Psychosocial Interventions for Children of War: The Value of a Model of ResiliencyRoberta J. Apfel, M.D., M.P.H.;* Bennett Simon, M.D.**
"State Parties shall take all appropriate measures to promote physical and psychological recovery and social re-integration of a child victim of: any form of neglect, exploitation, or abuse; torture or any form of cruel, inhuman or degrading treatment or punishment; or armed conflicts. Such recovery and re-integration shall take place in an environment which fosters the health, self-respect and dignity of the child." Article 39, UN Convention on the Rights of the Child [1] There is a large body of painfully accumulated experience and knowledge about the impact of armed conflict on children and about interventions (short- and long-term) that make a difference in helping those children. This body of knowledge has generally not been readily available to those working with children, other than to a relatively small group of mental health professionals. Much of this knowledge has been garnered under the auspices of UNICEF or with the assistance of UNICEF. (See especially the chapter on psychosocial interventions in [1] and Macksoud's handbook for parents and teachers [2].) Similarly, there is a body of knowledge accumulated by individuals and organizations who are working directly with children but who are not designated mental health professionals. That body of knowledge and experience needs to be transmitted to mental health professionals more effectively. The 1994 UNICEF publications catalogue instantiates this problem -- there are very few publications dealing directly with mental health and psychosocial interventions while there are many publications containing material that is quite relevant to those interventions. There is a need for a better integration of the two repositories of knowledge. Limited Resources and Priorities for Intervention This review is also needed to help us escape polarizations in thinking that are prompted by the inevitable fact of limited resources. In the hierarchy of concerns, triage is essential. Yet we must avoid falling into the artificial dichotomy between giving priority to interventions that affect large groups of children and giving priority to working with individually damaged children. Similarly, we need to avoid the polarization of working with the most obviously damaged children versus working with those who have been through the same difficult circumstances but seem to be doing well. In terms of long-range prevention of emotional damage, including forms of damage that may lead to perpetuation of a cycle of violence and revenge, interventions for the children who seem least affected by the trauma of armed conflict must also be an important part of the vision of those who work with children in these circumstances. The needs of the majority and the needs of the small number of high risk -- and potential high gain -- children who are in the minority must both be recognized and addressed. There are imaginative strategies for allocating scarce resources so as not to be conceptually and practically trapped by some of these dichotomies. The findings concerning mental health and psychosocial needs and interventions must be presented to governments, politicians, and administrators in such a form that they can be digested and can begin to influence public policy decisions. Decisions about where and when and with whom to intervene are also inextricably involved in complex and explosive political situations, frequently involving major considerations about human rights. The psychological state of these children affects not only their psychological developments but also their future roles in the political, social, and economic stability of their group or nation. It is important to convey this to the children's community, to their national government, and to the international community. Mental health professionals also need dialogue with politicians and administrators to learn more about how programs can be implemented and sustained over time. Finally, there is the pressing long-term need to find means to interrupt the tendency towards inter-generational transmissions of hatred and of propensities towards violent resolution of conflict. Our model of interventions that enhance resiliency allows us also to think about the inter-generational transmission of hope, about resources for renewal and regeneration, and about alternate means of conflict resolution. What Is Resiliency? The use of the term "resiliency" in child development arose in the context of studies of children who seemed to be at major risk by virtue of having seriously mentally ill parents (e.g. [3,4,5]) and, in related research, studies of children growing up in some very difficult economic circumstances in the United States (e.g. [6]). The question that the concept of resiliency attempts to answer is, "How is it that not all -- or not even the majority -- of children growing up in some very difficult circumstances develop significant psychopathology or other major kinds of impairments in leading their lives whether as children or, later, as adults?" Researchers in child development, some working in both clinical and research setttings and some working primarily in research settings, began to catalogue "risk factors" and "protective factors" in the attempt to get a more refined understanding of the phenomena subsumed under the term "resilience." Writing on the question of "what keeps people healthy, as opposed to what makes them sick?" Antonovsky [7] introduced the term "salutogenic" [factors] in contrast to "pathogenic" [factors]. Without much fanfare, various clinicians and researchers working with children in situations of armed violence began to think in these terms of understanding how well or how badly their populations of children were faring and also in terms of how to implement programs of intervention that would enhance the protective factors. An outstanding example of such thinking is seen in the work of Bryce and her associates in Beirut [8], where they studied the great variation in mental and physical health among children living with the intermittent and unpredictable terrors of bombing, shelling, and shooting. Looking at these and other studies, the authors have come to their own list of the variables most relevant to assessing needs and planning interventions. Resourcefulness This includes the gift of being able to extract even very small amounts of human warmth, and loving-kindness in the most dire of circumstances, including at times from these children's enemies or persecutors. There is skill at attracting and using adult support, which in turn leads to an early sense of the children's own power and competence. This also entails using adults as "polestars" [16] -- resilient children have a knack for turning to adults other than parents for guidance and resources if they cannot find such support in their own families. Resilient children do not merely get adults to care about them and take care of them, but they somehow promote a reciprocity in their exchanges with adults, so that the adults also feel they are deriving something from the relationship. Resourcefulness is a way of continually interacting so as to generate new emotional supplies for all concerned. But resourcefulness also includes the ability "to make something out of nothing," the use of imaginative skills in garnering or creating resources -- both concrete material resources and psychic resources needed for survival. This includes skills at playing as well as skills at planning and the two often overlap. Mom, a twelve-year-old unaccompanied Cambodian girl, developed her talents at acting in the refugee camp and thereby enhanced her possibilities for eliciting adult interest and eventually for being adopted by an American woman [16]. Elie Wiesel [17], as a thirteen year old boy in Auschwitz, got an extra bowl of soup from his malnourished fellow prisoners for telling the best story in the group -- a story about Friday night dinners in his home before the war! Curiosity and Intellectual