Lessons from Kosovo

Mimoza Shahini: mental health care for refugee children should be “culturally appropriate”

“Eighty per cent of the refugee children that we have seen were symptom-free at their arrival. It was an astonishing experience to see children – coming straight from a horrific war-zone – being so cheerful: they were laughing, playing and having fun. Until something bad happened. One child was badly hurt by one of his friends and we noticed that nobody showed any emotion. No empathy nor compassion, nothing.”

Dr Mimoza Shahini (Kosovo)Dr Mimoza Shahini is an expert in combat-related disorders. She published several papers on the subject and works as a lecturer and consultant for the World Psychiatric Association (WPA), NATO and other international organizations. But first and foremost she is an expert by experience, having contributed to the care of refugee children after the Kosovo war (1995-1998). Shahini was in the middle of the emergency mental health care for refugees and she managed to also do research on the event, concluding: “Mental health services that only address traumatic stress may fail to meet the needs of war-affected children. Comprehensive, culturally appropriate services are needed to address a wide range of problems.” Dr Shahini holds a treasure of knowledge and experience, and perhaps some important lessons to learn for European child psychiatrists who are facing the same challenge now, dealing with the mental health issues of the current entrance of refugee families in Europe.

“Only a minority showed
stress-related symptoms”
Shahini: “The other twenty per cent of the refugee children showed stress-related disorders. Clinically spoken they suffered nightmares, bed-wetting, different levels of anxiety and they isolated themselves from their peers. And we also frequently saw children with learning disabilities – due to the lack of services in Kosovo. We saw children, for example, referred by teachers for poor concentration; most of them clearly did not have ADHD or related problems: this was part of their stress response. During our work immediately after the war ended, a large number of children did not have a stress-related diagnosis but their distress manifested through physical problems, such as somatization and fainting.”
“All of these are serious problems, but nothing we cannot handle, one would say. But mind you: today, fifteen years later, the real problems come to the surface. Not only in the minority that showed stress-related symptoms from the beginning. Many more of them appear to have hidden their problems and we now deal with the delayed pain. In fact, the care load for this group is a lot heavier and more complicated now than it was when they first came in. As a result of something like an oppressed PTSD – these people now develop depression, anxiety disorder and obsessive-compulsive disorder. It is important to understand that labeling families with post-traumatic stress disorder or other diagnoses does not make it easier for them to request help when they need it. Trying to understand their problems and giving them the ability to process trauma together as a family is an important role for a professional.”

Beyond human
imagination
“The children and families from Kosovo who we have worked with in 1999-2001 were part of our study for the publication in the British Journal of psychiatry. At that time, due to lack of child psychiatric services, we saw the children in family medical centres or in their homes when possible. A large number of families and children were displaced because of the destruction of their property; we offered them assistance in the cities. These were serious cases. Even today we see refugees who suffer from their experiences in the excessive horror of war, from degradation of human values, physical and emotional humiliation. Every professional – local or international – who has worked in Kosovo in 1999-2000 recalls that children came together with other members of the family, facing experiences that often went beyond human imagination.”

Hiding symptoms
“Our recent study of children with a background of war and violence confirmed that children show much less mental health problems immediately after the war. The severe disorders appear ten to fifteen years later. A study by one of my students shows that those problems are war-related: children born before and during the war have more problems than children born immediately after the war. My very recent study confirms this: older adolescents are having more problems than younger ones. My impression is that the children had been hiding their symptoms, other than being free of the symptoms. For the new study we looked at mental health problems in Kosovar adolescents. It revealed that 25-30 per cent of Kosovar adolescents scored in the deviant range on YSR scales, a much higher prevalence of psychopathology than would be expected based on international norms.”
“In the years after the war ended, the number of suicide cases increased and so did intentional self-harm and substance misuse. Some cities in Kosovo had no suicide record at all before the war – we counted many cases in those places after the war. These are cities where there was fighting in the war. Sexual violation during the war was kept silent until thirteen years after. Now the victims finally come forward and dare to talk.”

Kosovo refugees, fifteen years ago.Survival comes first
“Those happy and playful children I saw at first instance were over the moon by having food to eat, a shelter, a safe playground and no more bombing around their homes. They felt a basic freedom that they had not seen for the most part of their lives, almost as if it was forbidden or incorrect to show pain after being liberated from the violence. Survival comes first in human nature, but only now we witness the damage that was done when they were very young.”
“Although the literature about stress related disorders shows evidence that people may show distress even years after the traumatic event, it seems that this aspect is not taken into account in after-war zones because most international and local organizations and services are focused on basic needs and dealing with acute problems. The attention of professionals should indeed be on those aspects, but should also provide interventions that prevent the effects of traumatic situations in the long term. Usually people in crisis situations increase cohesion with each other and this is a strong point to be used to launch interventions of this kind.”
“You have to bear in mind that the situation in Kosovo in those years was different from the current problems that Western European mental health professionals will have to deal with. We had virtually no facilities and no resources. We had one or two NGO’s coming in and thankfully they supported us to develop services, but a lot of the refugee care came down to improvising. We did not have the infrastructure that you have, we lacked sufficient professionals and we simply faced the problems step-by-step as they came towards us.”

Post war Kosovo, 2001.Shame and stigma
“What we witnessed was an exodus of families, often one-parent families because the fathers had died in the war. Generally we saw two or three categories, comparable to the present situation: families that had suffered immediate violence – they had been under direct attack and escaped from the actual combat-zones. And the second group were families that came from the periphery and suffered from fear: they lived in a completely traumatized society; they watched the violence coming closer and fled for it. The latter group is perhaps comparable to the witnesses of the recent terrorist attacks.”

