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
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.
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
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
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
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
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
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
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
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.
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.