Mastery; the Ability to Conceptualize Becoming knowledgeable about the crises around them increases these children's chances of survival, gives them a "commodity" (i.e. knowledge) that they can trade with others, and provides an important sense of activity, rather than passivity. To exercise this skill may mean bearing the anxiety and pain of looking and finding out, rather than the temporary psychic relief by means of avoidance and denial. This ability also entails the child's comprehending her or his experience not only as a personal travail but as a phenomenon affecting others as well. Such understanding diminishes feelings of isolation, failure, and defectiveness and may also contribute to the development of empathy. At times, in interviewing adults who are survivors of terrible childhood experiences, we hear them conceptualize their suffering in relation to the suffering of others and exclaim, "I didn't have it so bad; you should talk to so-and-so, who really went through terrible times." Compassion, but with detachment, is another facet of the child's skill at conceptualizing. For example, if the child has a very disturbed parent or caretaker, he or she simultaneously knows the adult is sick or disturbed or out of control, feels some compassion, but knows to keep a safe distance and to find a safe place. Flexibility in Emotional Experience This refers to the ability to be in touch with a variety of emotions -- not denying or suppressing major affects as they arise. At the same time, there is some ability to defer or defend against some overwhelming anxiety or depression when emergency resources are needed. This may mean compartmentalizing the pain and deferring the experience of overwhelming emotion until a time or situation when it is safer to experience it. It is important to note here that there is a great deal of cultural variability in how the child is expected to experience and express painful affects. Some cultures place a premium on articulating the pain and making it explicit; others (e.g., among Ethiopian children [18]) emphasize the importance of suppressing distressing emotions. Overall, a flexible array of psychological defenses includes the ability to use suppression or even denial when necessary for psychic sanity and psychic survival, but not so much as to impair the ability to assess danger and/or possibilities of getting out of danger. A wide affective repertory, including the ability to laugh even in the most trying circumstances and the possibility of delaying crying until a safer time, is also adapative. Cambodian child survivors of the Pol Pot terror reported how dangerous it was to cry, how crying was disallowed [16,19]. Yet they were able to laugh, indeed found laughter life-saving in the worst of times. The laughter provided both an emotional release of tension and also a group acknowledgment of something ludicrous in the surroundings. Access to Autobiographical Memory This refers to the ability to remember and invoke images of good and sustaining figures, usually parental figures. These images might at times be critical and demanding as well as warm, loving, and encouraging. It appears that the critical voice of the parent is important for maintaining certain ideals and standards, as well as for keeping in touch with some sense of the security that comes with belief in a "normal" moral order. The ability to remember, imagine, and be in touch with sustaining family stories and community legends is also important. For example, LeLy Hayslip, a Vietnamese woman, records how a legend recounted by her father of a distant ancestor -- a Vietnamese woman warrior pregnant in battle -- sustained LeLy in extremely difficult circumstances involving pregnancy and child rearing during the Vietnamese war [20]. The capacity to be in touch with positive memories and the availability of heroic models for emulation together help reinforce the all important conviction of a right to be alive, a right to survive, even in the face of suicidal despair and a temptation to give up in the midst of unbearable external situations. A variant of the right to survive is the notion of "survival merit," [16] a feeling that one has survived for some special purpose, including helping others. Survival merit can counter the negative impact of survivor guilt. A Goal for Which to Live Victor Frankl quoted Nietzsche with respect to the importance of a purpose in order to survive in the death camps: "He who has the 'why' to live for, can live with almost any 'how'" [21]. The sustaining goal may be that of seeing the parents again, or of achieving the task to "get your little brother to Palestine, no matter what!" Again, there is a delicate balance: autobiographical accounts suggest that at times failure to achieve the goal can lead to terrible self-reproach and suicidal despair. There is an analogous situation with the child having a sustaining ideology, be it religious or political. There is abundant evidence that being identified with a particular national-political ideology can be enormously important for the child's equanimity and drive to survive and triumph. The child may suffer greatly, though, from a real or imagined inability to live up to the ideological expectations. Also, if the ideology collapses, proves hollow, or is even totally destructive and cruel to its followers, the child can be in serious turmoil and be left more vulnerable than before. Having a goal intertwines with a sense of empowerment and the possibility of activity for the child in a situation marked by helplessness. The sense of a sustaining goal is intimately tied up with the next point, the role of altruism. Need and Ability to Help Others The unspoken assumption is that altruism also serves one's selfish benefit. A "learned helpfulness," in contrast to a "learned helplessness" [23,24] is a powerful aid to survival. This skill often draws upon identification with parents who themselves have instantiated the effectiveness of altruistic acts. Altruism as expressed by the child toward others may be modeled on the altruism of adults. Parental altruistic activity communicates not just calm but a certain effectiveness, and a sense that "you may be helpless right now to stop a bomb from falling, but you are not helpless to deal with its human consequences." Bryce's detailed studies of mothers under fire in Beirut [8] have shown that the children instructed to use the interval between shellings to go out and bring food to an invalid relative, instead of using the time to watch television, did much better. Maternal competence and altruism were strongly associated with children being relatively symptom-free under conditions of quite severe stress and danger and also relatively symptom-free in the more quiet intervals. A Vision of a Moral Order A vision of the possibility and desirability of the restoration of a civilized moral order may be crucial to survival. From time to time, even in the worst of situations, the child may take great risks to help someone else in order to feel and implement some sense of decency. A Lebanese Catholic boy whose brother had been killed in a Syrian shelling and who himself was seriously injured addressed the nun in the hospital. She had taught him that Christ said to love one's enemies and he asked whether he now had to start hating the Syrians and go against what she had previously taught him [26]. The child may harbor fantasies of revenge at moments when a persecutor is especially cruel and sadistic, but has freedom not to have to act on those wishes even in situations when some sort of revenge is possible. A need to act in order to restore the moral order may even take precedence over the need to "get even" (e.g. [27]). Forgiveness -- as problematic as that may be in both the short and the long term -- also constitutes a powerful force in personal and communal restitution. A vision of a moral order and of the importance of altruism constitute powerful forces in preserving and rebuilding community. Interventions That Can Enhance Resiliency These "protective" factors represent mostly capacities and