SUMMARY. This paper presents psychosocial services for displaced women living in the war zones. Two study groups were formed from two cities in Croatia, Zenica and Tuzla. The services were designed to ameliorate distress and improve psychosocial functioning. A questionnaire-based evaluation indicated that highly distressed women derived greater benefit from group psychotherapy (Tuzla) than did the group who participated in occupational activities (Zenica).[Article copies available for a fee from The Haworth DocumentDelivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com]
KEYWORDS. PTSD, psychosocial, trauma, war trauma
The war in Bosnia-Herzegovina started in April 1992 and brought great suffering and hardship to the non-combatant population. Not only were deliberate military attacks upon civilians and civilian areas common, but so were arbitrary arrests, arson, murder, torture, detention, executions, rape and sexual assaults, forcible removal, displacement and deportation.
According to the United Nations High Commission for Refugees (1994), roughly half the country's inhabitants were driven from their homes. Although many sought refuge outside of Bosnia-Herzegovina, the majority were displaced within the former republic.
WOMEN: THE HIDDEN VICTIMS OF WAR
Reports of rape being used as a weapon of war began to circulate in the Western media towards the end of 1992. This information was confirmed by several international missions to the region, including Amnesty International, Helsinki Watch, the World Council of Churches, the European Communities, as well as UNHCR.
In Norway, as in many other countries, news of such victimization aroused an immediate response on the part of women, with the shelter movement in particular putting the issue at the top of its agenda. Meanwhile, Norwegian People's Aid (NPA), a large non-governmental organization that had been among the first to respond to the tragedy in Bosnia-Herzegovina by setting up refugee camps, launched a fund-raising drive called "Women: The Hidden Victims of War." Having already raised two million dollars by the Spring of 1993, the urgent question became one of how best to direct the funds so as to maximize their impact upon refugee women trapped inside the war zone.
PREPARATION: DIALOGUE AND COOPERATION
In order to address this question, NPA retained the services of one of the authors (SD), who is a psychiatrist with long experience in setting up services for rape victims in Norway. Her first task was to assess the situation and advise NPA on what it could do in this field.
During an initial visit to the Former Yugoslavia in 1993, it was impossible to enter Bosnia-Herzegovina due to the fighting. Thus, she used her trip to study the type of projects being set up in Croatia. Community-based women's organizations had set up a variety of services for women, with mental health professionals going into the camps to work with women on a volunteer basis. Among those working in the health field, gynecologists were the most likely to encounter raped women; psychiatrists would only meet those who came to them with severe trauma. Discussion with various groups indicated repeatedly that care for raped women should be made an integral part of all health interventions.
Zenica
In June, SD visited Zenica, a city in Central Bosnia that was under the control of the Bosnian government. With a pre-war population of 120,000, the city had also become home to an additional 40,000 refugees, of whom the majority were women and children. Most were accommodated by their relatives and friends, while the remainder lived in a number of sites, including schools, sports centers, cinemas and public buildings. Living conditions were extremely poor. Refugees had to contend with shortages of food and water, along with frequent power outages. Moreover, their movement was restricted both by the war and the breakdown in infrastructure.
Many of the refugee women were overwhelmed by feelings of helplessness, and had lost interest in life and their children. Since the schools were not in operation, the children were left either to roam the streets with little supervision or to fall into a passive, depressed state. Although various types of services had previously been established for the women and their children, dialogue with stakeholders made it quite clear that there was a continuing need for a range of psychological services.
NPA's psychosocial center for displaced women and their families in Zenica was officially opened in September 1993. Personnel included a Norwegian coordinator, a local coordinator and a professional staff of one psychologist, three social workers, two pre-school teachers, two teachers and one interpreter. In addition, six individuals were hired to provide support services, including cooking and cleaning. Half of the latter contingent were displaced people themselves. The aim of the service was to improve the psychosocial functioning of displaced women by giving them an opportunity to overcome problems of passivity and helplessness, and to identify victims of severe traumatization who were in need of additional psychological intervention, either as individuals or fami1ies. The program's agenda was set by staff members and open to change based on feedback from participants. The women engaged in group-based occupational activities, structured group conversations, educational and recreational activities, as well as being given the chance to receive individual or family counseling.
