SUMMARY. The personal experiences of the author working with women's organizations in regions destabilized by war is the focus of this article. The author summarizes the results of a report commissioned by the Dutch government to analyze the state of para-professional work, describes her own work in the Former Yugoslavia and makes recommendations for the training of Western feminists to work in war regions. She also examines the effects of the trauma of doing this work on her own life. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com]
KEYWORDS. Trauma, refugees, feminist counseling, nationalism, ADMIRA.
INTRODUCTION
Professional and Personal Motivation
When the war started in the summer of 1991, I had been working for ten years in the treatment of sexually traumatized women, including many with histories of rape or incest who were sutiering from dissociative problems or identity disorders. I had also engaged in research on the impact of confrontation between incest survivors, perpetrators and other family members. Thus, I felt that my experience, both as a psychotherapist and as an educator (in which capacity I have trained shelter and crisis hotline volunteers), could prove useful in the war-ravaged region of the Former Yugoslavia. In addition to the symptoms of post-traumatic stress disorder per se, I was well aware of the long-term dangers inherent in denying or repressing trauma experiences, and of the importance of real contact, of being there to listen to survivors talk about the atrocities committed against them. There have been many times that I have witnessed "wars'' within families, so that I knew not to be surprised at the sadistic, impulsive and unpredictable behavior of which men, and sometimes women as well, are capable. I knew that dissociation, denial, hostility and scapegoating should not be seen as pathological reactions on the part of victims, but rather as normal responses in the face of unbearable life circumstances.
Societies have been all too willing to ignore the importance of grief and collectively acknowledging war injustice, and the Balkans are no exception, as is attested to by the perpetuation of revenge sentiments from one generation to the next. Thus, in deciding to work in the region, I not only hoped to gain some insight into the war situation itself, but I also wanted to help its victims, most of whom are women and children.
A good friend and psychologist from Belgrade phoned me one day just after the war started in 1991. She said, "I am no longer seen as a Yugoslavian feminist, but as a Serb, a citizen of the criminal nation that started the war and all these atrocities. As you know, I never chose this political system and I hate the politicians it's produced. I still think of myself as a Yugoslavian woman and an international feminist. Please be my witness. I need friends here who believe in the work we're doing, like that of the 'Women in Black' who protest every Wednesday in the center of Belgrade, as well asJhe SOS hotline we're running for raped and sexually abused women and girls. I need the warmth of friends from abroad to help energize me and keep me focused on the anti-war cause." For my friend, the war engendered feelings of helplessness and uncertainty. When she called, I was suddenly brought face-to-face with these feelings myself, and I was left with the sense that the only way forward was to try to transform my sense of powerlessness into concrete action.
Dutch Policy in the Wake of Publicity About Mass Rape
Prior to disbursing funding in support of women's projects in the Former Yugoslavia, the Dutch government commissioned a report analyzing the state of para-professional and volunteer organizations working with traumatized or war-raped refugee women (Foeken and Kleiverda, 1993). Gunilla Kleiverda, a gynecologist, and I spent three weeks in the region in September of 1993 gathering data for this report, which we subsequently presented to our government. A summary of our findings follows.
INTERVENTIONS
Most refugees were sheltered by their relatives, with only five percent in Serbia and thirty percent in Croatia housed in refugee camps. The principal problems they faced included lack of contact with family members who had remained in Bosnia-Herzegovina, tensions with host families, little opportunity for meaningful activities, uncertain prospects for the future, and poor mental health, itself the product of such traumas as the loss of home, family members and personal belongings. In the camps, mothers' wide-ranging responsibility for the care and education of their children would exacerbate feelings of apathy and depression, making them less likely to set limits upon the aggressive behavior of their offspring, angering camp leaders in the process. Children would latch onto teachers and other adults, making burnout that much more likely among these latter groups. As for more complex psychiatric problems, outside professionals visited the refugee camps whenever possible. For example, a Bosnian psychiatrist based in Zagreb organized regular group sessions for adolescents, ex-concentration camp prisoners, and women from different ethnic communities. However, she admitted to us how difficult it was for her group of professionals to integrate questions about rape, even if participants had no problem in discussing other violence-related issues. There was simply too much shame, and raped women were at risk of being driven out of their community if they were found out. Despite these difficulties, the group was very interested in receiving training in this field.
At a more general level, state mental health agencies were overwhelmed by the demands placed upon them, particularly in an environment in which lack of funding delayed or stopped altogether the payment of salaries. Indeed, many female professionals decided to leave their posts in order to work, on a volunteer basis, for feminist NGOs providing health services in the region.