abilities of the child, but it is readily apparent how much the child's capacities are constantly interacting with what the surrounding adults can provide. This interaction leads to an obvious but absolutely crucial point in working with children, namely the need to support and care for the adult caretakers be they parents, refugee camp workers, teachers, or mental health professionals. The kind and nature of the care obviously vary, inter alia, with the developmental age and stage of the child, as well as with the immediate traumas to which the child is or has just been subjected. Several long-term retrospective studies [28,29,30] and one prospective study [12] of adults who were children in war and in persecution indicate the protective value of some intense, reliable, relationship to an adult, though not necessarily over the whole childhood of the person. Here the capacities of the individual child to internalize such support and carry it with her or him as permanently available psychic nutriment are important. At times, lacking such an adult, children could turn to other children for such support and then might collapse when withdrawn from this group, which has come to be a kind of family [30,31]. Legaretta's followup of unaccompanied Basque children sent abroad during the Spanish Civil War [29] also emphasizes the importance of having some adult from the same culture accompany the child, or group of children, as a link to the community in which the child is grounded. Caring for Caretakers As a simple example, consider the work of an early intervention program for Bosnian refugee kindergarten children in Slovenia organized by a Slovenian child psychiatrist, Anica Kos. The program includes paying close attention to the cognitive and emotional needs of the teachers, many of whom are themselves highly traumatized young Bosnian refugee women. In order for the adults to provide as consistent and reliable a program and surrounding for the children as possible, the adults need to feel that someone else is giving something to them. Optimally, the generations and genders "feed each other" -- there is mutual enhancement. This example also points us to the tremendous importance of school in establishing and re-establishing some order and sanity in the lives of children traumatized by violence. School can provide the stabilizing framework in which the child's imaginative and cognitive skills can safely grow, or grow in relative safety. The "school in a box" program [a crate flown in that itself can serve as a schoolroom structure and is filled with simple school supplies for numbers of children] instituted in Rwanda refugee camps is a recognition of this importance. There is room for legitimate debate on whether or not (and how) schools in areas of combat ought to be encouraging students in the discussion of the violence around them and how it is affecting them. Some argue for the crucial importance of such opportunities and others have argued that the school must be a place where the children can temporarily put their minds elsewhere. This is an area where the accumulated experience in different parts of the world needs to be assembled and sifted and further research needs to be done. Resourcefulness and the Encouragement of Play Consider the factor of "resourcefulness" outlined above: the ability of the child to use his or her imaginative skills both in interpersonal situations and in situations involving mastering the environment in order to survive. Interventions and programs that encourage and allow children to play, including playing out some of the traumatic events to which they have been subjected, may have a considerable impact on the child's ability to cope, whether in an acutely dangerous and traumatic situation, such as in the concentration camps in World War II [32], or in refugee camps, or in resettlement in a new country (e.g. [33]). One group has developed a training program for adult caretakers of traumatized Latin American refugee children, a program that involves actors, primary school teachers, and mental health professionals. The program is designed to enhance the child's ability to play, helping the child through a series of carefully graduated exercises that eventually allow for safe expression -- in art, drama, games, and story-telling -- of the terrible events they have experienced and of the meaning of those events to them. At the same time, the training program helps protect the adults from being overwhelmed by the child's expression of extremely painful emotions and stories that, as adults, we might not always be able or willing to hear. Such a training program, in principal, could be modified according to different cultural settings and different cultural expectations around emotional expression and suppression. The program is also very important as a "multiplier" -- providing people who can work with many more children than the core group alone could. The training program, in so far as it stimulates the imaginative capacities of the adults, helps provide role models for the children to do likewise. Another lesson inherent in the program is the need for caretakers to devote a percentage of their time to training others to do the work -- a form of generativity and a means to increase the community of caregivers. Creativity and Distress A simple unplanned intervention that accomplished a great deal within a family was witnessed by the authors in Israel during the 1991 Gulf War. In late January 1991, after the Allies started bombing Bagdahd, Iraqi SCUD missiles began to fall on various parts of Israel, mostly on the population centers along the Mediterranean coast. Out of a fear that Iraq might be using chemical weapons, citizens throughout Israel were issued gas masks, were given instructions on how to use them, and were told to make one room in each home a "sealed room" equipped to keep poisonous gases out and supplied with food and water in case of prolonged emergency. One family comprised a mother, a father, and four young children: an infant a few months old, a two-year-old boy, a four-year-old boy and a six-year-old girl. Infants had to be placed in a special plastic crib sealed to prevent gas from entering, since they could not be fitted with gas masks. The older children and the adults all had their masks. While all members of the family were subject to similar risks, the protection against the gas had different import for all of them. For the infant, the difficulty was being put into the sealed plastic crib, with only visual contact with the family, and deprived of the chance to be held and soothed. The four year old and six year old responded by drawing brightly colored pictures that they put on the top of the plastic crib so that the baby could see them and be occupied -- even, perhaps, amused. The older children faced dealing with their own age-appropriate understanding of the dangers, the distress of possibly seeing their parents as quite distressed, and an enforced passivity and relative immobility. For them, the responsibility (and the fun) of watching out for the well being of the baby in the plastic crib was an important adaptation -- an opportunity to do, to improvise, and to experience themselves as useful. The two year old turned out to be subject to the greatest distress because he could not so easily join in the activity of the older children and had to rely more on the availability of the parents for support and comfort. The parents themselves were very capable and imaginative people, but like everyone else they were worried and fearful, as well as angry and frustrated. But their sense of competence and imagination helped the older children mobilize their own skills. The parents, in turn, derived support from each other, from the resourceful response of the children, from their role as parents in doing their best to protect the children, and from being part of a community at risk. The government tried to use the radio and television media to stay in touch with the populations in the sealed rooms. A particular military spokesperson kept the country informed