During wars and their immediate aftermath, the United Nations and international aid organisations try to help deal with people’s most immediate needs: food, shelter, water and sanitation. In recent years, helping refugees and displaced people deal with the trauma of war has also become a growing priority. The world’s biggest independent organisation dealing with psycho-social and mental health care for survivors of war and organised violence is called TPO or the Transcultural Psychosocial Organisation, which is based in the Dutch capital, Amsterdam. TPO’s director, Dr. Joop de Jong, spoke to Eric Beauchemin about TPO’s work and philosophy, how different cultures deal with trauma, and the issue of traumatised asylum-seekers in Europe.
Original broadcast: May 2004
We see that mental health and behaviour-related problems, they almost produce 50% of the disability caused by all kinds of disorders world-wide, whereas malaria, it’s only a few percent. Infectious diseases, it’s only a few percent.
During wars and their immediate aftermath, the United Nations and international aid organisations try to help deal with people’s most immediate needs: food, shelter, water and sanitation. In recent years, helping refugees and displaced people deal with the trauma of war has also become a growing priority. War destroys all the certainties of life, and that in itself is stressful. But in addition, many survivors have been subjected to a wide variety of traumatic events, ranging from torture and rape to seeing family members killed or their houses destroyed.
Charities are becoming increasingly aware that most war victims will never be able to truly pick up the pieces of their lives unless their traumas and mental health problems are also treated. The world’s biggest independent organisation dealing with pyschosocial and mental health care for survivors of war and organised violence is called TPO or the Transcultural Psychosocial Organisation, which is based in the Dutch capital, Amsterdam. In this special edition of AGL, Eric Beauchemin speaks to the organisation’s director, Dr. Joop de Jong, about TPO’s work and philosophy, how different cultures deal with trauma, and the issue of traumatised asylum-seekers in Europe.
The Transcultural Psychosocial Organisation operates in 17 countries around the world with a staff of over 600 people. It was set up as the result of a chance encounter Dr. Joop de Jong had over a decade ago, during the final years of South Africa’s apartheid regime.
In ’92, I went to Geneva as an advisor to the World Health Organisation and one day, the ANC from South Africa and the Minister of Health from Malawi, they all came to me and said well, could you do something about our problems with our refugees, people who are doing resistance work for the ANC? And could you help us in doing something to reduce the stress level of our people? So I thought about it and I didn’t do anything. But then, one year afterwards, the same people came to me on the same day and they said, and what did you do since last year? Then I had to admit that I did very little besides thinking that it was a very difficult question, and even more difficult to solve. So then I started. I went to South Africa. I talked to the ANC. I talked to many local NGOs. I found that what they were doing was very helpful and there were many different organisations that did both psycho-social counselling, but also legal counselling for people who got involved in the apartheid struggle, etc. So then we sent someone to Malawi. But that didn’t work out because the South African secret service at that time, the Boss, they still were playing the cards in Malawi. So although the Minister of Health asked me to do something about the Mozambican refugees in Malawi, the woman we sent couldn’t do anything and she moved to the field of AIDS. So that was the starting of TPO. And then gradually we went to other countries: we went to Mozambique on the request of the head of the Department of Mental Health. And so we started a project in Mozambique. We started a project in Uganda with Sudanese refugees. In the same time, ’93, ’94, we started in Cambodia and that’s how it gradually started to develop. EB: What was your own background before getting involved in this project? I had a long history of working as a tropical doctor and having specialised in the field of public health in different war circumstances, both in West Africa and Angola, and then I became a psychiatrist and a psychotherapist and after my residency training, I went back to Africa. I worked again five years as a psychiatrist in West Africa, Guinea Bissau. I set up a nation-wide mental health and primary health care programme. Together with other people, I built up a small psychiatric clinic, very lovely small clinic in the middle of some villages, where people would come in the evening, the villages around. They would dance with our psychiatric patients. It was kind of ideal therapeutic setting which by the way now has completely been destroyed after the last war. And then, based on those experiences, I felt able to get some of these lines of my life together. So that’s also where our philosophy started, combining public health, public mental health, epidemiology, anthropology, psychology and psychiatry and psychotherapy. That’s the kind of inter-disciplinary approach we have in our work.
