The Kosovo family support project: offering psychosocial support for families with missing persons.
Key words: assessment; collaboration; human rights; international social work; missing persons; psychosocial support; war crimes
The aftermath of war presents numerous challenges for societies attempting to recover and rebuild. Among the most difficult are locating and identifying missing people who died during the conflict. Based on its work worldwide, the Boston-based group, Physicians for Human Rights (PHR), has recognized the importance of providing support to families searching for missing relatives. Providing families psychosocial assistance and education about the identification process is an essential part of all forensic investigations involving recovery of human remains and identification of bodies. The role of social workers and other mental and public health professionals is integral to the success of that task. The following case example of a collaborative effort between the PHR family-support team working with local staff to provide culturally appropriate assistance and a forensic team from the International Criminal Tribunal for the Former Yugoslavia (ICTY) illustrates an effective emergency intervention and the role of social work in providing family support in this war-induced traumatic situation.
After the 1998-99 conflict in Kosovo between Serb forces and ethnic Kosovar Albanians, who represented 90 percent of the population, thousands of people were reported missing. Forensic experts from the ICTY began investigating reported mass gravesites within days of the peace settlement in June 1999. The U.S. Department of State asked PHR to help the FBI, the United States' forensic investigative team collaborating with the ICTY effort, by serving as the family liaison between the forensic teams and the families searching for their missing relatives. PHR public health and social work professionals trained local staff and social workers as interviewers to collect antemortem data from families (data that provides descriptive physical information about the missing person and personal effects, such as clothing and jewelry, at or before time of disappearance or death) to help in the identification process.
Recognizing the need for a long-term strategy, PHR also conducted a needs assessment of local social work, mental health, and forensic resource capacities. Although a system of community-based multidisciplinary Centers for Social Work existed in Kosovo, their services were intermittent and fragmented. During the tumultuous 10 years preceding NATO bombing in 1999, Serbs had excluded Albanians from university training and leadership positions in most professions. PHR provided training on postwar trauma and forensic investigation to local social work and forensic professionals, with a goal of developing local long-term sustainability and responsibility.
The issues about the derivation of the conflict in Kosovo are complex and beyond the scope of this article. A brief description of the situation during the past decade merits mention as a framework for the case description. Yugoslavia is currently composed of the republics of Serbia, including Kosovo, and Montenegro. In 1989 Serbia usurped Kosovo's autonomy, resulting in the establishment of parallel Serb and Albanian systems of education, medical care, business, and government. In effect, two separate societies existed between Serbs and ethnic Albanians in Kosovo. In early 1998 armed conflict began between the Yugoslav army and the Albanian insurgents known as the Kosovo Liberation Army (KLA) (Physicians for Human Rights, 1999). During the next several months, the conflict accelerated, and Serbian forces devastated numerous Albanian villages and drove thousands of Kosovar Albanians from their homes. Some relocated to major towns, sought refuge in the hills, or fled from Kosovo. Serbian aggression worsened, and in March 1999 NATO forces began bombing in Kosovo and Serbia to stop the Serb forces from continuing abuses against the Kosovar Albanian population. During the next three months, an estimated 848,100 Kosovar Albanians fled their homeland to neighboring Albania, Macedonia, Montenegro, and other Western countries. Another 500,000 to 600,000 were displaced within Kosovo (United Nations High Commissioner for Refugees, 1999).
On June 12, 1999, after nearly three months of NATO bombing, an uneasy peace settlement was reached and Serb forces withdrew from Kosovo, along with thousands of Seth civilians who feared for their safety. Before and during the bombing, thousands of Kosovar Albanians were killed or went missing. The number of people killed or missing was not immediately known and was difficult to determine. Many local and international groups recorded disparate reports of missing persons with no official central repository for the information. (The International Committee of the Red Cross eventually centralized all tracing requests and families' reports of missing persons.)
In this political environment, the ICTY and its participating international forensic teams from 14 countries began exhuming graves in Kosovo to collect evidence to support their indictment of Yugoslav President Slobodan Milosovic and his top officials for crimes against humanity, genocide, and war crimes in Kosovo (ICTY, 1999). The PHR family support team was with them.
