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Exquisite Corpse - A Journal of Letters and Life

Foreign Desk
From America to Kosova and Back
by Stevan Weiner ||
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I traveled to Kosova in November, a month before the snow and flu makes visiting harder, a week before their elections might spark troubles. I went to work with my friend in Pristina, the psychiatrist Ferid Agani, and his Kosovar mental health colleagues. I too am a psychiatrist and one focus of my work concerns reform of mental health systems of care in post-war societies. The Kosovar/American professional collaborative that I am a part of had just received a new grant. Because the funder is based in Manhattan, we worried that 9/11 meant the end of their support. Fortunately they still regarded their work in Kosova as a priority. Kosovars and Americans are trying to build family-focused community based public mental health services in Kosova, a society where family is everything but where no such services have existed for the severely traumatized or mentally ill. It is a long-term proposition.
     After 9/11, there was sufficient reason to postpone the trip, but Ferid and I thought that my presence was required. I also believed that going to a place where people had survived terrorisms, even if of a different sort, I might learn something that would be helpful to those of us in America now wondering about our place in a changed nation and world. Ferid had e-mailed on 9/11, "Please be strong. I deeply understand how much difficult it is to go through this. All my family and your friends in Kosova are with you at this difficult moment." And so I went to Kosova, but I was also thinking about New York. I listened to how the stories of traumas get told in both places by those trying to help.
     Kosova is destruction, ugliness, sorrow, stubbornness, but also pride, solidarity, beauty and triumph. While there I make notes of all that I can, but when I reread them later, I can't make them fit into psychiatry, or for that matter, history, politics, or literature either. To deliver true observations on the historic spectacle international helping hand colliding with the consequences of rampant ethnonationalism, may require combining all these disciplines with the literary observations of Central European prose-poets. But in Kosova, instead of Gustaw Herling and Czeslaw Milosz, there are hordes or international journalists, politicians, mental health professionals and assorted beaurocrats pushing information and ideology, rather than bringing historical metaphysical reflections to lived experiences. The lack of new ideas cannot possibly be without consequences for Kosovars. Never did I dream of similar consequences for New Yorkers.
     On this visit, almost every Kosovar I meet tells me how horrified they were by 9/11. With Kosovar elections the following week, U.S. flags were flying side by side with the Kosovar flags in Pristina and the countryside. Kosovars love the States and talk endlessly about how much they value our help, not just in the crisis, but over the long haul. "There's no reason for the U.S. to close its consulate in Pristina, like in Sarajevo. We're with you." They spoke as if it was my decision. Yet they also appeared to grasp all too well the single-mindedness that can be associated with being under siege. For Kosovars, national independence occupies the first place. There's a lot that they don't understand about America's post-assault moment. But what they do know makes them fear how easy it would be for the U.S. to simply drop them.
     In Kosova, the marks of terrorism still infiltrate many aspects of daily life, including language itself: "If there was one Serb in the room, we spoke their language, not ours. Even if there were one hundred Albanians but one Serb, we showed them that respect. Now I think we respected them too much and for that we suffered." I speak no Albanian. When I try a little Bosnian it surprises them, "Oh you speak Serbian?" "No, Bosnian." There is very little difference, but in the inflamed ethno-nationalist landscape of the Balkans, little differences are a very big deal. They will converse in private but in obvious discomfort.
     Kosova has nineteen psychiatrists for more than two million people. Ferid Agani has been the leader in psychiatry, which is what brought us together several years ago. Now he is the Coordinator for Mental Health for the Department of Social Welfare of the United Nations Mission in Kosovo. The challenge Ferid faces is to build a community mental health system with professionals too few in number and often lacking in confidence and competence. How do you make up for those "ten years lost", as Ferid says, when Serbian authorities had denied Kosovar professionals' education and training, access to health care institutions, and contact with international professional and scientific communities? How do you do that under conditions of needs that cannot wait and resources that cannot be found? How do you convince overworked and underpaid psychiatrists to not leave public service for private practice?