“A little bit later on we discovered a third group with heavily traumatized parents: they did not search for help before because of the stigma, but they did bring in their children. These parents were having the real problems themselves, and of course they had strongly affected their children. We should not underestimate the impact of shame and stigma within these communities.”

Be human before
being a professional
Dr Shahini’s spontaneous first recommendation to mental health workers who meet refugee families is to focus on empathy: “When you meet these families you sometimes need to be human before being a professional – simply being there for them is most important. They are so very, very stressful that our first obligation is to create a secure place for them. This should of course always be together with their families – separating them or moving them from one place to another will do them more harm.”
“I think this is important for the professionals too, they have to feel confident when they work with these people. All of us know that a good therapist does not influence the beliefs, values and judgements of patients. It looks nice when you say you are helping war victims, but in these situations you will also be working with clients who have committed serious illegal acts, like fighting in the war, killing, raping or other. It is necessary that professionals who work with such people are trained and prepared – because these are the hardest challenges of the job. Another important challenge – in my personal observation – is the naivety which many of the families of refugees represent: sometimes it is hard to come ‘into their world’, especially for western professionals.”

Do not move or isolate
“The best thing to do in my opinion is to provide services to these refugee families in the place where they are right now. Do not move them or isolate them for their alleged mental health problem and certainly do not take them to institutions.”
“This is the way we approached them: after creating a calm and safe environment, we looked for trusted people around the children within the family, the group or community they were with. And then we supported these people in helping the children – they could be mothers, aunts, older brothers and sisters, but also their own doctors, nurses and religious counsellors who have been travelling with them. Not our professionals themselves, but the ones with close relationships did a great deal of the job. We sensed that these children were extremely vulnerable and this was the least hostile way of getting close to them. Of course you will have to bring in professionals for diagnostics and care, but I would recommend to do this carefully and leave social structures intact.”

Socio-cultural barriers
The mental health workers in Kosovo encountered the same socio-cultural issues that their Western European colleagues have to deal with now, mostly of a religious nature, “especially now, considering that all Muslims seem to be labeled as terrorists”, says Shahini. “Apart from language barriers – we had to work through translation in many cases –, rules, customs and rituals came in many variations and for us it was impossible to exactly determine what regulations were practiced by each group. In some cases being in therapy affects the social status; for example in some religious circles a woman is not allowed to be treated by a male therapist and vice versa. In most cases we chose the safest way, which is: work with female therapists as much as you can and work with the mothers. With this strategy we managed to avoid a lot of trouble. In Kosovo I worked like that myself as a local professional, with the support of my supervisor from London. For someone from England to work directly with these refugees would have been a lot more difficult due to the language barrier. Often the patients simply do not want to talk to foreign therapists, although we have also seen cases where patients wanted to be seen by international therapists, as they did not trust the local helpers. But mostly it is advisable to work with local helpers if they are available, even if they are not professionally trained for working with trauma. So we empowered those local helpers and created a safe environment to enter a therapeutic relationship.”

Respond to this story.

  • Mimoza Shahini

    Dr Mimoza Shahini was educated in Cambridge, Tirana and Vienna. She is a medical doctor, specialized in adult psychiatry with a sub-specialty in child and adolescent psychiatry and family therapy. She is a lecturer at the University of Prishtina and at several private universities in the region (AAB College, European University of Tirana, Dardania College). She is an international advisor to the World Psychiatric Association (WPA) for the Global Programme on Child Mental Health, and a member of the editorial board of the journal for Translational Developmental Psychiatry.

  • Publications

    Mental health services that only address traumatic stress may fail to meet the needs of war-affected children. A comprehensive, culturally appropriate CAMHS is needed to address a wide range of problems including learning disability. It should be developed through local actors, and build on existing local infrastructure. Services can also have an educational role in ‘depathologizing’ normative responses.”
    These are the conclusions from a study by Lybbe Jones, Alban Rrustemi, Mimoza Shahini and Aferdita Uka, published in the British Journal of Psychiatry (2003), titled: Mental health services for war affected children – Report of a survey in Kosovo.
    The 2015 follow-up study is titled Mental health problems in Kosovar adolescents: results from a national mental health Survey (Neuropsychiatrie journal). Dr Shahini also contributed to the NATO publication ‘Political violence, organized crimes, terrorism and youth’ (2008), including the proceedings of the workshop on this subject at the Hacettepe University in Ankara (Turkey).
    View other publications by Mimoza Shahini.

  • Child and adolescent psychiatry in the region

    Kosovo is still a disputed area. Although it runs its own governance and a majority of UN members have recognized Kosovo as a sovereign state, Serbia still continues to claim the area as their ‘autonomous province’. The population of about 1.9 million people live on a land-locked area of almost eleven thousand square kilometres (less than half the size of Sicily). The official languages are Albanian and Serbian; recognized regional languages are: Bosnian, Turkish, Gorani and Romani. The child and adolescent faculty of the Kosovar Psychiatric Association is a member of IACAPAP, the international Association for Child and Adolescent Psychiatry and Allied Professions.
    Read more about youth psychiatry in the Balkan region on our pages on Albania, including a referral to the article ‘Management in child and adolescent psychiatry: how does it look in the Balkans?’ in the Greek Psychiatriki journal (2014). Note that in this article, Kosovo is not mentioned by name and appears to be considered part of Serbia.