The Transcultural Psychosocial Organisation tries to incorporate both Western psychology and local culture and traditions. It works with some of the poorest communities in the world, particularly those that don’t have access to any other type of support. One of the countries it has been very active in is Cambodia, a country that suffered heavily in the late ’60s and early ’70s as a result of the war in neighbouring Vietnam. That was followed by the Khmer Rouge’s rule of terror that left more than two million people dead.
All over Cambodia we found women who were living on their own in villages and normally, the image of a low-income country culture is that people always have a lot of contacts and that like in most places of the world, women have a lot of social interaction and they have a lot of fun together and they discuss things, etc. But when we started in Cambodia in ’93, ’94, we found out that many of these women, they had been in their huts for 15 – 20 years on their own. They were generally called the ‘war widows’. Every woman who lived on her own without a husband or a partner, whether he was fighting with the Khmer Rouge or whether he had gone abroad or whether he was killed, were called ‘widows’, and they were alone in their huts. So we then found out that these women were kind of sitting there and they never shared their problems. So one of the things we did was identifying key figures and key leaders in the communities. And one of them was initially called the ‘acha’. And after we found that out, we went to the acha and we said, look, it surprises us that these women are sitting on their own in their houses. Couldn’t we do anything about that? Or could you do something about that? And the acha would say, well, look, in the old days, we as the achas would do something about this, but now we can’t go to those women. They have to come to us. So what we then did, we kind of brought them together and then we started self-help groups with women. And in the beginning it was a bit hard to discuss, but then we found out that there was a tremendous need to express their plight. And then women started to talk and they started to talk about the cruelties of Pol Pot and during the Vietnamese occupation, horrible stories. One of the women telling us her story that one of her children stole an orange from a tree and then she was tied with her ankle to a rope at the back of bicycle and then she was drawn throughout the village until her head burst open, etc., all these kind of horrible, nightmarish stories. And then, another thing that amazed us in the beginning that the women kind of repeated this same story a couple of sessions, without any difference, which are a kind of serious symptom. You know that the whole trauma narrative experience is kind of frozen in people’s mind. But then after a few sessions, they started to kind of melt and started to talk about it. And then the women they felt relieved and what was also very special that after about 8 or 12 sessions, then the women said, OK, we now shared our past. We came to know each other. They started to like each other. Many of them started friendships and then they said OK, this is enough of talking and then they started to work together. They started to set up small projects. Some went into preparing food and meals and selling their banana leaves or in a small shop. Others started a micro-credit scheme together. So we then did a study where we found that the women got much better, both in their symptoms of demoralisation and that the symptoms of depression, the post-traumatic stress symptoms that they had. We also looked at what was the cost outcome of our work because we did that study with co-funding from the World Bank, and there are economists at the World Bank and they like the hard figures. They said OK, this is nice, you shrinks, etc., but show us that what you do works. We found out that when we invest $8 a month in a woman in a self-help group, that in the same month the benefit for the woman in economic terms is about $20. So we invest $8. The outcome, the benefit is about $20, just because she feels better. She’s able to work a bit more. She doesn’t visit so many healers or medical specialists. She doesn’t have to hire so many people to till her land or to do something for her. So that’s how we saw both on a clinical level that people got much better but we also saw after the research that it really did a lot, whether it was that self-help group work or whether it was individual counselling or whether there were family interventions, etc.
The Transcultural Psychosocial Organisation has treated over 2 million people in Cambodia so far. The large number is due to the fact that almost all Cambodians were affected by the events of the 1960s and 70s. But TPO also runs much smaller programmes, for instance in Uganda, where it’s assisting refugees who fled the war in neighbouring Sudan. Dr. de Jong remembers one case, in particular, of a small group of rebels who approached Rose, one of his colleagues.