     Before I leave Chicago, my wife Laura tells me, "You wouldn't keep going there if it wasn't for Ferid." She's kind of right. Kosova is not a charming place, but I have grown close to many people there, and come to believe in their struggles. Especially Ferid who is "touched by history". Ferid is the nephew of Fehmi Agani, a founder of the League of Democratic Kosova, who was murdered by Serbs on May 7, 1999. "I come from a family that has a feeling of dedication to the nation, to the people, not only to the individual. I am known as somebody who has chosen to do something and who will give something." Ferid is the heir to that family legacy and it is this obligation, originating from the family Agani, which makes Ferid not just a psychiatric leader, but a leader in a larger sense.
     It also ties psychiatry to history. The work that we do in Kosova can be tedious and slow like any effort at large-scale organizational change. It helps both Kosovars and Americans to see the work from the perspective of being a part of something larger: the historical task of helping an oppressed, tribal, and post-communist society take steps towards a European liberal democracy. They are trying to move forward and we are trying to help our friends to take the first steps ahead. Because we see this in historical terms, we realize that it is a long-term proposition and that we must stay in it for the long haul. What also happens over the long haul is that friendships form, and the blossoming connections between persons parallel the alignment of historical struggles and each makes the other stronger.
     Talking with Ferid and others in Kosova causes me to think of just how much United States needs Kosova. This is not the time for America to break away from Muslims in Europe, Mid-East, Asia, Africa, or at home in America. It is the time to build relationships with Muslim people and Muslim nations. Of course my perspective is rooted in the small world that I inhabit -- psychosocial and trauma programs for refugees and in post-war societies. Each visit to Kosova draws my attention to what the United States and other Western nations are doing or are not doing in the post-conflict phase to help make social progress, and also whether these efforts build the kinds of lasting friendships that Americans and other Western nations need in the Muslim world.
     Over dinner with Ferid's family, I teased his wife Shpreza, "Are you ready for Ferid and I to go to Afghanistan? They need our expertise in mental health reform in post-war Muslim nations." She rolled her eyes and gave us that same look which I get at home. Many others will go, but with what thoughts and obligations?
     The fact is that recent events have shifted the focus of the trauma psychosocial governmental non-governmental complex away from the Balkans to new places. Kosova is neither Afghanistan nor New York. But whether or not Americans and Kosovars get it right in Kosova should have relevance for the new post-conflict scenarios that Americans face at home and abroad.

* * *

The historical moment of Kosova'a liberation from the Serbian regime, brought huge numbers of governmental and non-governmental organizations, their dollars and deutschmarks, health and mental health care professionals, white trucks and walkie talkies, from the West into Kosova, like Bosnia and Croatia before. This global spectacle of rich Western nations going to aid poor people in undeveloped countries, is not only crisis and response, as it is often framed in the media. It is also ongoing globalization, and thus, also a part of the problem.
     It can be said that Kosova has survived two kinds of occupations in recent history. One is from the Serbs and the other is from the international community, which may be called the "humanitarian occupation". By this I mean the invasion of large numbers of international humanitarian organizations that come to provide humanitarian assistance. They act autonomously and with little coordination or oversight. Some do good work for local people, but many no good or even harm.
     One pervasive and problematic example is called "trauma training". It is the model that has characterized a large proportion of the international psychosocial and trauma work in Kosova. Governmental and non-governmental organizations (NGO's) hire Western clinicians to train local health professionals in individually oriented Post Traumatic Stress Disorder (PTSD) assessment and trauma counseling. They search for appropriate training manuals, and under time pressure and ideological bias, end up borrowing manuals developed in completely alien contexts and utilizing them as is, with no particular attention to their fit with the real world of Kosova. Local people get trained in alien concepts with no realistic basis for expecting that it will result in actual services being offered to help people. Visiting Prizren in August 1999, I was in on trauma trainings conducted by a leading international NGO, and wrote in my journal:
     "Trauma training is a corrupt affair. It benefits horribly more from the real suffering of humanity, than it gives in return. Trauma cannot be separated from social suffering, from culture. Trauma is the assault upon individuals, but not only that, when it is the family, the community, institutions that are the target of destruction.
     I am troubled to be a trauma psychiatrist, as if, on cue, I would lecture to them on the answers to their individual suffering. I became a psychiatrist, not a historian, because I wanted to be involved with lives lived in history, not history without lives. This is an acceptable dilemma compared with the predicament of trauma training - completely removing lives from all social, historical, cultural and organizational realities. Trauma training is not what I studied and worked for."