The Implications of Nationalism
For many refugees who were forced to relocate for economic reasons or because of their ethnicity, retraumatization was a daily occurrence. AntiMuslim sentiment ran so high on the Croatian coast, where refugees were housed in empty hotels, that some police agents would simply tear up the documents of Muslim individuals whom they encountered. The politically neutral stance of United Nations agencies and foreign NGOs was interpreted by many as evidence of anti-Croatian sentiment. We had occasion to experience this hatred directly, when stones were thrown at our vehicle when we were traveling in a United Nations car. In short, it was widely believed that the United Nations coddled the Serbian and Muslim refugees, providing them with two meals a day while many local people were forced to go hungry. It was also reported to us that there were cases of refugees being raped and beaten up by members of their "host" families. Needless to say, the level of general aggression in these societies had increased enormously over the war years.
It was also in this region that we encountered, for the first time, strong nationalist feelings, even among women. In one particularly telling incident, a leader of the Women's Association of Bosnia-Herzegovina grew angry with me when she heard of our plans to meet with feminists in Belgrade. In her view, Serbian feminists had no value, since they had betrayed their sisters elsewhere in the Former Yugoslavia, had done nothing to prevent the war, and had been shielded from the sexual attacks suffered by Croatian and Bosnian women. When I asked her what possible int1uence she thought Serbian feminists had over their government, she had no response.
As it was almost impossible to visit or send money to projects in Bosnia, and Serbian feminist organizations received little sympathy in any case, Croatian projects benefited disproportionately from international funding initiatives, with the Center for Women War Victims in Zagreb being an especially notable case. Individuals working at the Center were receiving salaries that were considered extravagant by local standards. Not only did this serve to engender widespread jealousy among area residents, but it led many non-feminist women to become involved in the project only because of the wages.
Meanwhile, in our hotel in Split (Croatia), pornographic pictures were shoved under our door and we received obscene calls during the night. We assumed that the hotel's owner was responsible. However, despite the crudeness of his acts, he was not alone in showing hostility to us. In several cases, professionals accused us of only wanting to work with Bosnian women, and of underestimating the suffering of Croatians. Obviously, it was all too easy to go astray in this nationalist minefield, and we were left with the sense that ADMIRA's philosophy of promoting transnationalism (see discussion below) by its insistence that support be given to women's groups regardless of ethnicity was more a case of wishful thinking than a reflection of actual conditions.
Politics served as a constant interference in the handling of the mass rapes. Politicians from all sides wanted gory accounts of rape and sexual abuse that they might present to the international community as evidence of the barbarity of their foes. Of course, in doing so, they showed themselves to be all too willing to sacrifice women's emotional recovery on the altar of political expediency. While these incidents served to underscore the extent to which nationalism and health care were working at cross-purposes to one another, they also highlighted serious problems among health workers themselves, including feminists, many of whom were competing to be first to exploit the stories the victims told.
Of course, foreign journalists were not blameless in this regard, fueling this exploitation by offering money to raped women who were Englishspeaking. Western governments' policy of making raped women a priority in aid programs was in many cases counterproductive, since it served to downplay the seriousness of other war crimes committed against women. In the end, I was left feeling very confused, since I had expected the issue of rape to be treated in a careful, respectful manner, only to discover a reality in which callousness and insensitivity were the norm.
Consequences of Rape
Although the number of women seeking abortions has doubled since the beginning of the war, hospital staff never ask why the abortion is being sought. While this is in part due to the fact that the procedure is generally far less controversial in Eastern European countries than it is in the West, it is also the case that many physicians did not want to know the answer. What would they do with the information? Also, we know of at least one incident where a colleague was raped by her husband who had come home drunk from the war zone. As one might imagine, such an attack was even more shameful for the victim than one inflicted upon her by the enemy.
In our workshops for mental health professionals and volunteers, the issue of sexual violence was ever-present. Participants often asked us if we thought it wise to ask clients directly whether or not they had been raped. In one scenario described to us, a 16-year-old girl was placed in care in a psychiatric hospital for refusing to speak and severe anorexia. She was the daughter of a Serbian father and Croatian mother and, over the course of several weeks, was subjected to multiple rapes by her father and his friends. She hated herself for being Serbian, and her revenge was to attempt to starve herself to death. Faced with these circumstances, we argued that it would be impossible to talk about the rapes at this point; of far greater importance was to make contact with her in a manner with which she could identify. The psychologists attending the workshop were relieved, as they had the idea that Western psychotherapists always address the issue of rape explicitly, without taking into account the particulars of a given case.