The leader came to me and he said, I’m crazy. But my 12 co, ex-rebels they are much more crazy than I am because a few of them set their hut on fire because that’s what we have been doing for years. And they’re all drunk and they beat up their wives and their children. So Rose then said, I did a couple of sessions where they kind of confessed, where they had a catharsis. And then we did relaxation exercises and then they felt better. And then we started an Alcohol Anonymous group, the way we do that in Uganda. And they still even felt better. And then we helped them with some of the modern techniques to have less problems with their nightmares and their intrusive memories and then after 10-12 sessions, some of them went into their original profession. They took up fishing or agriculture again. Some learned from another NGO a new profession, and 2 at the end became counsellors in the TPO programme and that was a beautiful example of how after half a year she kind of got those 13 crazy ex-rebels, how she got them back into their communities.
Dr de Jong believes strongly in cultural psychology, but over the years, he has come to acknowledge that there are similarities in the way people across the world react to traumatic events. These include intrusive memories or persistent, uncontrollable flashbacks and nightmares. These symptoms are typical of post-traumatic stress disorder or PTSD. In The Netherlands, 5% of the population suffers from the disorder. In the United States, the figure is 7.5%. In Cambodia it’s 20%, while in Algeria, where Islamic militants fought a brutal war against the state for nearly a decade, the figure is 40%. War and conflict don’t only leave large numbers of people traumatised. People who feel that they have lost control over their lives are often likely to suffer from depression, even though that’s a concept which is foreign to many cultures.
Depression is a very kind of Western thought. It’s something like a kind of sinking of your mood. It’s a kind of very much influenced by our Western idea that it’s important to be happy in life. You can imagine that in Buddhism where life is ?, where life is suffering, where there are cycles of reincarnation that you have to go through in order to reach enlightenment, where suffering is part and parcel of daily life, there’s another view. What you also see is that in many cultures, instead of using that kind of Western concept of a sinking of your mood, that you rather see that a symptom like brooding, like thinking too much is a more prominent symptom than feeling depressed in the Western sense. What you also see in many cultures is that depression, like other problems where you kind of emaciated, where you become thinner or slim, like tuberculosis or AIDS, it’s often related or associated with soul-loss or somebody stealing the life principle, the life force or the soul of another person, and trying to use that theft to become better materially. So in egalitarian cultures, you often see that when people they have to be equal and preferably equal with others and not better off than others, you often see that becoming richer is associated with using witchcraft to become better than your neighbour. EB: But how can you identify and treat people who are depressed if there are no manifestations or the manifestations are very difficult for you as a Westerner to identify? Yeah. What you then have to kind of do is when people have a mix of symptoms, which may overlap with some other kind of disorders like I mentioned tuberculosis or AIDS, you have to kind of go through all the symptoms and you have to try to disentangle and get to the core of their symptoms in trying to find whether there is a depression or not, and then you find symptoms which are, when it’s a serious depression, which are similar across the world. So you’ll see in general a loss of appetite, you’ll see sleeping disturbances, you’ll see fatigue. You’ll see that people lose their pleasure in whatever, whether it’s dancing or having sex. So you can then kind of distill the depressive syndrome out of all those symptoms that are presented by the people.
Many cultures offer other means for people to express their psychological distress. In numerous African and Asian cultures, traumatised people appear to be possessed and go into trances.
You see that people who are facing very difficult situations, they may go into trance. And they may ventilate all kinds of complaints or they may kind of act out a very strange behaviour. What you also see is that sometimes you see that there are group forms of possession where you sometimes even see mass possession, like in Nepal, in one of the refugee camps of the Bhutanese who were in Nepal. There was a whole group of adolescents that went into trance. They had all kinds of complaints, felt dizzy. They kind of lost consciousness, apparently because there was filth in the refugee camp or because some of the adolescents had sexual contacts before they were married and so the spirits got angry. In West Africa, in Guinea Bissau, I saw a very large mass possessive movement called Yanga-Yanga which I know start to re-interpret as what I call a popular mode of stress resolution, meaning that an ethnic group who had contributed very significantly to the war of liberation, the Walante. There were a few thousand people who went into trance and they did very weird things. They kind of swam across mangrove, arms of the sea, where there were crocodiles. They climbed into the rafters of their hut. They undressed themselves, which is unheard of in Africa, only when you are really very seriously mentally ill. They then went to one of the leaders of that movement where they confessed their sins and after a couple of weeks, they started to hear voices of their ancestors. And these voices told them to change their behaviour, to change the rules of the younger to behave towards the elderly and they got a whole kind of, whole set of directives from those ancestors that in a way re-moralised the whole ethnic group, because the ethnic group felt marginalised after the war of liberation. They contributed a lot to the independence but they felt that they had been treated very ungrateful by the government. So the movement kind of re-moralised them to find a meaning for all the difficulties they had been confronted with. So that’s how these cults of mass possession tried to find a solution to the massive stress, which are typical culture specific reactions. You might say they are ways of coping within those cultures with the trauma of war.