The ICTY teams arrived in Kosovo within days of the peace settlement, and thousands of Kosovar Albanians also returned from neighboring border camps. This presented challenges for the war crimes investigators to preserve the integrity of the crime sites, protect and collect evidence, document cause and manner of death for use in prosecution of war criminals, and proceed with the recovery and examination of bodies. The families' interests, on the other hand, were focused on information and identification of their missing family members and the expectation that recovered bodies would be identified and returned to them for proper burial and closure. There was never any doubt that the families in Kosovo with missing relatives would seek identification of the exhumed bodies. Families seeking answers reacted with anger and resistance to any attempts by local or international groups to address the issue of the missing or unidentified recovered bodies from mass graves, as simply "war dead" (the result of war). The United Nations' Declaration on the Protection of All Persons from Enforced Disappearances (1992) stated that "investigation of a case of disappearance should be able to be conducted for as long as the fate of the victim remains unknown" (Article 18 ). It also guaranteed the missing victim's family the right to complain to a competent and independent state authority and the right to be informed of the findings of an investigation. Collaboration was essential to meet everyone's goals. Although the ICTY teams' mandate did not include identification of remains, the recovery and return of missing people would not have been possible without these teams' assistance.
The liaison role of the PHR psychosocial support team was critical in helping meet the families' expectations and needs. PHR quickly designed and implemented an emergency intervention to assist, inform, and support families. Each exhumation site required a victim-recovery process that was sensitive to the families' needs while also meeting the needs of the investigative teams. The intervention plan included a culturally sensitive and supportive approach to educating these traumatized families about the process of recovery and identifying remains. It also included provision of support for the bereavement and grieving process and warnings to families of the reality that not all remains could be recovered or identified. The liaison role frequently involved assistance in obtaining food, medical care, and emergency funds for burial. This intervention was designed to respond to a particular crisis situation and may serve as a useful example in response to other similar emergency situations. We believe this intervention was effective in the short-term and provided a framework for continued development by local Kosovar experts to meet their long-term needs.
Case Study in Cikotova
The PHR family support team's work at one exhumation site illustrates effective social work intervention through partnering with local professionals to provide culturally appropriate counseling, interviewing, concrete services, and follow-up whenever possible. In July 1999, after several weeks assisting other ICTY forensic teams, PHR began work with the ICTY's Belgian Disaster Victim Identification (DVI) Team, assigned to the village of Cikatova 20 miles from Pristina, Kosovo's capital. This area had experienced fierce fighting and contained multiple mass graves. The Belgian team arrived with a preplanned commitment to implement a system of family support that included efforts to make identifications from the graves by using antemortem and postmortem data and investigative information particular to each site.
Team Development and Deployment
The PHR international team included a master's-level clinical social worker and public health professional. Each had similar experience with PHR's forensic and identification program in Bosnia from 1997 to 1999 as the psychosocial coordinator and director of the Antemortem Database Project. Four recently hired and trained Kosovar Albanian translators and data collectors, a social worker, and a psychologist who had assisted in the family liaison role with PHR in other sites completed this team. The staff spent the first day at the exhumation site getting oriented to the community and its limited resources. Cikatova, believed by Serb forces to be a KLA stronghold, had sustained major damage, resulting in many burned and demolished houses and businesses and hundreds of missing people. The ICTY and PHR support team gathered together community leaders to describe the proposed exhumation, recovery, and identification procedures so that the leaders could inform the broader community about the process. The plan called for forensic experts to attempt to identify bodies by using the antemortem data collected by the PHR team and to match it with the postmortem data collected by the forensic team.
Working with the affected families, who were immersed in complex stages of grief and coping with the identification process, required a delicate and dedicated approach. The families' situations had a profound impact on the teams and were central to the implementation of their work plan, which required families to relive, through the telling of their stories, the last moments of their loved ones' lives.