minute by minute as to what was happening and as to when the danger had passed. This spokesperson became a major resource and support for both adults and children and he became elevated virtually to hero status. Television also produced specific programs for children: "Sesame Street" was devoted to dealing with fears of children in the situation [34]; the program included a "call-in" segment where children could speak to one of the "Sesame Street" characters to ask questions and receive advice. Community Mobilization The next examples are drawn from programs in New York City that mobilized adolescents in important community and public health service [37]. The first is about a component of a comprehensive neighborhood-based youth program called El Puente ("The Bridge"), located in a Latino section of Brooklyn, New York (next to a bridge -- hence the name). Young people were given stipends to identify and address problems in their community. One group addressed difficulties in getting parents to have their children immunized -- a consequence of the reprisals the neighborhood parents often feared would take place because of their immigrant status, should they access public health services. The young people went door to door speaking with parents about immunization and telling them that they could bring their children to El Puente to be immunized. El Puente had established credibility in the community, the parents were willing to come, and the youth who recruited the parents and their young children were very serious about their work and very proud of it. Another group, calling themselves the Toxic Avengers, did work that eventually led to the first coalition ever formed between Latinos in this Brooklyn community and their Orthodox Jewish Hasidic neighbors -- groups that had been quite antagonistic towards each other. The coalition worked together to fight against a government proposal for a garbage incinerator and against the continuing operation of a radioactive waste storage operation in their shared neighborhood. Another program recruited young people in every neighborhood of the city to document, block by block, all services and programs for youth. Data on each program were amassed and then coded onto a software program. Young people were then trained to answer phone calls as "listeners" and as information providers to young people and adults who called and either "just wanted to talk to someone who would sympathetically listen" or wanted to find out about services. This database is also used for youth and youthworkers in the field to provide feedback about the effectiveness and responsiveness of programs. The youth played -- and continue to play -- an invaluable role in conducting the needs assessment and in operating an invaluable service based on this work. Such projects empower youth by providing them with a goal and a purpose, greatly enhance their legitimate self-esteem, facilitate their forming close relationships with adult mentors who can help them in specific tasks, and give them a meaningful and constructive role within their communities. Anecdotal information suggests that the youth so engaged also become more amenable to individual mentoring and counselling -- including more formal psychological and psychiatric help -- since their enhanced self-esteem allows them to admit to needs and to accept help that might otherwise be experienced as humiliating. Rebuilding Morale In Cambodian refugee camps at the Thai border, Mollica et al [38,39] emphasized the importance of rebuilding and sustaining the morale of the Buddhist monks and some of the traditional healers within Cambodian society. The monks were desperately needed to help this highly traumatized and still endangered refugee population get in touch with its roots and its traditions and, especially, to resume some sort of traditional Buddhist education for the children. The children needed to hear the traditional tales, to learn of the traditional healing methods, and to sense that they had a connection with something older and larger than themselves and their parents. This was absolutely necessary in order to help develop the part of the children's personalities that needed heroes and ideals in a setting of fallen or impotent heroes and totally shattered ideals. Accounts by observers and accounts by children themselves have attested to the need for this work of restoration and to its healing power. Recovering Autobiographical Memory Another example relates to access to autobiographical memory (see above). In the first year of the Intifada [late 1987-1988] a human rights investigator, Anne Nixon, was collecting data in the Palestinian refugee camps on deaths and injuries of children due to the Intifada. In the course of collecting data, she gave out pencils and notebooks to the children, primarily to help them keep busy. But recalling newspaper accounts of the work of an Israeli psychologist, she asked the children to keep dream journals. After a closure prevented her from returning for several weeks, she came back to the camp and was beseiged by children waving their notebooks and telling her they had many dreams for her to read. Nixon herself had no psychological training and was not sure what to do with the material, but the children did not seem to mind the activity and wanted to write more dreams. Meanwhile a number of the parents had read their children's journals and were astonished at what they learned about their children from the record of their dreams -- especially the intensity of their fears and their hopes. The impact of this exercise was manifold: it helped the children get in touch with and document and preserve a record of their own inner world. At the same time it served a major communicative function to their parents, who became more aware of the intense inner mental life of their children. It also communicated to the human rights investigator a dimension of her investigative work that had hitherto not been deemed so important -- the emotional and inner life of the child. The construction of an autobiography and the recapture and preservation of personal memories is a life-long task and requires different kinds of facilitation at different life stages. Projects that interview survivors of various wars and persecutions (most notably interviews of adults who were children in World War II) are frequently therapeutic in their own right, assisting the interviewees to re-organize, recollect, and narrate their experiences, and to integrate them into their adult lives. Such a construction and recording of an autobiography is also a communal effort, representing a community response to the needs of the interviewee, but also to the needs of the community to have a memory and a permanent history of events which, by virtue of their traumatic nature, can be forgotten all too easily or neglected with the passage of time. Restoration of a Moral Order One of the most disturbing aspects of late-twentieth-century warfare has been the use of child soldiers. In the armed conflict in Mozambique the rebel forces, Renamo, comitted horrible atrocities, among them the kidnapping of children as young as five from "enemy" villages and forcing them to fight against their own tribe and family. At times these children were forced to witness or participate in the burning of villages and even the killing of their own family members. As some of these children, one way or another, were able to find their way back to government territory and, even more so, as the fighting drew to an end, the government was faced with the problem of what to do with these children, many of whom were, in effect, incarcerated [40,41]. There were several aspects to the government response to this problem, one of which was to build a few residential centers for treatment and rehabilitation of some of these "child warriors," especially older ones who seemed more hardened and more difficult to reach. But a broader move involved issuing an amnesty for these children and asking their tribes and families to forgive them and to take back as many as possible into whatever