Other participants asked us to comment on the accuracy of their guesses regarding signs of sexual violence among concentration camp survivors. As an example, they referred to instances where mothers would adamantly declare that only they had been raped and their daughters had been spared, whereas the girls themselves showed signs of depression, recoiled at every touch, suffered from vaginal infections and spent long periods of time under the shower.
We suggested that the daughters could also be protecting their mothers. Women would often claim that they were forced to undress, but that they had been too skinny to be raped, or that they were spared because of their period. Everyone understood what it meant when a Bosnian woman arrived in the camp dressed in Croatian clothes, or when a woman hated and neglected her newborn child. Everyone knew, yet no one challenged the stories told. Thus, we agreed that all of the signs touched upon above could be indicative of a rape experience, and we supported them in integrating questions about rape into their discussions with this individuaL
We also sought to emphasize the importance of seeing denial and repression as necessary survival mechanisms rather than pathologizing them. Interestingly, most workshop participants appeared not to be familiar with this perspective. Thus, we suggested that rape was one of many traumas where women should be encouraged to verbalize their feelings in order to overcome the sense of shame within them.
Issues Raised by Staff During the Consultation
Guilt feelings for not doing enough and individuals' sense of powerlessness in the face of so many multi-traumatized people were other areas touched upon during the workshops. We shared with those present the helplessness which we so often felt during the course of our own working lives, and noted that things must be far more difficult in a war situation. We stressed the importance of boundary issues and the need for self-protection. Although participants recognized immediately the risk volunteers ran of becoming entrapped in the "rescue triangle," we realized that further training about this issue would be needed.
During consultation, participants would often be left feeling drained and overwhelmed, so we would also ask them to share with us their successes as well as their problems. On one occasion, we suggested that we should try to find at least one funny thing in the midst of the misery. Several group members came forward to share humorous anecdotes, with one refugee describing, all the while laughing out loud, how she had seen a woman in Sarajevo rushing out of her house the moment a mortar exploded nearby to lock all of her doors and windows. The smoke blowing around her body while she was doing this gave her the appearance of a ghost. Having heard the story, all the participants burst out laughing.
In conducting workshops and consultations throughout the region, we were generally very impressed with the educational background of professionals working in the field, whether psychologists, psychiatrists or social workers. Some had been trained in the diagnosis of post-traumatic stress disorder. Thus, in many cases we were simply providing participants with information on recent theoretical advances in the field or giving them concrete suggestions that might prove helpful in their counseling work. At the same time they were very interested in learning about other countries' experiences in refugee counseling, indicating that there had been no local research done in this area, and that they believed that the extent of sexual violence during the war was unprecedented in their society. One woman went so far as to suggest that the latter may be due to the intrusion of Western capitalist values into the region. Incest was another area where information and training were lacking. However, volunteers were beginning to be faced with it more and more often, perhaps because women felt at greater ease talking about sexual violence than they had prior to the beginning of the war.
Although we found women's volunteer projects to be in a pioneering phase, with enthusiasm and willingness to learn new techniques and approaches, most were also in severe need of organizational support. The majority were being sustained through the charisma of their managers and the strong commitment of the volunteers.
Founding of ADMIRA
Presented with our recommendations, the Dutch government initiated funding of ADMIRA for three years, which it subsequently extended until 1999. Members of this new foundation included women's organizations working in the field of sexual violence, along with the Mental Health Institute for Refugees (Pharos) and a research center studying the sociological and psychological impact of the Second World War.
The Aim and Policy of ADMIRA
The purpose of ADMIRA was to provide information, advice, support and training for NGOs in the Former Yugoslavia working with multi-traumatized women from different ethnic and religious communities. However, following implementation of the Dayton peace accord, the emphasis has shifted somewhat toward the provision of support to key organizations, which would then be in a position to train other women's groups, networks of care providers and professional mental health agencies working with sexually traumatized refugees, women and children.
In order to carry out this mandate, eight trainers with a background in refugee counseling and sexual violence were dispatched to the region. The group was divided into four teams, each consisting of a specialist in one of the two areas. I was selected as one of the teacher/trainers. To participate, organizations had to have a policy of anti-nationalism and be willing to work with women and children of all ethnic and religious backgrounds.
My Experiences as a Trainer
Workshops were developed that focused upon the recovery process and staff empowerment. However, once the workshops were underway, we found that issues related to leadership, task management and delegation of responsibilities were just as important in many women's organizations as trauma counseling.
