The destruction and dislocation engendered by war in Kosovo will leave hundreds of thousands of refugees to contend with lingering terror, depression and despair, and could leave some with permanent psychic scars, mental health experts say.
In fact, as refugees make their way to safety in other countries, attending to their physical wounds may be far more straightforward than soothing their psychological pain, the experts say.
Many have been traumatized and re-traumatized--not just forced from their homes, but beaten, bombed, burned, raped, left to watch as loved ones perished, separated from relatives and stripped of belongings. Many have been robbed of any sense of power over their lives, what one expert called "the hallmark of trauma."
"When people can't protect their families, the people they love, they start to deteriorate," said Dr. Geoffry White, a West Los Angeles psychologist who has worked in Bosnia-Herzegovina. "Some people will get violent, others will withdraw, some people will go out to the woods and hang themselves."
Trauma experts say they expect the emergence of both short- and long-term stress disorders. Suicides, eruptions of violence, psychosis and emotional withdrawal would be among the more extreme fallout. Far more common responses may include sleeplessness, hyper-alert behavior, suspicious or distrustful attitudes, panic and anxiety attacks, depression and nightmarish flashbacks.
Poor nutrition and unsanitary conditions in some camps will only add to the suffering.
"Initially, you'll see a lot of numbness that will thaw out over time," said Dr. Charles Portney, an assistant clinical professor of psychiatry at UCLA who has treated Holocaust survivors. "It's like a soldier in battle who loses a limb, who doesn't feel any pain at first. After that, you'll have any range of symptoms."
Children, often less able to express themselves verbally, may develop physical ailments and clinginess as a result of their fears and losses, experts said. Many will take their cues from parents, themselves heavily traumatized. But having no family to rely on is worse.
For "a child who loses a parent or parents . . . the natural system is not available to them," said Dr. William Arroyo, a USC psychiatrist who has treated Central American refugees, primarily children. "That tends to compound the psychological trauma."
Individuals' reactions will vary widely, depending on their history and personality, as well as the stability of their new environment, doctors and psychologists said. Unfortunately, for many refugees the future is uncertain. They are staying in countries that may be hostile to their presence, where they have no established social networks and no guarantee of employment. Many cannot speak the language.
"People will grieve for years, sometimes forever, about the loss of their culture," said Shotsy Faust, a family nurse practitioner at the Refugee Clinic at San Francisco General Hospital, which treats many Bosnian and Croatian refugees. "There is a tremendous sense of dislocation."
Faust said that refugees from the Balkans who come to the United States often live in low-income inner-city areas, move frequently in search of employment and develop only tenuous social ties. This is in marked contrast to the life many rural residents knew, in which it wasn't uncommon to spend a lifetime in one village.
Still, many refugees manage to overcome enormous psychological and social barriers. "It is testimony to the strength of the human spirit that they can survive and even go on to surmount their problems," said Anthony Marsella, a University of Hawaii psychologist who has written a book on the mental health of refugee populations. Tragedy such as the war in Kosovo, a southern province of Serbia, "has the capacity for bringing out the very best in people as well."
Psychiatrists and psychologists said one of the most important first steps to recovery for refugees will be getting them to simply talk about what has happened to them.
Marsella recommends formation of self-help groups and, where possible, housing refugees in small rather than large camps where they can continue to practice their traditions and customs in a protected environment.
Others recommended what amounts to large-scale group therapy, a practice known as "critical incident debriefing" in mental health parlance.
"You can get people together in groups and just go over the incidents that have occurred," said White, the West Los Angeles psychologist. "You can do a group of 1,000 people. It creates a sense of community. You say, 'It is wrong, what has happened. . . . You are having a normal response to an abnormal situation.' "
Mental health professionals recommended a sort of triage process to identify people with more severe reactions so that they might receive immediate treatment and medication, if necessary. Several said refugees themselves should be encouraged to look for troubling symptoms among family members and neighbors so they might be helped faster.
The experts underscored that whatever help is provided should be linguistically and culturally appropriate--or it could backfire. For example, mental health workers must respect distinct gender roles, which could mean meeting with women and men in separate groups. And foreign counselors might do best to train Kosovo Albanians to treat their own population, rather than trying to treat traumatized people through translators.
"Somehow, you have to help people to transcend the situation, to look beyond what is happening right now . . . to instill a sense of meaning and hope, identity and purpose," Marsella said. "If this can be done, maybe they can move beyond the tragic circumstances."