SUMMARY. This article presents an overview of issues and concerns which can negatively impact the effectiveness of caregiving in a war zone by traumatization of caregivers, conflicting agendas and prejudice of foreign mental health organizers and trainers. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com]
KEYWORDS. Caregivers, war zone, war victims, trauma
From the perspective of a mental health professional, I would like to share my experiences of organizing psychosocial programs and trauma recovery training in a war region. I would also like to stress some of the pitfalls of effective caregiving arising from the psychological state of both local and foreign caregivers/professionals working in such an environment.
The central assumption of this paper is that the professionals working in a war region are more or less traumatized by the war. Being part of a traumatized community as well as mental health professionals, local caregivers suffer both primary and secondary trauma. Playing the role of mental health caregiver, frequently approached by friends, relatives and team members who would like to discuss their own mental health problems, they feel responsible and somehow obliged to demonstrate their psychological fitness to help. In trying to overcome their own problems with a range of coping styles, they often suppress or deny signs of their own traumatization. A sense of their professional dignity often persuades them not to show, or even accept the idea of, their own traumatization. Even when local professionals do not obviously suffer from traumatic signs and symptoms, they may be characterized by invisible forms of traumatization that are capable of influencing relationships and communication with foreign caregivers, undermining the effectiveness of caregiving in mental health projects. I would like to touch upon several signs that are not easily visible or recognizable, particularly in comparison with the symptoms of heavily traumatized people in a war region. These include the following:
Feelings of shame and helplessness. They suffer from a lack of hygiene, clothes and food and are unable to change their material status.
Mistrust: expressed in relation to the real motives of foreign caregivers in offering help, the goodwill of colleagues, or the stories of clients.
Increased vulnerability directly related to decreased self-esteem and confidence.
Foreign caregivers are also involved in organizing mental health projects and training in war regions. In all too many cases, they bring with them attitudes and motivations which prove detrimental to the cause of effective caregiving. These might include (inter alia): different motivations for coming to the war region; they expect acknowledgment and appreciation for helping people in need, while seeking to acquire experience (or wages) without adequate commitment to the human beings who are suffering; prejudice concerning the country and the people who live there; superficial statements and generalizations about the beliefs, lifestyle and culture of the people with whom they work; a more or less colonial outlook, given concrete form in such statements as: "They are basically different from us"; "They don't have the needs we have"; "They are not as skilled as we are"; "I know better anyway"; and so on.
The following model illustrates, in concise form, the relationship dynamics that might develop between foreign and local caregivers. Of course, my purpose here is not so much to develop a universal model, but rather to provide a means of sharing experiences for consideration.
In this way, communication between local and foreign caregivers who work together on projects becomes saturated with mutual hurt, sapping the energy and morale of both groups in the process.
I worked in a project that was developed and supported by feminist groups from Germany and around the world. Endeavoring to put into practice principles derived from feminist theory, we always sought to ensure that there was an open door for discussing power issues and problems that might arise within the organization. However, power issues themselves determined who appeared in that open doorway.
An analogy could be made here to the kind of interactions that manifest themselves within trauma work between therapist and client as a result of an unbalanced power dynamic. A traumatized local professional, engaging in transference, might expect some kind of omnipotent rescuer and idealize the foreign caregiver/professional. However, this is inevitably followed by disappointment and fury when the reality fails to live up to such unrealistic expectations. The foreign caregiver (engaging in countertransference), faced with so much pain and need, might feel obliged to deal with more problems than is really feasible, thereby building unrealistic expectations among beneficiaries, and ultimately provoking negative reactions. In turn, this leads to feelings of disappointment and resentment towards those with whom s/he is working. Of course, the negative impact of unconscious attitudes and untreated traumatic signs is multi-faceted. In the first instance, this may be seen in foreign caregivers' sense that they are being neglected or have only gained superficial acceptance, leading to resentment and disappointment. In this way, they lose an opportunity to use the crisis situation for learning, development and growth. Meanwhile, local professionals may find themselves caught between identification with their community on the one hand, and their role as mental health professionals on the other. Not allowing themselves to express their real emotions and vulnerability so as to remain professional, they may very well develop problems of dissociation, and have to invest more and more energy into trying to compensate for this gap between their two roles. However, having done so, they run the risk of burning out that much faster.
As for the project's client population, they receive precisely what they do not need or want: false care, overprotection, neglect, misuse, creation of unrealistic expectations and a tendency to become stuck in the role of victims. Needless to say, this process serves to undermine the effectiveness of local professionals, who lose their capacity to meet the real emotional needs of beneficiaries. They may also offer clients inappropriate coping techniques for their trauma symptoms, or discourage them from expressing their authentic emotions.
Along somewhat different lines, foreign caregivers, because of their prejudices and colonial attitudes, may offer false support or not meet the real needs of beneficiaries. Their unacknowledged personal motivations might lead them to build unrealistic expectations among beneficiaries, offering overprotection instead of support and strength. Meanwhile, the temptation of professional self-promotion may cause them to misuse the traumatic stories of beneficiaries.
What can be done to avoid these pitfalls in similar future war situations? There is a need for individuals to assess carefully the roles and goals of all parties, and to sensitize themselves to power issues inherent in the relationship between local and foreign care-providers. Thus, counseling of foreign caregivers/professionals should be provided, and include issues related to their own motivations, expectations, prejudices and colonial attitudes. It is also important that all parties develop a basic knowledge of transference and countertransference issues involved in working with traumatized people, as well as a thorough understanding of trauma issues more generally, including symptoms, relationship dynamics and forms of communication that might be indicative of traumatization in local people and team members.
Training for local mental health professionals should offer them a chance to get in touch with signs of their own trauma. It should provide a space and an opportunity for vocalizing their owns fears and concerns. While such an approach would not necessarily entail therapy, it would provide professionals with an awareness of and sensitivity towards their own emotional problems. At the same time, it would create an opening within which local professionals could receive acknowledgment and acceptance from foreign colleagues and others.
It would be possible to combine this approach with theoretical issues associated with trauma, legitimating caregivers' traumatization without damaging their professional dignity, and encourage them to accept themselves and their vulnerability. Needless to say, it could also serve as an important means of preventing burnout among local mental health professionals.
If these requirements are to be met, the training should be regular, organized as early as possible, and involve stable groups. It should be a combination of self-experience and educational interventions. Exercises and workshops used during the training would also provide professionals with a tool they could subsequently use in their own work with clients.
Edita Ostodic is affiliated with Medica in Zenica, Bosnia-Herzegovina.
Address correspondence to: Edita Ostodic, WTC Medica, Mokosnice 10, 72000 Zenica, Bosnia-Herzegovina.
[Haworth co-indexing entry note]: "Some Pitfalls for Effective Caregiving in a War Region." Ostodic, Edita. Co-published simultaneously in Women & Therapy (The Haworth Press, Inc.) Vol. 22, No. I, 1999, pp. 161-165; and: Assault on the Soul: Women in the Former Yugoslavia (ed: Sara Sharratt and Ellyn Kaschak) The Haworth Press, Inc., 1999, pp.161-165. Single or multiple copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-342-9678, 9:00 a.m. 5:00 p.m. (FST). E-mail address: getinfo@haworthpressinc.com].
© 1999 by The Haworth Press, Inc. All rights reserved.