family or kinship group had survived. The government decided upon a policy that recognized the terrible plight of the children, not denying the horrors in which some of the children may have had to participate. But the morality of the situation before the amnesty was so complex -- for the society as a whole and, especially, for the children -- that any form of treatment or rehabilitation would have been doomed to failure until the government helped establish a new public moral order. Preliminary followup has suggested some significant degree of success for the policy. In a different context, many hundreds of Argentinian children had been kidnapped by the military dictatorship during the 1970s and given to childless military families, while their parents were tortured and killed. After the restoration of democracy, in a bold move and against the advice of some mental health professionals, the Argentinian judiciary decided that the children had to be removed from the families who had been rearing them -- but who had gotten them immorally -- and returned to their closest living relatives (usually grandparents). Some of these children had been living with their military parents since they were infants and had no memory of another family. Others, taken at later ages, had varying degress of conscious memory of their families of origin. The judiciary argued that it was not good for the children or for the society as a whole to leave them with families that had obtained them in such horrible ways -- that a moral statement had to be made. Subsequent followup of many of the children revealed that, while their adjustments to the families of their relatives were not free of problems, they themselves, in various measure, had been aware that they had been living in families that had lied about their origins and that had been complicit in the disappearance of their own parents. The children themselves signaled in many different ways that their own stability depended on knowing and living out the truth. Interventions That Pay Attention Both to Large Numbers of Affected Children and to Individual Children
Israel Cambodia Bosnia Interventions Combining Maternal and Child Health Programs With Specific Psychosocial Interventions Children (and their parents and caretakers) afflicted by the traumas of war must never be given the impression that they are totally unusual, let alone "crazy" or "insane," because they are experiencing psychological distress. The vast majority of children and their caretakers need help with the trauma of war and persecution, while these events are ongoing and in their aftermath. But there are grounds for fearing that interventions specifically labelled as "psychological,î let alone "psychiatric," can alienate most of the people they are intended to help -- shame or guilt over not being responsible enough or capable enough can lead to formidable resistance to getting even minimal help. In countries where psychotherapy may be readily available, survivors of terrible traumas such as the Holocaust or the Cambodian genocide have conveyed that they have already been labelled, categorized, and declared deviant, if not sub-human. These groups do not need any further psychiatric categorizing. Combining psychosocial interventions with basic health and welfare interventions, therefore, tells both the clients and the providers that to be upset is expectable and that such responses are not deviant. This consideration makes all the more crucial the skilfull blending of bodily health and psychological health interventions. Consider a basic UNICEF child health intervention: the preparation, distribution and use of Facts For Life , and Using Facts For Life-A Handbook . These UNICEF publications about maternal and child health present practical and low-cost ideas to families in more than 100 countries in numerous languages and have already been distributed to more than eight million people. The pamplets are addressed to men as well as to women and the charge is to all adults to put into practice the essential health knowledge that is commonly seen as "women's work" -- especially in third world and devastated areas. The publications are organized around "the most important messages," all of which entail profound psychosocial teachings that could be enhanced and made more explicit. Program interventions might add a psychosocial awareness and dimension that implements and enhances those areas already in focus: the timing of births, safe motherhood, breastfeeding, child growth, immunization, hygiene, child development, and attention to illnesses such as diarrhea, coughs and colds, malaria, and AIDS. Consider the possibilities inherent in a few of these topic areas: Family Planning Timing births is something that families will do when birth control methods are available and when families understand the value of spacing children and feel more secure about their futures. Family planning services have to be more than dispensers of contraceptives to be effective. A discussion group at the site of the dispensary/clinic can give young women and couples a chance to talk about their wishes to become and not to become pregnant. Some prospective parents will have lost children they may be wanting to replace; a chance to talk about the loss and to grieve (with others who shared similar losses) may allow for delaying another pregnancy until a healthier time for the mother and next baby. Women can talk with each other about planning and managing families. Realizing the possibilities for one child can make for greater satisfaction and involvement with the living child, and greater willingness to delay another birth. Information about the option to plan births and about available technology can empower mothers, making them more effective as parents and increasing the resiliency of their children. Showing them simple new ways to solve major life problems like birth can become a message that there may be solutions to other serious difficulties they confront now or will confront later. Family planning can be especially problematic in situations of armed conflict and their aftermath. Apart from many concrete difficulties (in massive refugee situations, for instance), there is the psychological struggle between the knowledge, on the one hand, of how difficult and, at times, dangerous it would be to be pregnant and to bring an infant into the world and the urge, on the other hand, to assert the continuity of life and to make up for terrible losses by begetting children. A sensitivity to this issue is of immense importance in working with women (and men) on family planning. A keen sense of the particular cultural context in which these issues are taken up is absolutely necessary. Prenatal Care Safe motherhood involves good prenatal care and a trained person assisting at the delivery. Pregnancy is also an optimal time for psychosocial intervention, a time of receptivity by the woman who is caring for her baby-to-be and a time when the community may be more willing to devote resources to her. The pregnant woman can become the focus of good health practices and can receive attention to her nutrition and her overall health. Needless to say, all of this can be exceedingly difficult in situations of war, forced flight, and persecution. There are appalling tales of women giving birth among corpses or of terrible dilemmas in which infants have been abandoned or even killed because their crying could have betrayed a whole group of adults and have led to their deaths. No one can propose simple ethical -- or practical -- solutions to such extreme situations. Nevertheless, it is important not to despair. There are reports of communities that amazingly have mobilized very limited resources, drawing upon practical advice and emotional support from other mothers. Dalianis-Karambatzakis [12] documented the support program that Greek women imprisoned during the Civil War devised for each other -- sharing child care, tutoring illiterate mothers, and redisributing limited food supplies to mothers and/or infants most acutely in need. Also, when