Data Collection and Cultural Issues
PHR conducted a pilot test of the antemortem data collection tool to assess the amount of time and level of difficulty to complete each interview. The first sets of data were collected using English forms, by English-speaking staff using Albanian translators. This process doubled the time of the normally 45-minute interviews. To complete the interviews in the four-week period scheduled by the Belgian team, to ensure a culturally sensitive and easy rapport in administering the questionnaire, and to avoid the insertion of a non-Albanian speaking third party, PHR provided intensive training to local bilingual Albanian staff in the administration of the English data collection questionnaire (which was soon translated into Albanian). When the Albanian staff became comfortable and competent with administering the new questionnaire in Albanian and recording the responses in English, the interview time was shortened and allowed for a more intimate and culturally appropriate interaction with the respondent.
The staff initially conducted the interviews in a field near the gravesite. This left little room for privacy or confidentiality. Although the community shared a common tragedy, many families conveyed a need to talk one-on-one, to tell their individual story about their missing person, and to display emotion. Community leaders quickly offered the use of a classroom at the local elementary school, which created a more official and intimate space in which to collect the data, accommodate the families, and protect them and the staff from inclimate weather. The school was located across a dirt road from the mass gravesite where the Belgian team continued to work. The school had suffered severe damage during the conflict. Windows were smashed, desks were removed or broken, and the school was dirty, as a result of being exposed to the elements for several months. There were no books, no chalkboards, no running water or in-door plumbing facilities, and no heat. PHR staff organized remnants of furniture in one classroom and began a four-week process to interview families and record antemortem data. The staff posted hours for data collection so that families could plan when to come to the school and to receive updated information. PHR recorded 215 surveys on missing or deceased people and spent uncounted hours listening to and talking with families who waited for information from the graves.
Although PHR's primary task was to collect antemortem data while assisting families through the identification process, staff quickly recognized the need for additional psychosocial support in the community. PHR recruited a second sociologist-social worker and a female psychologist from the Kosovo Center for Social Work in Pristina, an organization PHR had contacted to help provide immediate and long-term mental health services, and trained them to collect antemortem data. More important, they were able to assess family psychosocial situations, discuss posttrauma issues such as families' fear, grief, and ability to care for their children during this critical time. The community had few resources, and while providing data about their missing relative, many families expressed concerns about lack of food, shelter, water, and medical attention. PHR collaborated with the local social workers to enlist the support of humanitarian aid providers to deliver services to these sites while the exhumations continued. PHR staff seized any opportunity to deliver tangible assistance, such as securing a donation of medicine for a family in need. The more difficult challenge was to provide emotional support during this period of overwhelming grief and loss and to understand and function in this chaotic environment. To help address these circumstances, the ICTY investigator and PHR staff presented daily announcements to the community about the status of the forensic team's findings and worked with community leaders to organize group meetings as necessary.
PHR staff were keenly aware of the importance of being good listeners. They were attentive and listened to each story as if this were the first time they had heard such a story. It was essential to allow each informant to detail what had happened and to describe the life and individuality of their missing loved one. Families needed personal attention, acknowledgment, and most important, the identification and return of a missing loved one.
A significant cultural issue arose that affected the accuracy and quality of the data. The expected cultural norm was for males to act as the family spokesperson. A brother, father, or uncle of the missing person serving as the informant often reported, however, that he had no idea about the clothing or personal effects of the missing relative because he may not have been the last to see the missing person before his or her disappearance. In many cases, the wife, mother, or daughter had last seen the missing relative and was the most familiar with the clothing, having washed and repaired it. This lack of precise information caused difficulty for the data matching. Male informants sometimes became upset and felt guilty for not being able to provide accurate antemortem data. Staff was particularly sensitive to this and, recognizing the status of the male family spokespersons, suggested that the whole family discuss the details of the missing person and return to give more accurate data.