     I found myself arguing with the program officer from the U.S. government who was responsible for funding trauma psychosocial programs. She said that what they wanted to fund was "prevention" and that meant training primary care doctors to assess for PTSD and insisted that it was "preventive". This makes no sense, I say, but she does not care that this wouldn't pass Prevention 101. My insights lead nowhere. A decision has already been made about how to spend the money and all that's left for the program officer to do is to rationalize. But what's surprising is that she actually believes her own explanations. I have similar arguments with leaders at several NGO's. In comparison, they are more practical. After hearing me out, several offer me jobs on the spot, much to my dismay. They must need help in spending their money. Others are doing just fine in that department and regard me as competition seeking to steal their trade secrets.
     This is not the kind of behavior that inspires respect from local professionals, although outsiders are not likely to hear them say it. I was surprised when one Bosnian local agency director in Bosnia-Herzegovina put it so bluntly in a meeting with young investigators from America, "The ideal is when you pay us and you take all of the responsibility. Some say we live like kings. Actually, we are only trying to survive and feel that we should get our piece. After all, most of the money you spend on yourselves anyways".
     During the 1990's, into Bosnia, Kosova, Rwanda, and East Timor (to name a few), international trauma psychosocial programs went, and too often gave themselves permission to trample. Claims were made about what would be achieved, and when they were not met, it was often argued that it was because those countries are uncivilized.
     From an economic perspective this behavior fits the pattern of globalization and international economic integration. Rather than promote local control, self-sufficiency, and diversification, the trauma psychosocial programs of the international helping hand too often sell them ideas that they cannot afford and that do not fit with their culture. "All organizations are emergency organizations. They can disappear in the moment," reported Ismet Ceric, psychiatric leader from Bosnia-Herzegovina. There too, they did not engage in the long-term process of transforming local institutions, but rapidly created new entities that employed local persons under the management of international experts to accomplish short-term missions.
     Approaching long-term problems with a short-term mentality is a sign of both arrogance and blindness. International visitors are very good at seeing a few things, and seeing only them. They are not necessarily untrue, but they are just so incomplete. What these behaviors reflect for Americans is an abdication of our public obligations now writ much larger in an era of globalization. There is a deficit in our vision of the historical struggles of other societies and other peoples and a lack of a sense of how we are implicated in and by their struggles. 9/11 rendered these ideas in very practical terms and thus alerted us to a public calling that could be truly preventive: If we do not go to them with respect and help, then they will come to us with exploding planes and bombs.

* * *

New York could not be more different from Kosova. No metropolis has more professionals or organizations of mental health. What's extraordinary about the first months after 9/11, is that with a new American post-conflict scene centered in lower Manhattan, many of the concerns regarding mental health activities in the public sphere are remarkably similar. Incomparable social landscapes would seem to make this improbable. In America it would seem impossible to claim that mental health professionals and organizations are going to heal the entire nation. Here, no one has given their permission for them to trample. Here, there are expectations that as both professionals and citizens, they will act in the interests of America and its peoples. Here, there is a high level of scrutiny over helping activities and their intended and unintended consequences.
     For the first month after 9/11, trauma was everywhere in America's news. Trauma was America's September song. I dedicated myself to close listening and reflection upon what trauma mental health professionals were saying in the national news, complemented by ethnographic investigation of professional meetings, listserves and websites.
     Overall, I found that in the American public discourse what mental health has been doing is consistent with what it was critiqued for doing abroad. In the public sphere, mental health professionals and organizations promoted professional interests above humanitarian concerns. They did not adequately show that they were doing work that was actually helping people. And they did not make a meaningful contribution to the public discourse on larger social concerns related to the events of 9/11.
     Given that I am one of them -- a psychiatrist, and a member of psychiatric professional organizations -- I will voice my concerns about the activities of the mental health profession in the first person plural. I do so in the spirit of Mikhail Bakhtin, who wrote, "I was not better than my time".
     When we talked to America, we spoke professional speak. Again and again we said it like this, "There's a concept called…and I think that this concept has something to teach us about what may happen to the general population as well."
     Our tone was detached and distant. It did not match that of survivors, family members, rescue workers, nor the general readers or listeners, who were all witness to mass murder on their televisions.
     We spoke with a condescension bred by satisfaction that our theories appear to explain what is happening before us: "But most of us will be able to incorporate these events into our worldview and move forward."
