, i.e. the migration of professionals and their techniques. This does not mean a simple transfer of technology but a mutual building of systems that have to be adapted to each situation. These technical systems must respect men and women, contexts, situations and cultures.
Psychological care in these circumstances is a matter of vital necessity. It should be associated with new technical reflection and research in many inter-related fields.

 

BIBLIOGRAPHY

Gozlan Y, Salignon P. Soutien psychologique auprès des ex-détenus bosniaques musulmans et de leurs familles : la mission de Médecins Sans Frontières. In : Moro MR, Lebovici S. (Eds) Psychiatrie humanitaire en ex-Yougoslavie et en Arménie. Face au traumatisme. Paris : P.U.F. ; 1995. p. 73-87.

Le Brun A. Les assassins et leurs miroirs. Réflexion à propos de la catastrophe yougoslave. Paris : Pauvert, Coll. « Le Terrain vague » ; 1993.

Nahoum-Grappe V. Vukovar, Sarajevo… La guerre en ex-yougoslavie. Paris : Esprit ; 1993.

Médecins Sans Frontières (M.S.F.) Rapport public « Le Processus de purification ethnique dans la region de Kozarac » (7 Décembre 1992), 8 rue St Sabin 75011 Paris (Public Report of M.S.F. : « Process of Ethnic Cleansing in the Kozarac region » (December 7th, 1992).