practical, working with the other children of the expectant or newly delivered mother while she is getting her medical care could be most useful. The mother's pregnancy is also an important opportunity for these children to get some adult support and to give some expression to their fears and wishes. Immunization Again, as programs for immunization are devised and implemented, all possible avenues should be explored for combining the immunizations with opportunities for parents (mostly mothers) to discuss questions about both the physical and the psychological health of children. In recent years, even in some very vicious situations of civil war and armed conflict, the warring parties have allowed "safe days" for childen to be immunized, providing an opening, however small, for mothers to get some outside help and advice about their children. Childhood Mental Health Child Development: Facts For Life , a widely distributed UNICEF booklet, gives readers a sense of the differences in children at different ages and of basic principles of childhood mental health. Here, families learn that "the child's greatest need is the love and attention of adults," a message that can be reinforced in discussion with families who come for physical health care, and can be demonstrated by the professionals and paraprofessional staff workers in kind and loving behavior toward the parents and children. Another UNICEF publication, Macksoud's Helping Children Cope With Stresses of War: A Manual For Parents and Teachers, [2] is a short book that has been field tested and that can be used with great effectiveness in transmitting some basic lessons not only about stresses, but about child-development. An elegant example of a simple "psychosocial" intervention with large practical benefits administered through ordinary health facilities is the giving out of disposable diapers to children in refugee camps who are bed-wetting (past the age of culturally appropriate toilet training). The shame parents and children feel as sheets have to be removed and publicly washed and dried, as well as the immense practical difficulties of laundering in crowded refugee camps, can be considerably alleviated by this simple measure. Overall, it is important to encourage traumatized communities to develop their own methods of teaching and training each other in child rearing. Professionals (whether within the culture or from the outside) should realize that they have to offer not only facts and advice, but skills at facilitating the mobilization of the community. Who Takes Care of the Caretakers? What Is Needed to Help Those Helping Children? The implicit assumption of this paper in discussing psychosocial interventions for children has been that the "average expectable caretaker" is reasonably skilled, mature, imaginative, resourceful, optimistic, and extremely dedicated to the welfare of children. We all know that even under situations of total peace and stability in developed countries we cannot make such assumptions about the caretakers -- there is simply too much individual variation. Under the stress and duress of armed conflict, whether acute or prolonged and intractable, the caretakers themselves are under enormous strain and cannot be the models of resiliency and resourcefulness we would wish for. There is a substantial literature and lore on what is needed to take care of caretakers -- some of this is subsumed under the rubric "burnout," and some of it under the heading "secondary trauma." An important review has been prepared by Danieli [43] of understanding and dealing with the enormous pressures on those working with children traumatized by war, persecution, and forced dislocation. There is also a body of literature originating in psychoanalytic studies of childen about how much the child's expression of grief and trauma can be inhibited by an adult's difficulty in seeing and hearing the intensity of the child's pain. Numerous examples were seen in 1963 when the president of the United States, John F. Kennedy, was assassinated. One six-year-old child complained to her parents who, with a group of neighbors, sat glued to the television set, that none of her usual children's programs were on TV. Impatiently, her mother told her to play by herself in her room, to paint something on her easel. Some minutes later, the child returned to show her mother that she had listened to her, had done a painting, and wanted to show it to the adults there assembled. She held up a watercolor (still wet and dripping) that showed a huge black mass with globs of bright red dripping from it. The adults all gasped with horror at this direct expression of the child's perception of what the past few days had been: blood and grief, grief and blood. One adult asked the child what she had drawn and the child answered, "Oh, it's just a lady's pocketbook with some lipstick on it," and the adults all breathed a sigh of relief. None of the grieving and anxious adults felt up to taking on the task of dealing with this six-year-old child's reactions to the assassination and its consequences. Multiply this story by large numbers of children and by the immensity of what they have been through. The fact is that the children are being cared for either by adults who have been directly affected by the same violence affecting the children, or by people coming from the outside (as international relief organizations) who themselves can easily be overwhelmed by the immensity of what they see and hear -- especially the experiences as conveyed by children. Surveys of children's distress and symptoms in situations of violence as a group have shown that adults tend to under-report the degree of suffering experienced by their children. A few general comments, then, are in order about what is needed to care for the caretakers. First is information -- the caretakers not only need to know as much as possible about what they are supposed to do, but they need to know as much as possible about the children (and families) with whom they are to work. This applies most obviously to workers coming from the outside, but adults need to be educated even about their own children ( or children of their own group) as if the children were of another tribe. Second, the assistance that the caretakers need must come not only from manuals and books, but in part from an experience of dialogue, of talking, and of processing their experiences. For each adult involved, his or her own childhood experiences -- fears, terrors, wishes, nightmares, losses -- are stirred up in working with traumatized children and there must be some dialogue that recognizes this aspect of caretaking. Several different models of such small and large group dialogue have been published [43,44] and many others have evolved in various local settings. Opportunities to discuss controversial aspects of the situations they are in -- the political dimensions and the basic human rights dimensions -- are important for the well being and ability of the caretakers to persist and endure (e.g. [45, 46,47,48]). Irving Harris, in an address to the Columbia School of Journalism, told the parable of the man who is at a picnic at a riverside and hears a shout -- "Child in the water!" -- and promptly jumps in to save the child. Over the next hour this scene is repeated a number of times -- shout and rescue --but finally the man who has repeatedly rescued the children walks away from the river. Someone shouts, "Where are you going? There's a child drowning in the river!" He replies, "I'm heading upstream to see who's throwing all those kids into the water!" For those who are deeply immersed in the day-to-day work with traumatized children, it is crucial that they have a chance to ventilate and, even more important, to discuss and to learn about the complexities of the situations they are in. While the caretakers must pay attention to the children in their charge, they cannot remain ignorant of the larger situation around them. This includes the problem of how one deals with the children's questions -- or their reluctance to ask questions -- about