Stevan Weine M.D.
Other Voices, v.2, n.1 (February 2000)
Copyright © 2000, Stevan Weine M.D., all rights reserved
In Art Speigelman's MAUS, the protagonist Art goes to see his psychotherapist, a Czech Jew named Pavel. Like Art's father, Pavel too is a survivor of Auschwitz. Art tells him that he cannot draw, "I am totally blocked". He is bothered too much by all the interviews and business propositions that come as a result of the immensely successful MAUS book. His relationship with his impossibly difficult father hasn't gotten any better. His therapist offers some reasonable interpretations of the second-generation variety. Tries to help him to understand his relationship with his father, the difficult bind of living constantly with Holocaust memories, and of writing a book. Walking home after a psychotherapy session, Art says to himself, "Gee, I don't understand exactly why...but these sessions with Pavel somehow make me feel better".
It is not the primary aim of his wondrous books, but Speigleman, the second-generation survivor and avant- comic artist does give a brief, indirect rendering of psychoanalysis' rather large presence in mental health work concerning Holocaust survivors. This is part consequence of all those Pavel's, either survivors or children of survivors who became psychoanalysts or psychoanalytically oriented psychotherapists. Survivor psychoanalytic investigators have been at the forefront of psychologically oriented investigations into genocide survivors, including Bruno Bettelheim, Henry Krystal and Dori Laub. But the fit between psychoanalytic theory and working with Holocaust survivors is clearly due to more than this overlap of life and professional experiences. It is perfectly obvious that psychoanalysis and Holocaust studies share concerns with extremity, narration, remembrances, reconstruction, identity, meaning and truth. These remain central topics in the ever growing field of Holocaust and genocide studies, which recognizes psychoanalysis as a major contributant. However, psychoanalysis was never intended to be all things. One thing it certainly was never to be was a public health effort to address the social suffering of genocide survivors. Psychotherapy was right for Art, the son, but Vladek, the father is not the type. Is there any other help for a Vladek?
The mental health work with survivors of subsequent genocides, take Cambodia, were influenced far less by psychoanalysis and more by the social psychiatry and the community mental health movement. The psychiatrists, Richard Mollica, J.David Kinzie, Joseph Westermeyer, and James Jaranson have each described the development of specialized refugee mental health psychiatric clinics, which modify the medical-psychiatric approach to address language, cultural and socio-economic barriers. There is a greater emphasis upon providing care that fits with the needs and the conditions of the survivors who in this case are refugees – poor, marginalized, and best by multiple life stressors. Treatment may involve psychotherapy, but not the private practice model: community setting, flexible times, no fee. Survivors who would otherwise never access psychotherapy, can have someone to talk to about their struggles.
When you read the mental health the mental health literature on these groups of genocide survivors, the clinical interventions most often discussed tend to focus upon the individual survivor and the presence of individual mental health consequences, especially traumatic stress and depressive symptoms. Far less attention is paid to family and community effects from genocidal trauma and influences on service use and outcome. There is also very little work with prevention. The impression it gives is that you must go to see Pavel in his office, not he to you or your family in the places where you live.
Then came the recent experience of ethnic cleansing in Bosnia-Herzegovina, with several million survivors, leading to a plethora of psychosocial assistance programs in Bosnia-Herzegovina and internationally to address the survivors' mental health needs. The international mental health professionals Inger Agger and Soren Jensen published a directory of the scores of psychosocial programs in the former-Yugoslavia circa 1995. Their descriptions show that there is a great variability amongst programming efforts, and give evidence suggesting that the models of intervention for genocide survivors have continued to evolve.
The critical element in many of these more recent efforts is the assumption that the suffering of genocide survivors is best framed as social suffering. This is to emphasize two important facets. One, that genocide survivors present a massive public mental health problem. Two, that their experience of suffering, and the choices made by survivors and their families in response to that suffering, is highly shaped by social and cultural forces. Social suffering calls for public health minded approaches, especially preventive interventions, but also clinical interventions that are grounded in the social realities of the survivor groups. For Bosnians, as I soon came to learn, this means the family.
Rather then commenting upon programs in Bosnia-Herzegovina that I have only visited, or know of secondhand, I turn to the work that some of us have been doing with the large group of survivors of genocide who resettled in Chicago. This is a story of growth and transformation and it will be told as such. The conclusions were not known from the beginning. We had to get there, and not alone. In recounting this story, it is not my intention to be critical of any the individuals nor organizations that have deployed themselves to work with Bosnians in Chicago. And yet, it seems a serious mistake to think that it is only the survivors of genocide that have to learn from us.
I learned from a lot of people, especially from Bosnians. This learning was facilitated by the existence of our Project on Genocide, Psychiatry and Witnessing, which we formed in 1995. The Project is lead by the Croatian American psychiatrist Ivan Pavkovic and myself, and also includes the Bosnian physicians Amer Smajkic and Zvezdana Djuric Bijedic, the Croatian psychiatrist Alma Dzubur, and the Bosnian literary scholar Tvrtko Kulenovic. We endeavored to provide specialized mental health services to Bosnians through our collaboration with the Heartland Alliance, and also to conduct research and interdisciplinary studies, so as to advance the understandings and interventions concerning genocide survivors.
Part of this effort has me working as a psychiatrist at a specialized clinic for Bosnians located in the Bosnian community in the Uptown neighborhood of Chicago. Over the past three years, we have treated several hundred Bosnians as a part of an interdisciplinary, Bosnian-American team. It is fortunate that those people are usually able to get the help they need. The treatments offered are similar to those discussed in the literature, including crisis intervention, individual supportive psychotherapy, individual exploratory psychotherapy, cognitive behavioral therapy, group psychotherapy, psychopharmacology, creative arts therapies, rehabilitation, play therapy and marital and family therapies. Our research on treatment has begun to systematically demonstrate which treatment activities can best help survivors to recover. But never have we let ourselves fall too deeply in love with our own small and provisional successes in the clinic setting.
It so happened that through other dimensions of our work, we came to see different sides of Bosnians. When we obtained their testimonies in their homes as part of our Bosnian survivor oral history project, we heard their trauma stories, and also came to know far more about Bosnian social and cultural life. We became so impressed by the strength and courage of those from the community who told their stories, and also that in the clinic context, we could expect less by way of expression and disclosure about facets of the experience that did not emphasize disability and pathology. We believe that this is at best partially explained by differences in psychiatric symptoms, and has more to do with the restricting expectations that being in a clinic setting may put on both survivors and providers. The existing system of care tends to place the emphasis upon identifying those individuals who are the most overtly distressed and who identify with the disabled patient role.
At the same time I was having this other experience with all the Bosnians I had come to know outside of the clinic. For the last six years, Bosnia has taken over the life of my family and myself. So I am with them all the time in our homes, on the basketball court, the café, the workplace, the pub. Most are not willing to present themselves as patients nor even to appear as pathetic enough to quality for that status. But there is real suffering there. What of all the others who may be suffering but do not necessarily want to go to a clinic or agency?
I rethought the work that we had been doing in the clinic. We were proud of what we did there. This program drew upon many of the recommendations made on the basis of previous mental health services for refugees, including trained bicultural staff and an appealing and non-threatening environment. We could see that it did help individuals to heal. But what about family healing? And what of community healing? It is not that I think that the clinic work is wrong. But I did come to believe that it is not enough and that it presents somewhat of a disconnect between the American mental health professionals' sense and the Bosnians' sense of what is amiss, what is still good, and what will help.
Estimates of the numbers of treated refugees support this claim. Over the past three years more than 400 Bosnian refugees have received mental health treatment at this program. A generous estimate would say that at most 600 more refugees (out of a denominator of approximately 16,000) have received some mental health services through other Chicago sites, either multi-service agencies, primary care, community mental health, or clerical counseling. The current situation in Chicago, where less than 10% of refugees have received some kind of formal mental health services, is a substantial underutilization.
What we have in our refugee mental health programs can be critiqued for being a "waiting" model, in which the patients are responsible for presenting to the clinic-based treater. A small subset of genocide survivors will present for such treatment, and may accept the patient role, but what of the many who do not? A major problem for survivors, is that despite the existence of formal mental health services offering efficacious treatments, there are still a great many who do not access or adhere to mental health care, and whom are suffering trauma related mental health consequences.
We can assume that for them, there may not be the social networks nor the shared set of help-seeking behaviors that would serve to channel their distress into becoming service recipients. However, these concepts have heretofore not been of high interest in the field of genocide studies. The Bosnians made me curious enough to take this further. But it meant that I would have to modify or replace basic assumptions of the conventional psychiatric approach to genocide survivors. Fortunately, I had ready partners amongst the Bosnians who helped me to more fully appreciate the bind that the proposition of psychiatric treatment for genocide survivors puts both them and us in. It goes like this.
We want to offer them mental health services that address the mental health consequences of surviving genocide. The interventions we have are mental health treatments that we direct at individuals with symptoms of psychiatric disorders. However, we do not want to shame or stigmatize individuals by giving them a label of a diagnosis, so we do not emphasize that all Bosnians are at high risk for Post Traumatic Stress Disorder or Depression. As a consequence we do little by way of education and outreach, explaining to ourselves that we do not wish to impose our value system on their. We end up transmitting a highly ambiguous message, which gets through to a relatively small number of Bosnians, who end up becoming our patients. These are ones who are most willing to accept the sick and disabled role. The others stay away.
One counter strategy in our field is to turn away from PTSD and to emphasize that they are victims of a historical crime. We choose the path opened up by the trauma story. For example, in testimony work, we encourage them to overcome all their fears and apprehensions about mental health care, through participating in a psychohistorical framework. And we gather the testimonies together so as to shine the light upon collective memory, as opposed to individual memory. For some this is enough, but for a great many, this is still improbable. (More than a few Bosnians seem allergic to the notion of "collective", having been burned too badly by the collective mentalities of communism and nationalism.) Some survivors (like Vladek) find that telling the story is more appealing then being a mental patient. But in the present reality this is still a very small minority.
What I eventually came to believe is that in our zeal to leap from the individual to the collective, from the personal to the political, because we think it is a more fitting response to the collective phenomenon of genocide, we may have skipped over what for most humans is the most important aspect of life: the family. Have we given due consideration to the role that the family plays in shaping an individuals' experience which includes the choice to seek mental health services? Have we given enough space towards a consideration of family memory of historical events? What appears to be missing is a focus on what is certainly the most important aspect of Bosnian life: the family and its strengths. And the question which immediately appears for Bosnian survivors of genocide: after all that families have been through, are their not ways to help families to be stronger? If we want to address the mental health needs of survivors, then the interventions must fit with the real world conditions of these survivors' families. This calls for an innovative approach to understanding and intervening with survivor families.
In the case of Bosnian refugees, the Bosnian family is widely claimed to be the most important entity in Bosnian life. For the refugees, whose countries were destroyed (Yugoslavia and Bosnia-Herzegovina), the family is the most important remaining social institution. Family plays a major role in shaping their experience as survivors. For the most part, these are families in which every individual family member has been exposed to traumatization, though with substantial heterogeneity (e.g. fathers in concentration camps, mother and children fleeing across the countryside, men in combat, women being raped). Bosnian families are likely to be affected by one of more members who are suffering from mental health consequences. These families may identify some persons as more vulnerable, weak or dysfunctional, though not necessarily as identified patients.
Not only its individuals, but the family itself, is traumatized. A great many of these families have suffered the loss of a family member, separation from family members, marital discord and divorce. One special problem pertains to families of mixed marriages (20% of marriages in Bosnia were mixed; more than 30% in Sarajevo), where there is often increased tension within the family, and increased isolation or hostility from the Bosnian communality. These current extreme threats to the integrity of the Bosnian family come in the context of several generations of massive social pressure on Bosnian, with the twentieth centuries' experiences of poverty, migration, urbanization, war, and ethnic nationalism.
Bosnian refugees think of the family as a two or three generation tight knit group. At another level, they will focus on a wider network of kin and community. Some village families, adhered to the form of "zadruga", which means "joint family, home of several brothers and families". These complex extended household structures involving the coexistence and cooperation of several generations. Ethnic cleansing and forced migration often destroyed these family structures. Families tend to be patriarchal and patrilineal. After surviving ethnic cleansing and displacement, families' sense of solidity can be very strong: "Those who survived and left, we are here and we are together".
Contrast this with the small family therapy literature on survivors of political violence which focuses on problematic interpersonal aspects of the survivor experience. Chambon addressed the problem of family disruption and the necessity of helping families to reorganize and to discover how they want to address traumatic memories. Sluzki's case study explores a family's silence after torture, and the role for family therapy. Simon studied Soviet and Vietnamese refugees, and looked at intergenerational conflict between mothers and daughters amongst Soviet and Vietnamese refugees. Ben-Porath addressed the problem of different rates of acculturation in the family and loss of family members. Westermeyer and Wahmanhold noted that family factors that contribute to pathogenesis. Agger and Jensen discussed how enduring torture and political violence forces family members to make impossible choices and may even precipitate betrayals, thus causing destruction or confusion of ordinary family roles. There may be an avoidance of open communication in the family, with the keeping of family secrets. Multiple writers note that refuge families may not let outsiders know of family problems, because they feel that these are best dealt with inside the family. It often takes time and the establishment of a trusting relationship, before family secrets will be revealed. Overall this literature emphasizes family weaknesses and problems and prescribes more family therapy. It seems closer to the pschopathologically oriented psychiatric literature then it does to the way I was coming to see Bosnians: healthy families who have passed through Hell.
There is another body of work concerning genocide survivors focused on trauma and family: the multigenerational aspects of trauma. I do not want to give the impression that there isn't much of value in this literature, but that here the primary concern is how trauma in one generation is passed on to another. That is asking questions about family that are similar to those asked about individuals in the psychopathological paradigm: how did trauma adversely change you? How did it break you and turn you into something other? It was through the eyes of Bosnians that I became convinced of the need to turn the table on that set of assumptions and to ask an entirely different kinds of questions. How does a family stay strong? How does a family learn to cope? How does a family get along? How does a family find support in other families and in helping organizations?
These were reminiscent of questions that had been posed in a memorable encounter several years earlier with my mentor, Daniel Levinson, who was a scholar of adult development, and author of the books Seasons of a Mans' Life and Seasons of a Womans' Life. Dan was the invited discussant for a case presentation on Bosnians at the Yale Psychiatric Institute in 1994. He posed the challenge to our group that we follow one family over time and see how they get by. You do not need to evoke psychopathology to understand them. You may not even need to treat them. Just watch what they can do for themselves and for each other as a family. Given that the family did not really want treatment, that was easy. We saw with our own eyes the remarkable ways that a survivor family could pull themselves together. This could not be explained by traumatic stress theory, nor the family therapy literature on trauma. And yet of all the papers our group wrote about the Bosnian trauma experience, this one seemed to closest to the real.
It also seems necessary to introduce that for Americans like myself, and for some of my colleauges, who became involved with the Bosnians there was another, very real basis for the connections we made to survivor families. My grandparents came as immigrants to this country from Eastern Europe, as did Dan Levinsons' parents. Having that experience in your family becomes a powerful reality check, telling you that there is a lot more to survival and displacement then trauma and loss. Of course that is also something reinforced everyday by my Bosnian collaborators.