Several other complicating factors arose thwarting efforts to identify exhumed remains. One grave in this community contained the remains of 68 individuals and another contained more than 50. The Belgian investigative team initially believed that identifications could be made by comparison of antemortem and postmortem data alone. It was impossible to view the remains because of the high degree of decomposition of the bodies. Many people who had provided antemortem data had also witnessed multiple tragic events, making it difficult to ascertain accurate witness testimony. Males of fighting age, as young as 14, and as old as 60 were targeted by Serb regular army, police, and paramilitaries. Many were able to hide in the hills and mountains around the villages. In cases where men were captured, however, witnesses stated that the captors forced the men to undress, forfeit personal effects and, in some cases, switch clothing. There were also reports of captors stripping bodies after the executions. Frequently, men and women were separated. While young men fled to the mountains, older men, women, and children were left behind in villages.
In some cases, families gave descriptions of clothing based on what was missing from their homes when they returned from the refugee camps rather than what the person may have been wearing at the time of disappearance. There were discrepancies between unmatched location of wounds on the bodies and bullet holes in the clothing. A most heinous complication, was the discovery of bodies that had been further violated at the time of burial by exposure to a white powdered substance used to hasten decomposition of facial features.
It was apparent that this was a complicated exhumation site and the community's emotions were running high. Community leaders explained to the international teams that traditionally with the death of a loved one, male members of the family washed the body of the deceased, wrapped it in a white cloth, and buried the body within a day or two of death. The circumstances of the killings and unceremonial disposal of the bodies in these graves had prohibited the community from carrying out its traditional rituals and grieving, thereby exacerbating the anxiety and disquiet of the community. The exhumation and identification process instituted by the forensic team and PHR was alien to this and most other cultures. Many in the community originally believed that the forensic team would exhume the bodies and present them for public viewing and for eventual identification by families. Because of the poor condition and decomposition of the bodies, this could not be done. A clear analogy is made between the traditional and societal rituals and the healthy expression of grieving and recovery for a community.
Antemortem and Postmortem Comparison and Viewing
To address some of these barriers to making identification, the PHR team added a second component to the antemortem and postmortem data collection. The community had asked the investigators and the PHR team for permission to view the clothing and personal effects found with the remains. Based on their experience in Bosnia, PHR international staff knew that this was a major organizational task (including cataloguing items, finding space large enough to exhibit hundreds of articles of clothing and personal effects, and so forth) and would take a physical and emotional toll on the families and staff. During the following three weeks, PHR, the forensic team, and representatives from the local community attempted to organize a manageable and appropriate viewing process. Family viewing times were designated based on available psychosocial support, forensic staff, and other material resources.
The clothing recovered from each grave was laid out in the field adjacent to, but visually blocked from, the exhumation activity. It was summer in Kosovo, and the weather varied from day-to-day. Families often stood in driving rain or intense heat and sun waiting to view clothing and personal effects. PHR staff and mental health workers escorted each family through the viewing. This was a painful, deliberate, and slow process as families trudged and plodded through rows of tattered, faded, foul-smelling remnants of clothing, half pairs of shoes and the few remaining damaged personal effects. Some women and men collapsed, fainted, became inconsolable with grief, or withdrew into a state of shock as they recognized familiar items worn by their missing loved ones. During the four-week exhumation period, one surviving male family member identified clothing from five missing sons and a brother.
PHR augmented its family support team during the viewing process by recruiting and mobilizing a community psychiatrist, nurse, and ambulance from the town clinic. PHR staff also networked with other nongovernment organizations, one of which provided a psychiatrist for several days to follow up with the families in the field. In addition to spending hours with the families at the exhumation site, PHR social worker and mental health staff conducted home visits to some of the families most traumatized by the process. After each day in the field, the staff discussed their concerns for the families in PHR team meetings and sought the best course of action to take with limited resources.
Although many people recognized clothing and personal effects from the bodies, it was clear after the antemortem and postmortem data review process with the family and forensic experts that reported descriptions did not always match physical findings. The Belgian forensic experts offered that clothing might have been switched among bodies either before or after death. In some cases, families recognized clothing belonging to their missing relative only to learn it had been found on another body of different age or gender. The mixing of clothing was common and became a source of frustration to the teams and the families. During this four-week period, approximately one-quarter of the remains from these graves were positively identified using antemortem and postmortem comparison. Confirming more identifications without further scientific investigation would prove difficult or impossible.