the political situation around them. This is easy, relatively, when you feel your cause is just, but what about when your cause is only partially just, or is outright unjust? How does one conceptualize the enemy's children and their plight? How does a Catholic therapist in one part of Belfast deal with politics with his eight-year-old patient whose father was killed by Protestant extremists? And how does the Protestant therapist, in the mirror image situation, deal with his patient whose father was killed by the IRA? At the programmatic level, those working with psychosocial interventions must take a position on what, if any, will be the relationships among the opposing sides in any given conflict. During the conflict in the former Yugoslavia, several international agencies took the position that they must deal with all the warring parties -- Serbs, Bosnian Muslims, Croatians, and other groups. Other organizations -- some national, some international -- made the determination that they would deal with only one side, "my side," or the side with which they had elected to work. The answers to these questions are not simple, but those working with children must be given some opportunity and some permission to tackle these and related issues. These last questions lead us to the final section of the paper, namely, what can be done to interrupt or alter the transmission of hatred and revenge from one generation to the next? If we cannot somehow stop slaughtering each other, can our childen learn to stop? Can We Interrupt the Cycles of Transgenerational Hatred and Violence? "YouÍve got to be taught All the preceding sections of this paper assume the continuous and reciprocal interdependence of the traumatized child and of the family and society in which the child is embedded. Here we must envision not only this "horizontal" interdependence -- that is, interdependence at any given point in time -- but also a "vertical" interdependence of the child with antecedent generations and with the generations the child will beget. Is the intergenerational transmission of hatred, fear, and need for revenge inevitable or can it be averted, interrupted, transformed? One can cite examples to answer "yea" or "nay" to this question. Thus, the Western nations have made peace with Japan; Europe and the United States have made peace with Germany. Fragile peace is in place in the Israeli-Arab conflict, in Northern Ireland, and between North and South Korea. In El Salvador there is a growing investment by all sides in maintaining the peace three years after the signing of an agreement between the government and the rebels, who now share power in a democratically elected government. On the negative side, one can easily cite the situation in the former Yugoslavia, the tribal hatreds in Somalia, Rwanda, and Burundi, and the persistence of hatred and acts of violence and terrorism even in places where, supposedly, there is a peace and, at least, a truce. What makes the difference in outcome? Does one's expectation and preliminary outlook on the possibilities of intergroup reconciliation affect one's actions? Both the more hopeful and the more pessimistic assessments are susceptible to oversimplification and to presuming some kind of mechanistic model of transmission. Each view may slight important aspects of individual and group psychology or may short-circuit important historical contingencies, such as the role of particular leaders at particular points or the appearance of a new "common enemy" uniting previously hostile groups. The assumption in the following discussion is that there is a major role to be played for human agency -- for responsible and caring human agency -- in working towards the gradual resolution of the tension between "remember, do not forget what Amalek did to you" and reconciliation. The conflict between urges to revenge, between unconscious needs to turn victim into victimizer, on the one hand, and the thrust towards leading a peaceful life, towards altruism, towards understanding, on the other -- these tensions are absolutely expectable and predictable, but the outcomes are not. (1) Psychological Models of Transmission There are sophisticated models of explanation both for the transmission of intergenerational hatred and for the mitigation and reduction of that hatred. These models have yet to be fully integrated with detailed historical and sociological studies, but a brief examination of the possibilities here is worthwhile. One psychological model of the transmission of hatred and propensity for violent revenge is based on assumptions about the effects of trauma in childhood and the need to repeat the traumatic experiences, now as an agent inflicting hurt rather than as a victim who has been hurt. Such a model can draw upon psychoanalytic concepts of the need to actively master trauma that has been passively endured, including the concept of "identification with the aggressor." In principle one could examine the historical and social particulars of what was traumatic and the particular cultural methods of ensuring that the children will remember the injuries inflicted on them, on their parents, and on their ancestors. There are studies, for example, about German children during World War I who grew up and turned to Nazism [49] and about how child-rearing practices of Greeks and Turks keep alive the Greek-Turkish conflict on Cyprus [50]. Overall, these studies tend to explain how hatred and violence are successfully transmitted. The term "resiliency" provides an underpinning for explanations of how the cycle of intergenerational transmission can be interrupted and even transcended. A model of resiliency allows one to focus on the plasticity and flexibility in human response to trauma without disregarding the difficulties of achieving reconciliation, forbearance, and mutual acknowledgment between previously warring groups. There is clearly an urgent need for such interventions, but there is also the possibility of devising and implementing them [51]. Interrupting or Mitigating Cycles of Intergenerational Hatred and Hostility The most extensive studies until now of attempts at reconciliation over the generations have been of survivors of the Holocaust. Both reconciliation among the generations and, more recently, reconciliation between descendants of Holocaust survivors and descendants of Nazi perpetrators have been studied. Bar-On [52,53,54] has been the most noteworthy in studying both aspects of reconciliation and important work has been done also by Hardtmann [55], Krondorfer [56]. Weissmark et al. (e.g. [57]) have done pioneering work; they and others are beginning to address how to generalize their work to other situations. Bar-On, in Legacy of Silence [58] has studied the painful process by which some descendants of Nazis have come to learn about and deal with the past of their parents (and grandparents) -- whether the parents were high Nazi officials or lower level functionaries agreeing with the official policies. He has detailed the resistance to this work, both within each of the descendants and within the society as a whole. But, importantly, some people have undertaken and continue to courageously pursue the goal of coming to terms with their past (and their present). Bar-On has also studied Israeli families -- three generations of Holocaust survivors, their children, and their grandchildren [53] and analogous studies are going on in Germany. In this work he and his students have demonstrated that the relationships among the three generations are quite complicated -- that no simple model of either transmission of trauma or of transmission of reconciliation fits their rich interview data. Rather, what emerges is the possibility and actuality in some instances of the generations helping each other come to terms with a horrendous past and helping each other leave more at peace with themselves and in their own intimate relations. Thus, studies both of descendants of Holocaust survivors and of descendants of Nazis have opened up the possibility of a meaningful dialogue between the two groups. That is, some process of each group first beginning to come to terms with its own history is a necessary condition of the groups coming together. At the same time, in the process of coming together, each group (and each individual) has a further opportunity to come to terms with the past of the group (and of the individual). The processes of intra-group work and inter-group work turn out to reinforce and enhance each other. The details of such encounters are very powerful, very distressing, very moving, and ultimately very inspiring. They show examples of great courage on the part of the participants -- the heroism of facing reconciliation with the knowledge of the existence and persistence of great hatred and an enormous burden of guilt. The Role of Apology A powerful theme relevant to resolution of conflict between and among warring groups is the role of apology, as exemplified by the writings of Montville [59,60]. Montville cites several poignant examples of apology by a leading representative of one group to another and details the positive consequences of such an admission of guilt and responsibility. Among his case studies are also examples of attempts to change attitudes over the generations by large-scale programs of youth exchange. He details the exchange of thousands of French and German high-school students in the wake of World War II -- each student living in a family of the former enemy -- and the powerful impact of these experiences. While Montville has no illusions about the sufficiency of such measures (apology, exchanges) in and of themselves, he also emphasizes how much such moves can catalyze and enhance other aspects of reconciliation (in the military, political, economic, and legal areas). (See also Volkan [61]). Montville emphasizes both the role of leadership in these movements and the necessity to have an impact on large numbers of ordinary people. The two go hand in glove. The Role of Education How does one educate children and youth to desire and learn how to live more peacefully? There is a large and quite relevant literature on working with children in methods of nonviolent conflict resolution that cannot be reviewed here (e.g. [62]). But an important aspect of education is the issue of the content of the school books that children and youth use. What version of history, whose version of history, and what portrayal of the "other," -- the enemy -- is in those books? There have been extensive studies in the U.S. of how history texts and texts in other academic fields deal with issues important within the U.S., such as race relations, the role of women, immigration and minority groups, and the history of the Vietnam War. In terms of inter-nation and inter-ethnic or religious group texts, there have been, to the authors' knowledge, only a few small scale and rather fragile (fiscally fragile) attempts to study the problem and, more importantly, to do something about it. There have been starts at writing common Middle Eastern history textbooks that can be used for both Israeli and Palestinian children and common European history texts that can be used for both German and Polish children. The Georg-Eckert Institut für Internationale Schulbuchforschung has been a leader in studying textbooks and working on the problems of producing new ones. Of course, changing textbooks without working closely with teachers would be of little avail and the two tasks must go hand in hand. Engaging schoolteachers -- and not only professional university historians -- in the hands-on task of revising texts is a move in the right direction. What applies to textbooks applies also to mass media, especially television and movies. Paradoxically, these media are powerful in perpetuating stereotypes and prejudices, but can also be very powerful in questioning and weakening prejudices. Television and the movies have done much to present accounts of the horrible events of the twentieth century and these accounts have had a powerful educational impact. An important issue from the point of view of the resiliency of children has to do with the role of ideology and commitment to a cause in sustaining the morale and, indeed, the very life of a child in situations of war and persecution. Mental health professionals must face (and thereby help governments and international groups to face) a crucial issue: How and when does commitment to one's group become a focus of self-destructive hatred -- an internal disease that interferes with eventual reconciliation. In the hypothetical (yet not so hypothetical) situation described above of two therapists, one Catholic and one Protestant, each treating a little boy whose father has been killed by the other group, the therapists must struggle with that question. Such a struggle must include a self-examination of the role of ideology and political commitment in their own lives and in their own internal equilibrium. The bankruptcy of some ideologies, especially since the fall of totalitarian Communism in the Soviet Union and Eastern Europe, has become an important theme and mental heath professionals, like most citizens in these countries, must struggle with the implications of the ideologies and beliefs they have lived by, lived with, or lived in spite of. None of this is easy, but none of this can be avoided. In a few parts of the world (e.g., Israel and Palestine), some small beginnings have been made by mental health professionals wrestling with these issues, both in dialogue groups and in personal, informal discussions. Endnote The discussions here are not intended as comprehensive, but as supplementary to other summaries, especially the chapter by Ressler in UNICEF's Children in War: A Guide to the Provision of Services [1]. The authors have tried to highlight particular issues that are not always emphasized in discussions of psychosocial interventions, especially in the literature to which those working with children outside the mental health professions have access. They have emphasized the value of thinking of child development and of children's response to war, persecution, and forced dislocation in terms of the model of resiliency. Ultimately, their plea is for mental health professionals themselves to mobilize their own resiliency and their own imaginative resources in the service of their ongoing work with children.
1. Nor do we get definitive answers to the question of the inevitability or avoidability
of destructive conflict from either evolutionary biology or cultural anthropology,
for all the contributions from the different parts of these disciplines ultimately
describe trends and propensities, not outcomes. Altruism is as "natural" as aggression;
a reverence for life as much "hard-wired" as destructive attitudes. This is aside
from how controversial and controvertible are the findings of areas such as sociobiology.
Relevant is a UNESCO declaration from the post-World War II years [63], declaring
that evidence from the social sciences in no way concludes that human beings are
innately primarily destructive, let alone that warfare is absolutely inevitable. References
1. Ressler E, Tortoricci JM, Marcelino A. Children in war: A guide to the provision
of services. New York: UNICEF. 1993. [Note: For a more comprehensive bibligraphy consult Apfel RJ, Simon B, Liberty S. Bibliography on the Psychological and Psychosocial Aspects of Children in War and Situations of Violence. Newton, MA: Working Group on Children in War and Communal Violence (International Association of Child and Adolescent Psychiatry and Allied Professions). July, 1994. (Available from the authors.) *RJA is Associate Clinical Professor of Psychiatry, Harvard Medical School, at the Cambridge Hospital and a member of the faculty of the Boston Psychoanalytic Society and Institute. She is a consultant at the Upham's Corner Home Health Service. **BS is Clinical Professor of Psychiatry, Harvard Medical School, at the Cambridge Hospital and Training and Supervising Analyst, Boston Psychoanalytic Society and Institute. He is a member of the Community Crisis Response Team at Cambridge Hospital. |