All women and children living in the refugee centers were invited to participate. The response was overwhelming and, in order to provide services to as many individuals as possible, two shifts were created, with participants only allowed to come in every second day. By December 1993, there were approximately 400 women and 250 children in regular attendance at Center activities.
Handicrafts were chosen as one of the activities because many participants wanted this, and it was a pastime that traditionally brought women together. Women were invited to take part in knitting, sewing, spinning and embroidery. Products were either sold in a shop created for this purpose (in the process providing individuals with a source of income), or made for use by family members. Emphasis was also placed upon cultural and educational activities, with courses offered in the English language, music, dancing and singing. Generally, women would also bring their children, who were divided into pre-school and school-age groups. With the educational system in disarray, many children had not attended classes since the beginning of the war.
The various groups were seen as ways for the women to engage in meaningful activities and reawaken their interest in life. The development of a social network was also facilitated hy the presence of a social worker, who participated in structured group conversations. While there were no formal psychotherapeutic group activities, the psychologist or social worker routinely met with the women so that they could talk about issues of concern. The focus was on expressing feelings and coping with the present situation. Individual counseling was offered by both the social workers and the psychologist, who also acted in a supervisory capacity. Training in counseling was also provided to those who would be working with the women.
By inviting all female refugees to attend, the aim was to offer a large group of women psychosocial support, and to provide individual and family counseling to those who were in greatest need. The service was also grounded in the assumption that social support is essential for those coping with many types of traumatic experience. Lack of support is often a contributing factor to mental health problems among victims of sexual violence. Many women might choose not to disclose their experience, and a broad-based approach affords women with different traumatic experiences a chance to benefit from the service while giving individuals who have been raped the opportunity to disclose and receive targeted psychological treatment.
The program was expanded in 1994. When it was observed that there were groups of women who wanted to become involved, yet were unable to visit the Center itself, a mobile unit was established, consisting of a number of local professionals who visited refugee centers, where they offered counseling and other services. Also, whenever possible, they arranged for the women to meet together in groups, thereby making it more likely that individuals would receive referrals if they were in need of medical treatment.
Tuzla
Tuzla is an industrial city in northern Bosnia with a population, including outlying areas, of approximately 600,000. During the war, hundreds of thousands of people sought refuge here. As in Zenica, these individuals were accommodated in private homes and in various public buildings. Also like Zenica, NPA had a long-standing presence in the city, where it was involved in building housing for the refugees. In Autumn 1993 the war was in its full intensity. Poverty and blockade meant that the basic preconditions for survival were not being met. Hunger was rampant.
The situation in Tuzla differed from that in Zenica in that the Danish Refugee Council (DRC) had already embarked upon a psychosocial program focusing on the educational and recreational needs of displaced women. However, as UNICEF staff had pointed out, there was an ongoing need for psychological services. NPA decided to respond to this challenge by initiating a project that would complement the interventions of DRC. The aim of NPA's project in Tuzla was to deliver a range of psychological services to support and treat women who had been exposed to war trauma and were at risk of developing serious mental health problems as a result. Furthermore, NPA also sought to build local capacity by offering training to local professionals in the mental health field.
Headed by psychiatrist Dr. Irfanka Pasagic, a group of local professionals had initiated an outreach program in the Fall of 1993 meant to serve the needs of women living in some of the local refugee centers. Their work was undertaken in extremely difficult conditions, without any outside funding. NPA's arrival meant that they could benefit from professional support while at the same time being assured of sustained financing. Drawing upon the expertise of these individuals, NPA's Psychological Center came to employ two coordinators (one Bosnian, the other Norwegian), one project assistant, four parttime professionals and 21 therapists employed on an hourly basis, responsible for one to four group sessions each. Together with UNICEF, NPA developed training and education programs for those who would be employed at the Center, which were to be delivered by outside professionals.
The Center opened in June 1994 and was located in an existing home for women and children. Given that a number of other projects were being delivered in the same building, including a DRC-run activity center and an education program operated by Gemainshaft fiir Frieden and Hilfe (GFH), it was hoped that inter-organizational cooperation would be facilitated, as would be refugee women's access to a range of services.