     When we talked to America, we spoke in generalizations. Generalizations based upon a professional truth, but stated in ways that contain multiple levels of presumptuous departure from reality. Someone "said she had not seen a trauma victim that did not feel guilty about something."
     When we talked to America, we flattened history, politics, culture, class and religion. In the world according to us, they rarely appeared. Instead, we offered platitudes: "Today we are a traumatized nation." We mostly didn't look for lessons abroad, and when we did it was clichés that we extracted.
     We were certain about what others had to do in uncertain times. People, "are doing exactly what they are supposed to do, and that is talking about it." We were not certain about what we had to do to help.
     What was especially striking was that time was the single most talked about concern. We spoke of "predictable stages" and said: "For the first 48 hours after an event like this, everyone gets a pass." And "Circle your calendar for October. We're really not post-traumatic yet." What is going on here? Time was used as a rhetorical strategy for creating authority over the experience. We used the prism of one month to say that only then will we know what is happening with us now. By inventing an end to the story, we can be the authoritative interpreters of it today. But isn't this power based on self-delusion?
     We missed the difference between here and there. What changed on September 11th is that for all Americans suddenly "there" is now "here". Our old assumption that "here" we are safe does not fit now that we are "there". That could be because the trauma mental health profession in America was formed in the prior historical context that has now been forever altered. Our readers and listeners inhabit that newly endangered world, but we speak as if we are still in that same old safe and secure place. For example, instead of speaking of actual safety concerns in an America under siege, we talked about "emotional safety" or "sense of safety".
     We spoke about trauma, but not about war, while America's government was preparing for war. We spoke about trauma, but not about homeland defense, while America's government was making new policies and new laws in the service of homeland defense.
     In September, a majority of Americans knew what trauma was because they felt it and they were talking together about it. Trauma mental health professionals were asked by journalists to say something about it. We successfully reassured Americans, but did so in such a way that privileged our narrow professional views over broader public concerns.
     In the short, run and in the dimension of funds, we succeeded. We helped the state to be seen as legitimate in their choice of how to spend their money. Our words made it easier to transfer large amounts of money to the professional institutions whose values and language were being promoted.
     If there was a chance of a sustained public dialogue that moved from the experience of traumatization to other areas of social concern, then we did not do our part. We said that America needs to know what only we know. What we told America is that America hasn't really changed (isn't unsafe, isn't in a new era, isn't at risk of betraying its values), but just may need our therapies.
     We thought we were informing the public. Instead, if anything, we possibly contributed to the processes that kept dialogue down. Of course we didn't do it alone. It was through our interactions with journalists, especially health and science reporters.
     Yet in the first three months Americans could learn far more about the human experience of trauma from reading restaurant and film review in the New York Times, and of course, from reading the extraordinary series, "Portraits in Grief". Journalists made clever use of existing forms and invented new ones to handle the 9/11 experience discursively. So many of America's public figures, including musicians, actors, professional athletes, and some political leaders, did the jobs that the public expects of them, but dropped pretentions, and added compassionate articulations that were both genuine and helpful. ''The city is still reeling, isn't it?'' asked Mick Jagger, ''I can sense it. I didn't think I was going to feel that, because it's nearly six weeks afterward. It's very tough and shocking, and very traumatic for the people who live in this town. For everyone else as well, of course, but much more so for the people here. It's incredibly stressful.'' It is in comparison to the vitality shown in the overall public discourse, that the mental health response seems overall so pallid and empty.
     The initial post-9/11 phase of trauma mental health response was notable for the lack of new ideas generated. During that time, America spent big bucks and valuable human resources on trauma that were based upon ideas from the pre-9/11 era. In New York, large university medical centers are the recipients of the federal and donated funds. They find themselves in the situation of the NGO's abroad, needing to spend the money through organizing trainings and providing services. My colleague Jack Saul is a psychologist who works with Ferid and I in Kosova and who lives in lower Manhattan. "What's happening in New York is an extreme version of what we see in Kosova. They are all coming to us assessing for PTSD, telling us we need trauma treatment, without asking what we need or want, without any coordination." Jack wonders how long will it be before journalists are investigating the gap between what communities actually want and what mental health professionals offer?
     What has been especially missing are any new ideas about history. We did in the U.S. what we accused mental health professionals of doing in situations of human rights violations: We privatized the experience. After 9/11, Americans realized that they were caught in traumatic circumstances. They asked and were told that for most of us, this will not lead to long-term mental health problems. Americas asked, "Are we crazy?" and we told them, "No you are not." We then went on to say that some of you might have mental health problems and that we could treat you for that. What I am hearing is that more Americans may be more open to the idea of psychotherapy than ever before. If true, that is a good thing. But is that all that this is about?
     I am reminded of how President Bush says American is in a war for civilization, and then tells Americans that what they can do for their country is to go shopping. When mental health professionals send the message that we can get psychotherapy and Zoloft, they are sending a valid mental health message, but they are privileging the same two dimensions of the American life as was President Bush: private life and American capitalism.
     Something's missing here in the image of mental health being promoted to America. That something is history and we cannot escape recognition of it. We are living in new historical era of vulnerability and connectedness with peoples of the world. This profound shift in the social landscape changes families, communities, schools, organizations, anxieties, ambitions, dreams and nightmares. Americans know very well that this is not life as usual, and that mental disorders don't adequately explain this difference. America should ask its professional experts in mental health to explore living in the new era and to find ways to be helpful. Ferid Agani offers an example of a mental health leader with feet firmly planted in historical realities and bound by a humanitarian obligation to the general population and their historical struggles.
     What's also missing is concern with Muslims and our relationship with them. For me, the path from Muslims in Kosova leads to Muslims in America. In Chicago, I spend most of my time with Bosnian Muslims. Although they came to America to be safe and free like other immigrant and refugee populations, many Bosnians feel profoundly unsafe after 9/11 due to the threat of further terrorist acts. In addition, like many other Muslims in America, Bosnians do not feel very free, as they have had to confront harassment, threats, discrimination and bias from other Americans that parallel their prior experience. One Bosnian man told me, "Now when they ask me where I'm from, I say Yugoslavia." Add to that the economic pressures that have a disproportionate effect on refugees and immigrants who are often at the most vulnerable positions in the economy. In this manner, the events of 9/11 press upon Bosnians, and other Muslim refugee and immigrant populations, at multiple points, and threaten to overwhelm an already precarious adjustment and future.
     This is an especially critical moment for Muslim youth, for whom 9/11 and its aftermath have been a polarizing experience. America needs no further evidence of what is at risk. Muslims who feel disconnected from the institutions of civil society are at worst, potential converts to radical Islam and potential terrorists, or perhaps just less strong voices of moderation against extremism. America is not going to get their way out of this without reckoning more with Muslim peoples, Muslim nations, and the Islamic religion.

* * *

The truth is that the public discourse on trauma in both Kosova and America passed its mental health professionals by and for good reason. The people are carrying on a conversation about trauma that doesn't need nor depend upon its mental health professionals. Psychiatrists may control the institutions that spends the money on mental health and health, but we do not have hardly any say in what the public thinks or says. This disconnect of mental health from the public discourse is actually encouraging but it is also problematic. I believe that there is more that mental health professionals and organizations could be doing to help in post-conflict settings. But it does not center exclusively upon professional ideas concerning mental illness and its treatment, but rather around ideas about history that can be shared with other civic minded persons and organizations that are wanting to take action.
     My travels abroad, the ongoing work in Kosova, the friendship and collaboration with Ferid Agani and others, demand a lot, but give back far more than they ask. These experiences enable me to become a psychiatrist that is synonymous with being a citizen of the world. More importantly, it gives me a different sense of what the moment requires of us both at home and abroad: a new kind of historical awareness that is based upon active engagement with families, communities, businesses, schools and religious organizations.
     New ideas regarding our public lives are precisely what times like these require. What I imagine are three actions for America's mental health professionals and other concerned citizens looking for a new public service mission. One, help America to understand and adjust to the new historical era of vulnerability and connectedness with people of the world. Two, reach out to Muslim youth in America so as to promote and deepen their engagements with American life and American values. Three, find appropriate community based interventions for engaging with Muslim nations that will aid in the building of civil society.
     In Kosova, you are called by your family to serve your nation. In America, you are instead called by historical events. To the peoples of the world, Americans are appallingly disengaged from history, even standing on the cusp of a new era. History did not begin on 9/11, but perhaps American's greater historical awareness will.

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