Burial and Follow-Up
Many in the community expressed to the PHR staff that it was agonizing to be unable to give their family member a proper burial. Some held on to the hope that if the family member could not be identified from the graves, that perhaps they were still alive and being held captive or had escaped. Those who received a positive identification reclaimed the bodies and performed their own family reburial. The team felt that a mass reburial of the remaining unidentified bodies was appropriate. However, community members did not want to rebury any bodies without proper identification and instead, considered creating a memorial with the listed war dead.
The ICTY exhumation team completed its work after four weeks and called a community meeting in the school. Family members, the PHR family-support staff, a forensic team representative, and the ICTY investigator attended. The goal of the meeting was to distribute written death notifications for confirmed identifications and to explain the subsequent procedures for those not receiving a confirmation. This was an emotionally charged meeting. The PHR international staff social worker and a Kosovar psychologist and translator met separately with each family who received a death notification. A member of the Belgian forensic team was present to answer questions regarding how identifications were made. Every family asked for the cause of death and whether or not their deceased family member had been tortured or abused. The forensic team, the ICTY investigator, and PHR staff met at length with families who did not receive a death notification, to explain why identifications could not be made and to describe the ongoing antemortem and postmortem data matching process that the Belgian ICTY team would use to search for more identifications.
The ICTY in Kosovo received information weeks later about new identifications made from this ongoing postexhumation process and forwarded it to the PHR team to present to the families. By this time, the local Center for Social Work had resumed services, and PHR enlisted the assistance of their social workers who had intimate knowledge of this community to deliver information of both positive identifications and negative results to families. Two social workers from this local center agreed to follow families on a more long-term basis, particularly during the severe winter months ahead. Despite these intensive efforts, and without more scientific resources such as DNA and computer reconstruction, for example, many families were left without answers as to the fate of their missing loved ones.
Effect on Recovery and Relief Staff
The effects of dealing with such complex trauma took its toll on the families and the support team. For many families, the humanitarian assistance processes in Kosovo, from exhumation and identification of bodies, to food distribution, to home repair, were frustrating and slow. Similarly, for the PHR family-support team, sometimes acting as the only humanitarian relief workers in a geographic area, the weight of these cumulative problems became overwhelming (Dunning, 1990). Ethnographer Olujic also noted the difficulties in working with traumatized victims (Nordstrom & Robben, 1995). She stated: "We should be careful in asking victims of violence to tell their story when we are unable to relieve the reliving of their trauma. We may give voice to the victims of violence, but we can never restore their lives" (p. 19). The professional mental health staff, trained principally as social workers and psychologists, found it easier than other staff to discuss their feelings about these issues and to express their struggles with the work. The nonprofessional staff hired as translators and data collectors, on the other hand, did not always find an easy mode of expression of their grief or anger. Some had missing family members and had witnessed the horrors of war similar to those individuals whose stories they recorded daily. Many hours spent traveling to and from the field, and in more formal debriefing sessions, were devoted to discussion of self-care. Discussion during nonwork hours was also encouraged as a way for the group to unwind. The field staff were young nonprofessionals and new to the workforce. Although their commitment to the family-support project was genuine and sincere, for some, merely having a job in this postconflict society suffering from high unemployment and being able to use their English language skills were as compelling reasons as any to be performing the job. Most were eager to return to their university studies as that opportunity now became available to them.
Transition and Recommendations
Because of the emergency response nature of the family-support project, training and supervision of local staff were carried out in the field for the first several months. A more formal training, designed to meet the long-term needs of families and local professional staff, was organized near the end of the exhumation period, which halted temporarily because of winter weather and poor field conditions. This formal classroom training incorporated the psychological impact of the work on staff, tools to provide support to the families, and data collection techniques. Both self-help and caregiving skills were addressed (Dunning, 1990). It was clear that despite attempts to provide staff support through team debriefings and individual counseling during the six-month project period, this remained an area requiring additional attention and exploration for long-term local support and sustainability.