Women were either referred to the Center by a health professional or approached project staff themselves. Personnel visited refugee centers in order to describe the project and identify potential participants. An interview guide was developed to assist in the assessment of the women. Individuals who might benefit from the program were interviewed by a staff member and the most distressed were advised to join a psychotherapeutic group. The latter were generally made up of eight to ten women, with their activities guided by a strategy that was at once self-reflective and sensitive to the local environment. Itwas for this reason that women from similar educational and class backgrounds were placed in the same group, as were sexually traumatized young women. Inall other cases, the groups were heterogeneous in composition.
Conditions under which the psychotherapeutic work evolved were extremely difficult. Most of the refugee women were from rural areas with little formal schooling, and many were widows or single mothers. Most suffered from multiple forms of traumatization, such as daily artillery shelling.
The first sessions were used to introduce participants to one another and lay the groundwork for subsequent interventions. Once mutual trust was established, the therapist could then move forward to the next stage, where women were invited to describe their histories. In order to work through the participants' traumatic experiences, a psychoeducational model was applied. In this model, women were shown how to recognize their psychological reactions and understand them, along with the relationship between their experiences and their present emotional state. Anxiety reduction strategies were also addressed. As the trauma became more integrated into the women's life histories, the therapist moved to the last stage, when women were encouraged to face the realities before them and make choices based on this awareness.
The groups met once a week, over a period that ranged from three to four months. The short duration was primarily due to a lack of resources. As more funding became available, the sessions were extended to six months, with staff taking steps to ensure that there was continuing social support for the women after the completion of the psychotherapeutic process. Moreover, therapists also encouraged participants to create self-help groups, with which they would subsequently meet on a monthly basis in order to discuss ongoing problems and concerns.
EVALUATING NPA'S SERVICES IN ZENICA AND TUZLA
Background
The development of NPA's projects in Bosnia-Herzegovina was shaped by local conditions and circumstances; the needs of the refugee women trapped in the war zone; and the heroic efforts of local professionals, many of whom were themselves displaced within the former republic. As the services evolved, we (i.e., both the local and Norwegian professional staff:) felt the need to document our activities in a systematic fashion, and determine whether or not we had succeeded in meeting project objectives. Thus, the authors of this paper, along with Atifa Mutpcic, a psychologist, carried out an evaluation of NPA's work in Zenica and Tuzla, drawing upon funding provided by Norway's Council of Mental Health.
THE EVALUATION STUDY IN ZENICA
After the Center had opened its doors in Zenica, there was a discernible change in the attitudes and outlook of refugee women and children. That is to say, they began increasingly to share in the enthusiastic, caring atmosphere generated by the project and the organized activities. As one woman put it, "It makes me feel like I'm worth something." However, despite these impressions, we wanted to address a number of specific questions concerning women's use of the Center and the degree to which they benefited from it. In particular, we asked ourselves:
Were traumatized women able to attend the Center?
Were post-traumatic stress symptoms common among the women?
Was there any relationship between the severity of the trauma and the likelihood that women would suffer from post-traumatic stress?
Was there a discernible difference in women's evaluation depending upon whether or not they suffered from post-traumatic stress symptoms?
Having developed a questionnaire with the assistance of the Center's interpreter, a small pilot test was conducted with four women. Itincluded questions on socio-demographic characteristics, types of traumatic experiences and post-traumatic symptoms. Additionally, women were asked to describe the kinds of activities in which they were involved and how these had affected their psychological well-being. Drawing upon a typology of traumatic events, participants' responses were then grouped according to the severity of trauma. In other studies of human rights violations during wartime, itwas generally found that women who had been detained were most likely to have been sexually abused.
Hence, Group 1 consisted of women who reported being incarcerated in a concentration camp, detained with other women, and/or been witnesses or victims of rape. Group 2 was comprised of women who had either witnessed or been victims of interpersonal violence. Group 3 included individuals who had been placed in situations where they felt their lives were in danger. Group 4 was made up of women who indicated that family members had been killed or were missing. Finally, Group 5 consisted of women who had been separated from their families and/or their homes had been destroyed.
The Post-Traumatic Symptoms Scale (PTSS-10) was used to assess the degree to which women suffered from such symptoms during the seven days prior to the study. This is not so much a diagnostic tool, but rather a simple screening test. However, Weisreth (1989) argues that a positive response for six or more symptoms might be taken as indicative of a clinical diagnosis of PTSD. Accordingly, we chose six symptoms as our cut-off point in identifying post-traumatic symptoms cases (PTS-C).
