This book resulted from a NATO sponsored Advanced Research Workshop held in Ljubljana, Slovenia June 7–9, 2003. The conference was the inspiration of Anica Mikus-Kos, MD, a highly respected international expert on community-based interventions to promote the psychosocial well being of children following war and terrorism. Twenty-six experts from the former Yugoslavia, the former Soviet Union, Israel, Palestine, NATO countries and elsewhere met for a three-day conference that combined formal didactic presentations with focused discussions.
Many participants were accomplished experts with extensive experience in providing community-based interventions for children during post-war reconstruction. Others had scientific experience conducting either research or program evaluation for such interventions. A third group of participants had experience in both the provision and evaluation of psychosocial services to children. These different perspectives are easy to identify from one chapter to the next and provide a creative tension regarding competing approaches to conceptualizing and implementing the most effective interventions. By the close of the conference, it was clear that such alternative views are complementary rather than contradictory. The purpose of this book, therefore, is to show how community-based psychosocial approaches can benefit from a thoughtful synthesis of both experiential and empirical strategies.
The range of topics covered theoretical perspectives, practical issues and scientific questions concerning psychosocial interventions for children. The major focus, however, was on community-based interventions that link individual mental health/psychosocial well being with the health and stability of the community.
There was much discussion about the best conceptual models within which to characterize the most effective community-based interventions and about whether it was possible to identify general principles for intervention that would be acceptable to all. In addition, three major domains of concern were identified as areas requiring further thought and development: implementation, program evaluation and research, and education and influence. The chapters in this book reflect the richness of the varying perspectives proposed on these issues.
A number of conceptual models were presented that included specific case examples. Adjukovic provides a comprehensive theory of social reconstruction in post-war communities that remain torn by ethnic distrust based on a painful collective history. His model emphasizes: recovery from losses, violence and trauma; establishing social norms and tolerance; building community empowerment; promoting tolerance and ability to live together; establishing community trust and cooperation; promoting reconciliation; and achieving community stability and progress.
Mikus-Kos provides a ringing challenge to the mental health community, urging it to broaden its focus to the suffering of children in post-conflict situations rather than concentrating on traditional diagnosis and treatment. She provides a vision of how mental health practitioners can achieve desired outcomes more successfully through community-based psychosocial initiatives. Drawing on her experience as director of the Together Foundation, she illustrates how to translate such a conceptual approach into feasible and effective interventions.
Laor and colleagues, drawing on the Israeli experience with disasters and ongoing terrorist attacks, offer a systemic perspective that provides a common professional matrix for medical and social interventions; this approach focuses on disaster as a continuous social phenomenon and proposes models of community-based health and social service delivery.
Metraux cautions against a unitary focus on post-traumatic reactions. He asserts that the key to social reconstruction is the working through of collective grief by acknowledging the irreversible loss of both the collective self and collective meanings.
Strang and Ager define effective interventions as those that promote psychosocial change through culturally sensitive facilitation and rebuilding of the local infrastructure. They provide a conceptual framework with which to explore the assessment of the impact of events and issues of effective, appropriate and ethical interventions.
Several chapters are devoted to detailed exploration of effective strategies for implementation of psychosocial interventions. Major barriers are also considered. Brymer and associates, describing their psychosocial program for children and adolescents in Kosovo, identify three distinct levels that had to be addressed: governmental (including UN divisions and NGOs), child-focused settings within the community (such as schools, children's hospitals and juvenile detention centers), and training of professionals and paraprofessionals.
Boothby and Halprin provide a superb case example in their longitudinal follow-up of Mozambican child soldiers reintegrated into their communities. Among the key psychosocial components that led to a surprisingly successful intervention were: family and community acceptance, traditional cleansing ceremonies, and attachments to adult caretakers and role models. Furthermore, practical participation within the community's social fabric through marriage, acquisition and maintenance of a home and employment such as farming, all predicted successful reintegration for these severely traumatized former child soldiers.
Many institutional barriers to successful implementation were considered. The list is quite extensive as noted in Agani's chapter regarding the challenge of building child and adolescent mental health services in post-war Kosova.
In addition, conference participants expressed great concern about institutional barriers to reconstruction efforts ranging from lack of receptivity by local schools, churches and community leaders to institutional turf wars between UNHCR, UNICEF, WHO, and international NGOs.
