Dividing them – setting apart problematic children in front of the whole community – is not advisable. On the other hand, setting up only social activities, leaving psychologically severely traumatized children without due attention, is wrong. This article summarizes the central elements of a programme of psychosocial rehabilitation for IDP children in Azerbaijan from 1995 to 1999, implemented by the Norwegian Refugee Council with BUTA Children’s Humanitarian Foundation, an Azerbaijani NGO. The methodology balances the ‘therapeutic’ and the ‘social’ elements of normal psychosocial rehabilitation, avoiding division and involving children in theatre, art, sport and music.
Methodology
The major principle is ‘restoration of the child’s world’ and the cornerstone of this is the child’s need for play. This implies also working with parents, teachers and the elderly, to re-establish intracommunal, intrafamilial and interpersonal relationships.
The children may participate in one of four ‘sections’: theatre, art, sport musical folklore. Depending on the motifs and game scenarios, the level and the focus of intervention shifts from medical-psychological to the educational with an emphasis on children’s rights. Each child chooses his/her preferred section and because of this element of free choice, the children and the community as the whole interpret their participation not as medical treatment but as part of creative, play activities.
1. Theatre
This section has roots in common with G Moreno’s method of psychodrama.(1) The difference is, however, that children do not re-enact their own experiences and problems. Instead, indirect intervention into problems takes place. Psychiatrists and psychologists individualize and adapt well-known fairy-tales and legends for the ‘child-actors’. The lives of the characters, their experiences and behaviour and, what is also important, the ways in which they solve their problems are very close to the lives of the IDP children.
2. Art
The methodology applied in the art section is based on art therapy; adaptation lies in the selection of themes. At first, in the ‘diagnostic period’, children are offered a free theme for drawing. Very often, children illustrate their traumatic experiences. Following this, children are asked to draw pictures with completely different themes, such as ‘my worst day’ (one drawing) and ