Where Is The Post? Post-Traumatic Stress Disorder in War Settings

Dr. Hanna Kienzler is a lecturer in the Department of Global Health and Social Medicine at King’s College London. She has a long-standing interest in the fields of organised violence, ethnic conflict, and complex emergencies, and their mental health outcomes. Hanna conducts long-term ethnographic research in Kosovo and the Palestinian territories.

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Refugees leaving Kosovo, March 1999

A: Hi Hanna, have you always been interested in trauma and conflict?

H: Not really to be honest. Prior to my interest in research related to trauma, and medical anthropology more generally, I was a cultural anthropologist doing research among the Hutterites, religious communities in North America. However I realised that these communities had this narrative around their identity that relates back to different eras of persecution and link back to Jesus himself. So I got interested in the ways in which historical trauma and historical narratives around suffering impacted and shaped people’s identities. This made me then want to conduct research in a community mental health centre in Kosovo where I really started to look at the more contemporary literature on trauma, post-traumatic stress disorder, and suffering related to violence and war.

A: And what did you find particularly fascinating about working in this community mental health centre?

H: I think what was interesting to me was to see how in this post-war context, trauma categories and interventions were very much developed on the spot. I mean people had a bit of training but it was more about relating to the people. Mental health workers would visit people’s homes, they would drive into different villages that were hit especially hard by the war, where people had survived large scale massacres, where people were grieving for the loss of their family members and dealing with their own experience of violence. And the role of these community mental health workers was to create a space for listening, for narratives to emerge, not so much to provide a kind of standardised therapy. And I was impressed by just how careful, how sensitive these community mental health workers were in doing their job.

A: It sounds like a very different sort of approach to a more traditional biomedical model of trauma…

H: Indeed what would often happen is that psychiatrists had been told to, and trained to, provide very standardised biomedical diagnoses of post-traumatic stress disorder, depression, anxiety and so on. But what actually happened in clinical practice was quite different. Psychiatrists would use the DSM, use the ICD but not necessarily on a regular basis but rather to develop their own diagnostic models in order to enquire into wider issues that affected people’s lives. Issues besides the war, such as poverty, family conflicts, issues with nutrition, sexuality etc. And based on this they gauged the needs of people. Nevertheless in order to provide treatment, a diagnosis had to be in place. Moreover since the treatment options were so limited due to the fact that there was not, and there isn’t, a lot of money for mental health care, sometimes it felt like the diagnoses were assigned to in order to provide actual treatment.

A: So it wasn’t all about a diagnosis?

H: Not at all, the information that these psychiatrists and psychologists would elicit was a lot more complicated and could not be fixed simply with medications or psychotherapy. You know, things like how do you deal with poverty and violence in the family? With state insecurity? I mean those are much bigger issues. Interestingly enough the counsellors touched on these issues and talked about them with their clients, even though they had very little to offer them besides talking.

A: So do you think these clinicians were skeptical or faithful of a biomedical model of mental illness?

H: I think to a certain extent they were both. I believe that they did believe that something like PTSD existed and that it was a valid and important diagnosis. However at the same time they also realised that PTSD as a concept was almost too narrow to capture the needs and the problems that their patients were going through. So they were quite ambivalent and while they could see and accept that the experience of extreme violence may cause mental health problems, they were not always sure about how could they dissect the traumatic experiences from poverty, from the need for education, or from state insecurity. I believe that they felt that something like the DSM could not capture these complexities.

A: But as you say they still used it right?

H: Well that is the moral dilemma! You cannot sit there and look on when you have a patient that presents with clinical symptoms of trauma, you have to do something! Even though you know that what you have to offer will not be sufficient and will not actually lead to the results that you were hoping for. But doing nothing is also not an option. So there is pragmatism in the face of a complex situation.

A: And relating to this, we have talked about the local use of psychiatric diagnoses, but what about the treatment that was offered to people who presented with clinical symptoms?

H: That depended very much on the clinical setting. If you had a psychologist on staff who would offer talking therapy then that was great, but a lot of the psychiatrists and a lot of the psychologists actually didn’t have time to provide talking treatment. There were just so few specialists available, so few psychiatrist, psychologists, social workers in the field that providing this kind of long term psychotherapy with follow-ups was not feasible. So actually what happened in a lot of the clinics was that clinicians handed out medication and adjusted the medications when there was a follow-up visit. And clinicians would often be quite frustrated about these situations.

A: And what about the service users, how do you think they conceptualised their condition?

H: That depended very much on where you were. I did my own work in villages and in the rural areas of Kosovo, mostly among women. And they did conceptualise their mental health differently than, say, highly educated women in the city. I found that these women who had survived extreme violence during the war conceptualised their mental health and their health more generally in very very complex ways. They were familiar with the term trauma and would say things like “oh I have post-trauma”. Here I would know there had been some contact with the clinical field but also maybe the influence of the media. But they themselves had local idioms, local expressions of distress that they would refer to. Whether it was nervoz, nervousness, or mërzitna, which means to be worried, or annoyed, or also bored, all three come together in this concept.

A: And were those concepts similar to PTSD?

H: Not really. For example when I talked about the aetiology, you know, what causes people to be nervoz or mërzitna people would usually refer very much to the political environment, to poverty, child rearing problems, conflicts among community members or the family. Those were the situations that would trigger these kinds of feelings that were often expressed emotionally, but also psychosomatically.

A: Could you give me an example of a situation in which someone might feel nervoz or mërzitna?

H: For example you might be quite worried about someone’s health but feel quite helpless. For example your sister might have been diagnosed with cancer, something that at the time could have not been properly treated in Kosovo. So often you would worry yourself sick about the situation. But again your sister’s cancer is very much connected to the political situation and to a healthcare system that is so bad that it doesn’t even provide proper cancer care. Plus you might not have enough money to send your sister to Turkey in order to get treatment. So there are a lot of these uncertainties that you are navigating and then of course you think: “Well, why do I not have money? Where is my husband, the provider of the family? Oh, he got killed during the war!” and all of a sudden memories of the war seep into something that had started out as a political discourse. So these local idioms would bring together different spheres of people’s lives in very complex ways.

A: And how would the women you worked with manage these feelings?

H: The women knew that there was no medication to deal with it. However medication was also considered helpful because the symptoms were real, the pain was real, and to once in a while receive something that could subdue the pain and allow you to somehow deal with the events of your ordinary life was of course extremely important.

A: From what you describe it feels like people experienced a sort of prolonged traumatic experience rather than a one-off event, would people identify a specific event they thought had caused them to develop PTSD?

H: Well, first of all they wouldn’t say that they suffered from PTSD and I would not ask about PTSD specifically. I didn’t even talk about trauma because this is also a category with its own history. I talked about health problems. But when I did ask them when they had experienced their health problems for the first time pretty much all of them referred to events they had experienced during the war. However when I would ask them what else had maintained their health problems until now they would not necessarily refer to the war, or to memories of the war, but rather to things like material hardship and social problems.

A: Was this similar to what you experienced when working in Palestine?

H: No in Palestine it was a different story. When I raised the notion of PTSD in the Palestinian Territories people were very critical about it. People were especially critical of the notion of “post” and “trauma”, they would say that there was no post, that what they are experiencing are ongoing violations and ongoing violence. There is no clearly defined trauma that would offset their suffering, it is just constant, the feeling of being under constant attack and threat. So even the clinicians would say that the concept itself does not make any sense in their work, because there is no post.

A: But at the same time I guess some people would say that armed conflicts must have some consequence on the psychological wellbeing of people exposed to them right?

H: Some of epidemiological surveys do indeed find very very high rates of clinical depression for example. But clinicians also question that. Clinical depression means that you might not be able to get out of bed in the morning because you are so depressed. But it’s not like 80% of the population of the West Bank lies in bed and can’t get up in the morning. People do get up, every day, to go to work, care for their families, despite the fact that they are suffering, despite the fact that life is not always easy.

A: Going back to the type of treatment offered to women in Kosovo, how would they see the medication they were prescribed by the psychiatrists?

H: People would refer to them as “calming pills”. Amongst the village population they would not say “I am taking an antidepressant” but rather “the doctor gave me a calming pill” and they would connect that to their symptoms. They would go to the doctor when they felt that their symptoms were too strong or that they could not handle them anymore with their home remedies. So they themselves were also looking for medications rather than talking therapies. People would tell me “you know Hanna, I am talking about these things everyday… it doesn’t help! So why should I go and talk to the doctor about these issue, how is that supposed to be helpful? I want medications, this is what I am paying for, this is what I want to receive. I do not want to do the whole work myself. I am not paying someone so that I can talk about things about which I am talking constantly with my neighbour and apparently that doesn’t help me“. So there was a real need, or a real desire, for medication and for medicalising one’s health problems to a certain extent.

A: That’s really fascinating. Moving to your recent piece on mental health systems in conflict areas and Palestine specifically, do you think those interventions are informed by scientific evidence?

H: Yes and no. I think what happens often is that the WHO comes in or is invited to assist in reforming, let’s say, a hospital-based mental health system into a more community-based system. This move from an institution-based system to a community one is informed by scientific evidence. It has been shown that these forms of community mental health systems are more effective than locking people up in hospital wards and treating them removed from the wider community. So here you have an evidence-informed decision. And based on this insight blueprints have been developed which are then implemented on the ground.

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Jalazone Refugge Camp, West Bank by UNRWA

A: And would you say that these blueprints also rest on scientific evidence?

H: Here I would question what this evidence is and how much knowledge we actually have in terms of how well we are at transforming mental health systems in post-conflict development contexts where there are very scarce resources. I would say that what happens on the ground has been kickstarted by an evidence-based approach. However the implementation of this approach and how it actually develops on the ground has only indirectly something to do with scientific evidence. Rather it is more shaped by large scale politics, development agendas, and scarcity of resources.

A: Right, I guess funding is key in these situations…

H: Definitely and this is why often these programmes turn into projects, patchy projects that can develop when there is funding and then the funding runs out and the project stops. If funding is found again then the project can start again. And I think this also has much to do with a misrepresentation of community mental health as something that can save you money in comparison to a hospital-based practice. But when you look at the amount of money that goes into doing, not even quite proper, community-based mental health care in the UK… it’s a huge apparatus of specialists, social workers, infrastructures that allow people to actually live and receive treatment in the community. And this costs a lot of money and most importantly it requires continuous funding, not funding for three years and then you re-apply and maybe you get another five years funding if you are really lucky. This is not how mental health works and it is not how a mental health system functions. Therefore when we talk about mental health reforms following conflicts we need to be very clear about whether we are talking about a project or about a program and I think what we are delivering is projects, projects that are short-term, short-lived and always on the verge of collapse.

A: And what would your suggestions be in terms of building an effective mental health system in a post-conflict context?

H: That is the million dollar question! It is a very hard question but I believe that if you want to build effective mental health systems in a post-conflict settings it cannot be done on a project-basis. This project approach is too much informed by the structure of emergency interventions. Emergency interventions are something quite short, quick responses to a pressing issue after which you move out. Another point is that it is really important to help a country to come up with its own funding scheme to make mental health a priority. Often in a lot of these places 2% or less of an already very underfunded health budget is spent on mental health. Mental health systems are usually partly funded by taxation but that’s again very difficult in a situation where you have incredibly high unemployment rates. In Kosovo the unemployment rate usually hovers between 30 and 50%.

A: What about international aid?

H: There are also issues related to international loans and structural adjustment programs. We are basically forcing a lot of these countries to actually cut their health budgets and their social spending in order to be able to pay back the loans that they have been provided with in order to boost their economies. So you have mixed messaged. On the one hand, Western institutions say that health and mental health are extremely important and we provide international funding for that. On the other hand, we give them development loans which they have to re-pay by scaling back  on social spending. I think these different forms of development aid have to be much more aligned for a country to actually develop its own strategies based on locally relevant evidence rather than on blueprints that have been developed in Geneva.

A: Going back to this notion of evidence-based, there is a lot of talk within clinical psychology about evidence-based practices validated by scientific tools such as RCTs etc. Do you think  the discourse on evidence-base could potentially draw attention away from the social and political determinants of poor mental health?

H: Again, yes and no. I believe evidence-based practices have their place and can be extremely important for people suffering from various forms of mental health problems but they have to be put in their place. If a person is primarily suffering from distress related to poverty, insecurity, social conflict, or social strive, then CBT will not be very helpful to deal with the root causes of the problem. That does not mean that CBT cannot ease some of the pressure or some of the suffering the person is going through. I think one has to be very clear about what these treatments can do and what they cannot do. And by putting too much emphasis on the delivery of evidence-based mental health treatments there is the danger of pushing aside the underlying causes, the causes of the causes, which of course are a lot more difficult to tackle.

A: And do you think tackling those underlying causes might be more efficacious than simply providing evidence-based treatment?

H: Well it would ease some of the underlying problems straight away. The rates of mental health problems, the stresses, and anxieties would go down automatically if you provided people with ways of earning an income in a meaningful way, of being able to send their children to school in higher education, of having a pension later in life, of being able to make decisions and fulfil some of their dreams. I think that tackling the underlying sociopolitical issues would get rid of many of what we diagnose as mental health problems, although I believe they are fundamentally sociopolitical problems. Nevertheless there is of course a certain percentage of people who do suffer from mental health problems that will very much improve by being provided with medication or something like CBT, or other forms of treatment. So I think there should not be an “either or” narrative, these different approaches need to be working together in meaningful ways in order to make a difference.

A: I agree but at the same time if resources are very limited one might make an “either or” case and if CBT only works as a sort of patch then one might argue that spending money on evidence-based mental health when the problems are sociopolitical will not be effective right?

H: I would slightly disagree with this simply because the suffering and the distress do affect people’s ability, for instance, to search for employment, and to deal with complex social relationships. I mean these things are intertwined. I believe there is a very important space for mental health care in these communities. However to claim that you will solve the underlying problems that cause a lot of the distress with mental health treatment, I think that would be wrong. But I still believe that you can ease people’s pains by giving them a space where they can share their stories, where you can provide them with medication, with some relief, with a “calming pill”. I think that this does have its place. And also, people want this, the pains are real and the suffering is real. But they also want a stable political system in which they can thrive and have a meaningful life.

A: So would you say that mental health should be recognised as a basic human right such as the right to shelter and food?

H: Sure, I think mental health is very connected to all the other things that we consider basic human rights. So I do consider mental health a basic human right. At the same time I wonder what that actually means. I do believe people should have the right for appropriate treatment, that they should have the right to live in circumstances that they feel are meaningful and allow them to thrive, to be in the world and feel that they are in a good place. At the same time, what’s a human right? Who came up with this concept? Are there different ways of conceptualising human rights? Is human rights a pluralistic concept that, just like mental health, needs to be studied and explored in various contexts? Again, it’s difficult.

A: It is. You have worked with Prof. Allan Young at McGill University who famously said in his book “The Harmony of Illusions” that “PTSD is a disease of time” and that “it is not doubt about the reality of PTSD that separates me from the psychiatric insider: it is our divergent ideas about the origins of this reality and its universality” (1995: 6)Would you say that PTSD is real?

H: For some people, yes. For people who can identify with a diagnosis of PTSD, of course it is real. For clinicians who believe that the symptoms they are seeing add up to something that they can call PTSD, it is real. And therefore, as an anthropologist, I have to treat it as a reality in people’s lives. However whether the concept makes sense in any context, that’s again a different question. I believe PTSD is as real as nervoz or mërzitna that the women in Kosovo identified with. So yes, I do believe PTSD is real because I also believe that nervoz and mërzitna are very real experiences.

A: Thank you very much Hanna.

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Graveyards of martyrs from Krusha and Madhe (one of the villages Hanna conducted fieldwork in) by Agron Dragaj

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