With regard to program evaluation and research the most important methodological question discussed was the best way to evaluate community-based interventions. Such an assessment must address both qualitative and quantitative variables with scientific rigor in order to generate a valid empirical assessment of community based intervention. The greatest challenge in such an approach is to ensure that such evaluations have sufficient scope and sophistication to encompass the many complexities, contexts and interacting processes that are involved in community-based interventions. In addition, there are important ethical issues that must be taken into consideration when providing community interventions or when conducting an evaluation of such initiatives. All participants were in general agreement that rigorous evaluation is needed to develop evidence-based psychosocial interventions to guide future practice and policy for program directors, practitioners, donors, stakeholders and the scientific community. They expressed major concern, however, about which indices should be monitored during the reconstruction phase. This is because of a general consensus that traditional quantitative approaches cannot capture many of the most important psychological and functional outcomes at both the individual and community level. Among conference participants, opinion was divided about the best way to implement such an approach.
Friedman's chapter attempts to clarify the scope of the measurement challenge by identifying many of the distinct components that need to be included in any research or evaluation initiative such as: comprehensive assessment of community function, risk factors among affected children and clear strategies for promoting psychosocial well being.
Balaban and associates provide a comprehensive review of the methodological challenges associated with rigorous assessment of persisting distress, functional impairment and behavioral/developmental disturbance exhibited by children and adoles-cents following war and terrorism. They also emphasize the importance of utilizing culturally sensitive instruments that will monitor the post-traumatic psychosocial environment since such factors may constitute independent risk factors for adverse psychological sequelae. This chapter contains a critical review and wealth of information on current empirical findings with assessment instruments utilized with children and adolescents following wars and disasters. Four domains are addressed: post-traumatic stress reactions/disorder, depression, anxiety and behavioral problems/disorders. Psychometric information is provided on all instruments that are cited. Finally, the authors provide a set of recommendations for future research to advance the assessment of children and adolescents after terrorism and disaster.
Other chapters identify predictors of resilience and distress among children and adolescents. Baker's chapter on Palestinian children exposed to the violent uncertainties of the Second Intifada illustrates that psychological, rather than geographic distance from aerial and land bombardment may be much more predictive of post-traumatic distress.
Ispanovic-Radojkovic, drawing on her experience with Serbian children affected by war, identifies parental behavior, disruption of social support systems, polarizing ideological beliefs permeating post-war communities and the recreation of a new social memory that will promote psychosocial well-being as major challenges.
The final domain addressed at this Advanced Scientific Workshop was education and influence. Given the usual lack of personnel qualified to provide psychosocial interventions, one of the practical challenges is to identify and train indigenous individuals to carry out such interventions. Van der Veer provides a thorough and practical primer for training counselors or psychosocial workers in areas of armed conflict. Such an undertaking requires a clear conceptual understanding about the relationship between theoretical knowledge, practical knowledge and counseling. Basic principles are discussed, and the training is described as an interactive process in which both the participants and the trainer develop their expertise.
Conference participants identified many educational barriers: families and children need to be educated about the normalcy of post-traumatic distress in order to overcome the stigma that might interfere with intervention efforts. Community leaders need to be motivated to support and participate in psychosocial intervention efforts. Western mental health professionals require education on culturally sensitive approaches as well as methods for community empowerment. Education as a tool for influencing policy makers and program directors was also considered at length. Finally, there was discussion about how best to educate and involve the media in this process so that its enormous power to reach the public can be utilized to promote resilience and foster recovery.
Unfortunately, wars and terrorism continue to rage. The countless children who survive such violence require our assistance for psychosocial recovery. As we launch community-based interventions to promote individual well being during the reconstruction phase, it is essential that we do our best to provide interventions that work. Recognition of this goal prompted conference participants to propose that we put theory into practice by linking future psychosocial interventions with rigorous evaluation procedures. Given appropriate institutional support, this is clearly an achievable goal. There is a wealth of community, clinical and methodological experience on which to draw. Hopefully, this volume and the spirit of this NATO Advanced Scientific Workshop will promote future progress in this area.
Matthew J. Friedman, Anica Mikus-Kos