Developing Knowledge from Experience
The concept of experience-based knowledge is central to women's therapy. In short, insight into a particular problem is gained by analyzing one's own feelings, cognitions and conclusions, together with the reactions and responses of others. In the example below, I seek to illustrate what I mean by discussing a guided fantasy I used with workshop participants.
First, I asked group members to focus on their childhood and think of a secret that they had not shared with their mother or caregiver. Then they were to write down the reasons why they had not been able to tell their secret and what would have been necessary for them to do so. In sharing and analyzing the range of responses that this exercise engendered, the group learned that it is "normal" not to reveal a secret, how secrets isolate individuals, and how shame or fear of punishment prevents people from opening up. The exercise was also useful in establishing a connection between participants' childhood experiences and those of girls or women who have been sexually assaulted, in the process blurring the boundaries between "us" (the care providers) and "them" (the clients).
Along similar lines, emphasis was also placed upon the contradictions inherent in the mother-daughter relationship. For example, although men's violence is a given, it is seldom presented as an inevitable part of marriage. However, when daughters verbalized different, more romantic expectations of the men in their lives, mothers blamed them for being naive or stupid. Another issue that was frequently discussed in the workshops was the problems associated with men's inability to perform sexually, causing them to be rejected by their mates. A<> a number of women laughingly put it, "no fun, no marriage." I suggested that the increase in alcohol consumption by male war survivors may partially explain this problem, as would war traumatization itself.
Differences in political ideology were also a source of difficulty for many workshop participants, particularly among those who were Serbian. That is to say, parents would often accuse their daughters of disloyalty when they voiced their hatred for the war or indicated their preference to be identified as feminist rather than Serbian. After sharing these views, volunteers who worked on crisis hotlines (such as the SOS Telephone Hotline for Sexually Violated Women and Children in Belgrade) found it easier to understand their irritated reactions when listening to women who expressed nationalist sentiments, many of whom were members of the same generation as their mothers.
Learning Techniques for Counseling Clients
Although some techniques were readily adaptable to conditions in the Former Yugoslavia, others had to be modified somewhat. On the one hand, participants welcomed information on strategies to avoid feeling overwhelmed, such as self-protection measures which involved thinking about happy memories before sitting down with an individual suffering from severe trauma. On the other hand, techniques foc'Used upon the development of a "safe place" in one's mind were generally less well-received. For example, our suggestion of imagining a forest caused one woman from Sarajevo to experience unpleasant tlashbacks to the time she had to tlee through the woods to escape the fighting. The suggestion of a beach was painful for many Serbian women because they were barred from traveling to the Dalmatian coast at that time. Faced with this situation, we asked those present to take a moment to comfort each other. At this point some group members criticized us for placing so much emphasis upon fantasy when the real world was so hard and cruel. We agreed whole-heartedly with this assessment, and argued that it was for precisely this reason that fantasy might play a useful role in helping them to cope. Another woman came forward to tell us that she had been living a fantasy life in Sarajevo the last few years, and was fed up with the need to do this. We indicated that we respected her position. We added that we had come to the Former Yugoslavia from a country that was at peace, and asked what we could do that would be preferable from their perspective. Needless to say, this experience taught us that we must be careful not to assume that strategies that work well in one context are necessarily the most appropriate in another.
In other cases, the women were so tense that conflicts within the group manifested themselves, making it impossible for us to relinquish a measure of control. Indeed, it was precisely in this context that we brought up the question of safety, stressing the importance of always maintaining self-control in dangerous situations, either by means of a pause for self-retlection or by focusing on one's breathing and physical feelings. Interestingly, once group members began to use these techniques themselves, their capacity to address other difficult issues was enhanced.
Techniques to Encourage Cooperation Among Participants
Personal conflict within organizations was identified as a problem that was becoming increasingly serious. As one might imagine, lack of communication was one of its root causes. Thus, considerable energy in the workshops was devoted to communication training, stressing the development of listening skills, distinguishing between feelings, opinions and intuition, giving positive feedback, being honest with one's emotions, and curbing destructive behavior such as projection. Generally speaking, participants found it extremely difficult to express their anger in a self-reflective manner and avoid scapegoating others. To make sense of this anger, we would first interview all of the individuals involved in a given organization, then analyze and categorize the different responses. In most cases, problems were due to one or more of the following reasons: the structure of the organization itself; the nature of its work; poor communication among staff members; lack of dearly defined roles; and issues related to leadership style or personality. Once we had undertaken the analysis, we would share the findings with all members of the group, and then help them work through the problem areas, thereby lessening the level of mistrust and facilitating communication.