Even though the Transcultural Psychosocial Organization prides itself on the attention it pays to local cultures and traditions, Western psychology is also an essential element of its work. Much of the knowledge about mental health care for war victims stems from the research conducted on survivors of the Nazi concentration camps and soldiers who served during World War Two. When the war ended, these men and women were expected to forget the war and help participate in the reconstruction of Europe.
It took us many years to discover that it was not a very coping strategy because research gradually showed that people who don’t disclose their traumatic past, they get all kinds of medical problems as well, apart from suffering and other disability. So people get more cardio-vascular problems. People even get more cancer. People get more skin diseases. So in the ‘70s, you gradually saw a disappearing of that conspiracy of silence in the West. And of course, we even found 45, 50 years after the Second World War, that resistance fighters, that still about 45% of them were still suffering from post traumatic stress syndrome. And I think that what in a way is happening is that what we do in those countries is learning and using the lessons that we have learned from the past in the West. EB: And those lessons can be applied in developing countries? Yeah, with a lot of buts, because of course you have to be very careful about the culture. You have to kind of weave your own Western interventions into the local culture. You have to combinations like self-help groups are in many low-income countries are a kind of normal thing to have a talk under the big tree. Combine that with some Western approaches, allowing that those Western approaches are used in a different way, in a different setting. So we try to find that mix of Western approaches with a local approach including use of healers. In some cultures, we work with commemorative rituals or we try to promote them. We often work with cleansing rituals, like in Sierra Leone or in Mozambique. It’s very hard to get child soldiers back into civil life, so you often need a ritual to get them out of the combat mode into the civil mode, and they sometimes have to be ritually washed. They have to be ritually punished in order to be re-integrated into the local community. EB: Isn’t one of the problems in trying to deal with trauma that there is a big stigma attached to psychiatry in general? You see that in many countries. It’s believed that you’re crazy if you go and see a psychiatrist. It is. But it’s also not. I think that there is in many cultures including the West, there is a stigma attached to mental health problems. There is gradually some changing. In my opinion, the stigma in low-income countries is sometimes exaggerated. I think that the stigma often has to do with people who have acute problems. Being suicidal or being homicidal is very dangerous. If you commit suicide in many of these re-incarnation cultures, whether it’s in Buddhism or in Africa, your spirit changes into a capricious, wandering spirit that can attack other people and create all kinds of predicaments from a wasted crop to infertility and all kinds of diseases. So acute, violent behaviour or violence towards the self is very much stigmatised. If people have a chronic mental problem like a chronic psychosis or a schizophrenia or other problems, aside from epilepsy which is all over Africa very stigmatised, in general you see that because of the external attribution that the problem is caused by witchcraft or sorcery or angry spirits or discontent ancestral spirits who didn’t get the sacrifice that they should have got, then in general you also see that the local cosmology can kind of explain away the problems of psychiatric illness. So it’s quite a mixed picture in my view.
Over the past two decades, Europe has seen a massive increase in the number of asylum-seekers from Africa and Asia. Many of them were traumatised by the events they experienced in their home countries. In Holland and in some other European Union countries, these asylum-seekers were forced to spend months or even years in camps while the authorities decided on their asylum request. With funding from the World Health Organisation and the Free University in Amsterdam, TPO studied a large group of Iraqi refugees to determine the psychological impact of this long period of uncertainty.