This account of a critical response by a psychosocial support team to a traumatized population describes intervention tools that may be useful in similar situations. The approach used, which may warrant further exploration and development, is an example of the role that social workers and mental health workers can play in an international postconflict setting with a grievously traumatized society. It is intended to illustrate and share lessons learned from a crisis based, rapid, and effective intervention. It is important to keep in mind the limited resources available for assisting families; the crisis mode in which all organizations were working in the first few months after the end of NATO bombing; and the effects of the multiple losses sustained by the population.
This support team did not exhaust all possibilities for helping families address posttraumatic situations; they provided an immediately responsive community-based intervention that attempted to be culturally appropriate in the face of a tremendous tragedy affecting a total population. To be effective, it was essential for the PHR family support staff to engage professionally trained and experienced Kosovar mental health and social workers with knowledge of communities, cultural norms, and expectations. An integral part of this effort was to provide an environment for local staff to do their work with supplemental professional and financial support from the international staff.
In such situations, it is imperative for the response team to quickly assess local needs and resources; identify and develop a collaborative relationship with community leaders; foster local and international interagency collaboration and partnerships; and build on local capacity for long-term programming and sustainability. Capitalizing on international resources to help in collaborative rebuilding of local infrastructures can pave the way to longer-term success. Emergency interventions must be seen as a short-term solution. The need to leave a culturally and fiscally viable framework in place must be recognized.
Declaration on the Protection of All Persons from Enforced Disappearances, G.A. res. 47/133, 47 U.N. GAOR Supp. (No. 49) at207, U.N. Doc. A/47/49 (1992). (Adopted by General Assembly resolution 47/133 of 18 December 1992). Geneve: United Nations Centre for Human Rights of the Secretariat.
Dunning, C. (1990). Mental health sequelae in disaster workers: Prevention and intervention. International Journal of Mental Health, 19(2), 91-103.
International Criminal Tribunal for the Former Yugoslavia. (1999). The prosecutor of the tribunal against Milosovic, Milutinovic, Sainovic, Ojanic & Stojiljkovic. The Hague, Netherlands: Prosecutor of the tribunal, Public Information Service. (Case number IT-99-37)
Nordstrom, C., & Robben, A.C.G.M. (1995). Fieldwork under fire: Contemporary studies of violence and survival. Berkeley: University of California Press.
Physicians for Human Rights. (1999). War crimes in Kosovo, A population-based assessment of human rights violations against Kosovo Albanians. Boston: Author.
United Nations High Commissioner for Refugees. (1999, June 11). Kosovo crisis update. Geneva: Author.
Mary Ellen Keough, MPH, is former director, Kosovo Family Support Project, Physicians for Human Rights, and currently director, Educational Programs, Meyers Primary Care Institute, and instructor, University of Massachusetts Medical School, 630 Plantation Street, Worcester, MA. 01605; email: email@example.com. Margaret F. Samuels, MSW, CSW, is former assistant director and psychosocial coordinator, Kosovo Family Support Project, Physicians for Human Rights, and is currently clinical instructor/clinical administrator, Yale University School of Medicine, Child Study Center Trauma Clinic, New Haven, CT. The authors thank the dedicated Kosovo field staff and Centers for Social Work, who interviewed and assisted hundreds of Kosovar families searching for their missing; the Kosovo leadership of the International Criminal Tribunal for the Former Yugoslavia for their support of the family liaison project, particularly ICTY investigator Peter Stewart and the Belgian Disaster Victim Identification Team; the FBI; ICTY investigator Tom Parker; Physicians for Human Rights; and the International Commission on Missing Persons for financial support. Special thanks go to the families who continue to seek to learn the fate of their missing loved ones for their participation and support during this painful process.
Original manuscript received April 27, 2001 Final revision received February 8, 2003 Accepted April 14, 2003
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|Author:||Keough, Mary Ellen; Samuels, Margaret F.|
|Date:||Oct 1, 2004|
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