All women present at the Center during the morning shifts of June 13, 14 and 15, 1994 were asked to fill out a questionnaire. Due to a shortage of paper products, only 239 forms were available. These were numbered and given to the women as they arrived. The women were asked to complete the form and leave it in a box. Those who did not wish to participate were asked to leave the questionnaire blank, though they were still encouraged to provide background information. Moreover, we endeavored to ensure that the women were given a measure of privacy by asking half of the women to go into one room and half into another. Staff members were on hand to assist participants if asked to do so. Of the 239 questionnaires distributed, 209 were completed. Results were analyzed with SPSS. We conducted an initial assessment of the data, which was then presented to the Center's staff as a basis for discussion and interpretation (November 17-26th, 1994). Personal interviews were also conducted with three women who visited the Center, as well as three staff members. Finally, we invited women served by the mobile unit to fill out the questionnaire, with 69 agreeing to do so.
RESULTS OF THE EVALUATION STUDY IN ZENICA
The women who participated in the study ranged in age from 15 to 70 years (mean 35), and had been displaced anywhere from two to 32 months. Of the 119 married women, 31% were separated from their husbands due to the war. Roughly 23% of the participants had children who were less than 13 years of age. While a high proportion of the women had suffered severe trauma (see Table 1), none reported being raped. In total, 111 participants (53%) could be classified as a PTS-C. Incidence of distress was highest (71%) among those in Group 1 (see Table 2). Moreover, it was also found that multi-traumatized women were more likely to suffer from post-traumatic symptoms, as were those with children and/or an absent husband.
When asked to evaluate the Center's activities, women without severe PTS symptoms (91%) were significantly more likely (91%) than those who were PTS-C (82%) to rate "being with other women" as very helpful. Moreover, differences were also identified in women's evaluation of their emotional problems. Among those with few symptoms, 93% stated that they felt "somewhat or much better" after having taken part in Center activities, as compared to 88% among women who suffered from six or more symptoms. However, it should be noted that the incidence of PTS-C was significantly higher among women who never visited the Center (68% as compared to 53% for women who took part in Center activities on a regular basis). While acknowledging that one must be careful in making comparisons between the two groups, there was nothing in the women's profiles that could explain this discrepancy, leading us to conclude that it was likely due to the role of Center activities in diminishing PTS symptoms.
Many traumatized women came to the Center and post-traumatic stress symptoms were common. Although the war took its toll on everyone, individuals who had undergone severely traumatic experiences were among the most likely to suffer from PSTD. Moreover, this group of women appeared to derive less benefit from Center activities than others who were less distressed.
THE EVALUATION STUDY IN TUZLA
As was made clear above, the approach taken in Tuzla was somewhat different from Zenica, in that the project was designed specifically to identify women who were highly distressed, and hence in greatest need of therapy. Moreover, by the time evaluation had begun in Tuzla, several groups had already completed the program and others were starting. The specific questions were:
How might one characterize the traumatic background of women who are attending or have attended group therapy?
How did participants evaluate the group treatment?
Might one identify any differences in symptom level between those who had completed the program and those who were just starting?
The Zenica questionnaire was used as a guide for developing the one in Tuzla, with the only major alteration being the replacement of the word "rape" with "sexual abuse." This change was made at the behest of local staff. Moreover, an instrument was added for evaluating therapeutic success that was based upon Yalom's model: 1995. Twelve statements (see Table 3) were listed, with women asked to identify the one that they agreed with most (ranging from "did not help me at all" to "helped me very much").
Collecting Information
During two weeks in May 1995, women attending the psychotherapeutic groups were asked to participate in the study by completing a questionnaire. The procedure was similar to that used in Zenica, with personnel available for assistance should the need arise. Women who had already completed the program were recruited by means of the self-help groups in which they were involved.