While these exercises did not differ significantly from those we had previously undertaken with volunteer groups in The Netherlands, our efforts to help women's organizations in the Former Yugoslavia move toward greater professionalism and transparency were met with a markedly different reaction. Our attempts to encourage group members to invest in the development of their agency's organizational structure engendered considerable opposition, albeit at an unconscious level. At first we did not understand why participants were responding in this way, but it soon became obvious that the problem was in large part due to the fact that many were faced with such uncertainty in their own lives that long-term planning meant little to them. As several women asked us, why should they think of the future of the organization when it was what they were doing right now that was important? There was also significant resistance to the models of coordination and leadership we presented. Probing participants' feelings in this regard, we were told of the deep distrust, fear and anger that welled up inside them whenever they thought of the politicians who had brought so much grief to their country, both before and after the fall of communism. They tended to associate leaders with manipulation, deceitful power games, and only being interested in helping their cronies at the expense of all others. This in turn meant that women who attempted to assume a management position were also looked upon with suspicion or contempt by other members of the organization. However, after we discussed these issues in the workshop, the groups generally became more open to new models of coordination and task delegation. In our view, the disappearance of communism had left something of a vacuum where new forms of demo<.-'fatic governance needed to be developed.
Boundary Issues
As trainers, boundary issues often proved problematic for us. In one case, a para-professional asked me if I would be willing to meet with her for a private consultation in connection with a couples counseling issue. I agreed, and also accepted her choice of translator. In the meeting, she indicated to me that she was fearful she was taking sides in her work with a particular couple, and I helped find a solution to the problem with which she seemed happy. However, as I walked out of the room at the end of the session, the translator turned to me and said that the couple in question was her and her partner. I felt manipulated and asked them why they had not told me earlier; they replied that they thought I had known all along.
Boundary issues were also complicated by the war situation. Volunteers resented the fact that they were not being paid, and all the more so because of the long hours they worked, and the apparent lack of appreciation for their efforts on the part of the refugees. Meanwhile, the professional staff would become defensive and blame them for not setting limits or establishing clear boundaries.A<>one might imagine, communication group work was extremely helpful in addressing such cont1icts.
Interdisciplinary Work
In our training workshops, we also encountered significant problems in the area of interdisciplinary cooperation. Although we offered facilitation to help work through these issues, there was great resistance to our interventions, particularly within those organizations dominated by physicians. In these instances, psychologists would generally serve as the survivor's advocate, defending her right to remain silent in the face of physicians' demands that she immediately reveal the details of her assault to the police or other state official. However, as the groups became sensitized to their colleagues' perspective, they were more likely to engage in cooperative behavior and support each other's interventions.
Among the other issues raised by workshop participants in this regard, many wanted to hear about the working relationship between gynecologists and psychologists in the West and what I, as a psychotherapist based in The Netherlands, thought gynecologists in the Former Yugoslavia should know. Interestingly, it was precisely in this context that cultural differences between the trainers and the participants arose. My partner, herself a gynecologist, suggested that physicians may wish to give a small mirror to patients during the course of a gynecological exam with the aim of fami1iarizing women with their bodies and giving them a greater sense of control.When she said this, all those present started to laugh and suggested that the patients were more likely to use the mirror to look at their hair. However, the next day one of the physicians did offer a mirror to a patient, who was curious enough to use it in the proposed manner. As long as one is in a position to make one's own choice, the chance to act in a novel or unconventional way can be refreshing.
Hate and Guilt Divided Feminists
As one might imagine, we were particularly interested in working in Serbia, as this would give us the opportunity to hear the perspective of the war's "perpetrators." At the beginning of the contlict, the guilt feelings of the Serbian volunteer staff were overwhelming, causing them to feel torn between their sense of shame and their belief that Serbia was being unfairly demonized by its neighbors and the international community. However, the wish to help former friends and refugees from all ethnic communities was great. In the words of one Serbian woman, "The war is the most awful and shameful experience of my life, but I also want to do what I can for the refugees and other traumatized women." Many volunteers kept in regular touch with their old friends in Sarajevo, sending them letters and care packages, as well as crawling through a tunnel under the city's occupied airport in order to visit them in person.
The multi-ethnic professionals working for Medica Zenica emphasized to us the importance of personal friendships in preventing the perpetuation of hatred. For example, when Bosnian Croats rampaged through villages in the northeastern region of Bosnia-Herzegovina, burning houses and killing people, one of the organization's Croatian staff members felt ashamed because she knew that her colleague's parents lived in one of the affected towns. She did not dare speak to her friend, fearful that she had lost all respect in her eyes. However, the Bosnian staff member sought her out and said, "I need your friendship no