When I came to Chicago in 1994, and had the opportunity to help develop a refugee mental health clinic, I first put family in the background, and let other figures occupy the first place. Psychopharmacology. Testimony. Psychotherapy. Dan Levinson, who taught me so much, did not have a chance to talk with me more about family strengths. But the Bosnians did. They would continue to tell me that family comes first. That if I wanted to understand Bosnians, I had to deal more with the family. Their belief in family strengths mixed with Dan Levinson's faith in the power of adults to learn and grow. And I came to pay increasingly more attention to what the Bosnians had been telling me about the importance of family in their lives after genocide.
And I then had the good fortune to connect with another of Dan Levinson's mentees in Chicago, the psychiatrist, John Rolland, the creator of family-systems-illness theory. John (whose family immigrated from Germany) as well as other family theorists, clinicians and researchers, awakened me to the world of family approaches and interventions, and especially ecological theory. It was then left to me to bring it all together into a new way of understanding and intervening with survivor families.
This difference between this and existing approaches to genocide survivors is basic. The one approach emphasized how damaged are the individual survivors and their families as a result of genocide, and put the focus there. The new approach emphasizes what remains strong and intact in survivors and in particular survivor families and aims to help them build on that. The bottom line is that for families life goes on. The family survives. It continues to provide a context for growth, nurturance, meaning making, love, and generativity. The family mediates the trauma experience: how a family deals with trauma will have important consequences for all members and for the survival of the family unit. And the family has a great influence upon whether the person goes to seek mental health services. The advantage of this claim is that after all that families have been through, there are ways to help them to be stronger so that they can adjust the most successfully to new lives in new surroundings.
The United States National Institute of Mental Health also recognized the need to develop new knowledge in this area and began an initiative to study the consequences of torture and related traumas. In the field of genocide survivors, there has been very little systematic research into the mental health consequences. That which exists focuses on PTSD, not families, nor prevention. And there are no controlled studies of mental health treatment nor other interventions. Considering that genocide presents gobal mental health problems, and that huge ammounts of money go to providing psychosocial programs to address these problems, this is a remarkable deficiency. Our group proposed to do a project on Bosnian families that would scientifically assess a family intervention and they agreed to support it.
This project is called CAFES: Coffee and Family Education and Support for Bosnian Families. It is multiple family discussion group. It aims: 1) to help families to be able to draw upon their strengths and resources to cope together under the stresses of survival and exile; 2) to give families' information that will make it easier for them to obtain appropriate care and services in Chicago. We think that through participation in CAFES, families will be stronger, as will their relationships with all the helping organizations in the Bosnian community.
This is not family therapy. Rather, it is a structured multi-family discussion group program aimed at building upon family strengths. We want to help families to overcome isolation by creating a supportive social context where families can interact, learn and teach one another. By linking the family with other families and with organizations the group helps to expand the families' social network and to create linkages between community and service networks. We will talk with family members about potential problems in a non-threatening manner (i.e. helping family members to see how the family can diminish their family member's vulnerability). We provide families with information that they can use to solve problems.
The CAFES group is seven Bosnian families meeting for coffee and informal discussion at a community setting for nine meetings over fifteen weeks. It is co-lead by two Bosnian group leaders. Over the next two years we will ask more than one hundred families to participate in the group. We have assembled an outstanding team of Bosnian people who will carry out this project.
We conduct the study in the hope that it provides validation of the integrity of the model and the effectiveness of the intervention. However, there is something that we know before we even do it. We know that the family and strengths focus which is at the core of this study, is itself a product of the Bosnian experience of surviving genocide. Irregardless of the study results, this model itself is a legacy. That is because it is something that Bosnians have given to the world of genocide studies. I want for the message to outdistance the messengers, such that when people think genocide survivors and their families, they see not only devastation and ruin, but also resources and hope and join affirmitively with the families in the work of building new futures. It is still to early to fully explain all the ways that the promise can be fulfilled when we stand with the family and champion its strengths – but we do believe that much good can come, for them and us.
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