RESULTS OF THE EVALUATION STUDY IN TUZLA
Of the 172 questionnaires that were returned, 14 were incomplete. The women had been displaced for periods of time ranging from three months to more than three years. The majority (75%) had children under 13 years of age, and most were separated from their husbands (67%). Not only were many of the participants characterized by severely traumatic backgrounds (23% were in Group 1), but most were PTS-C (70% or 111 women). When comparing the incidence of PTS symptoms among those who had completed group therapy (N = 82) and those who had not (N = 76), no significant difference was observed. However, the groups did differ in other characteristics related to the risk of becoming PTS-C. In particular, among those with children, the level of PTS-C was considerably lower for those who had completed the therapy program (69%) than those who had not (81% were PTS-C). Again, while acknowledging the difficulties inherent in assessing whether or not this is a valid comparison, one might nonetheless suggest that the therapy had helped to reduce the level of distress within this particular subpopulation. Further credence is lent to this conclusion by the fact that the women's subjective evaluation of the therapy points in the same direction. Here, participants with children who were identified as PTS-C were among the most likely to state that the group therapy had helped them a lot or very much (see Table 3).
Although the proportion of participants who indicated that they had been severely traumatized was similar in both Zenica and Tuzla, the level of PTS-C was higher among the latter group. Of course, this is only to be expected given the criteria for taking part in the Tuzla program. Despite the fact that almost all of the women stated that the group therapy was helpful, a higher proportion of participants who were PTS-C reported that specific aspects of the program helped them "a lot" or "very much." As well, women with children who had completed the program were generally found to have fewer symptoms than those who were still in therapy, thereby underscoring the latter's effectiveness. In the words of one of the women, "I feel more relaxed and I can sleep now."
CONCLUSION
Displaced women living in a war zone constitute a high-risk group for traumatization and mental health problems. Moreover, in the context of the Former Yugoslavia in particular, there was wide recognition of the need to empower and support women who were victims of the conflict. As one might imagine, this was largely the product of sustained media attention on the issue of rape as a weapon of war, which served in turn to awaken the international community to the fact that the traumatization of women is closely associated with the destruction of families, social networks and societies.
In this paper, the authors have described two psychosocial projects focused upon the needs of displaced women living in war zones, as well as discussing the results of a questionnaire-based evaluation of the same. Of course, given the degree of difference between the target populations of the two projects (the Tuzla project was aimed specifically at women in need of therapy, whereas the Zenica Center was not), one must be extremely cautious in comparing results. Still, the findings do suggest that highly distressed women derived greater benefit from group psychotherapy (as was offered to them in Tuzla) than they did from the occupational activities organized by the Zenica Center. Those planning future interventions in war conditions may very well wish to take these findings into account.
REFERENCES
Dahl, B. and Schei, B. (Eds). (1996). The burden left my heart. Experiences from a group psychotherapy project among displaced women in a war zone. Oslo, Norwegian People's Aid, 1996.
UNHCR. Information notes on the former Yugoslavia. No 1(1995). Zagreb: UNHCR office of the special envoy for the former Yugoslavia, external relation unit.
Weisa:th, L. (1989). The stressor and the post-traumatic stress syndrome after an industrial disaster. Acta Psychiatry Scand (Suppl 355) pp. 25-37.
Yalom, I. D. (1995). Theory and practice of group psychotherapy, 4th edition, pp. 74-78. Basic Books. New York.
Berit Schei, MD, PhD, currently holds the Atkinson Chair in Women's Health Research at The Centre for Research in Women's Health, Toronto, Canada. Solveig Dahl, MD, PhD, is at the Psychosocial Center for Refugees, Department of Psychiatry, Faculty of Medicine, The University of Oslo, Oslo, Norway.
The authors wish to acknowledge the following:
Address correspondence to: Berit Schei, 790 Bay Street, Room 749, Toronto, Canada (e-mail: berit.schei@utoronto.ca).
[Haworth co-indexing entry note]: "The Burden Left My Heart: Psycho-Social Services Among Refugee Women in Zenica and Tuzla, Bosnia-Herzegovina During the War." Schei, Berit and Solveig Dahl. Co-published simultaneously in Women & Therapy (The Haworth Press. Inc.) VOl. 22, No. I, 1999, pp. I 39-I 51; and: Assault on the Soul: Women in the Former Yugoslavia (ed: Sara Sharratt and Ellyn Kaschak) The Haworth Press, Inc., 1999, pp. 139-151. Single or multiple copies of this artide are available for a fee from The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: getinfo@haworthpressinc.com].
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