One of our Ph.D. students, Kees Labam, found out for the first time in one of the provinces, in Drenthe, that waiting for the status for more than 2 years kind of doubles the amount of psychological problems people have. So that what we already knew on a clinical level is now proven in a scientific way, that waiting for the endless asylum procedure is an enormous, traumatic stressor for people. EB: Does this long asylum process mean that people who are already traumatised become more traumatised and those who weren’t traumatised become traumatised? Yes. That’s in a nutshell, you might say that’s what we find. But you would think that the government would try to do something about that because this creates problems for the future. Yeah, we have this new refugee law in the Netherlands which part of it is Fortress Europe, kind of closing down the gate and trying to get European standards and Lubbers who’s now in charge of UNHCR, our ex-prime minister, is trying to get some centres in Europe where people, they would kind of get thorough and quick assessment. That’s also what we try to do in The Netherlands now. We do see some shortening of the procedure which in itself is very good, and we also see a kind of trimming down the numbers of people who try to get asylum in Holland like elsewhere in Europe. EB: But is there also the likelihood that if these people remain here within 5 or 10 years that you are going to start seeing some very psychotic behaviour where they actually pose a danger to others and the society, even though they aren’t actually formally part of the society? Both. I would think both things would happen. You see more people who are getting very depressed, who often have co-morbid disorder. So in addition to the patient, you see PTSD symptoms or anxiety symptoms, all kinds of pain disorders and whatever, and they pose problems to themselves. They kind of drift towards the margin of our society. There will be some violence in the future. There will also be violent acting out, and that’s the kind of bill we will have to pay if you don’t pay more attention to it.
The Dutch government decided earlier this year to send 26,000 asylum-seekers back to their countries of origin. Some of these asylum-seekers have spent up to 10 years in The Netherlands, waiting for the government to decide on their applications. The expulsions have caused an outcry among many sectors in Dutch society. The government’s plans have been condemned by Human Rights Watch for violating international law and putting the lives of thousands of people in danger. Dr. de Jong shares some of this criticism, but having treated refugees in Holland for one day a week for the past decade, he has – what even he admits is – an unpopular perspective on the issue.
I think people in general are better off in their regions of origin. That’s what we see throughout our work. And if I’m honest and I see with all my years of psychotherapy training and how I stumble and get forward very slowly in treating clients and patients here, and how I see how easily many people with a couple of sessions are much better in the countries of origin, I think for their own well-being, it’s often better if they get a way of living in their countries of origin. But it means that we really have to shift our attention and what we now do is we are closing down Europe, but we don’t seriously, really seriously consider increasing the budget of UNHCR, getting much more funding to those countries. An average refugee in Africa has an annual budget of $25 – $50. A month? A year. And in Holland, we spend about $33,000 a year on one refugee. So we are closing down Europe but we don’t discuss seriously to get the major part of that money back to their places of origin. The African governments get fed up taking care of large amounts of refugees, while they themselves are very poor. So we have to support those governments. We have to take care of a balance of how to take care of the refugees but also the local populations benefit, that there is no jealousy, no envy between them. And invest much more in agriculture, rural development, vocational skills training, trying to stimulate the economies over there. I think that in the long run is a better solution. What type of impact does it have on you to be involved in this type of trauma counselling all the time? Getting a bit sadder and sometimes a bit wiser, but that may be…that’s an enigma of the long term. I must say, it’s also important that I feel that I’ve found something to do which I find very useful. It’s a kind of thread that kind of goes through my life, working since ’70 in Bangladesh, being exposed to one of the worst cyclones in Bangladesh, and then going to Africa, working in all kinds of war circumstances and then now being able with all these colleagues we have all over the world – we are about 600 in 15 to 17 countries – so it’s also very beautiful that we are able to do that, although of course it’s also work where you have to look daily at your own cynicism and where you have to be careful of not becoming cynical and sceptical because it’s also carrying water to the sea, but on the other hand, there’s now a change in attitudes towards psycho-social and mental health issues. We see that mental health and behaviour-related problems, they almost produce 50% of the disability caused by all kinds of disorders world-wide, whereas malaria, it’s only a few percent. Infectious diseases, it’s only a few percent. So it’s also a gradual change that donors, governments, that they see the importance. But it still will take a few decades before mental health receives the attention that it needs in this world, whether it’s in the West or whether it’s in a low-income country.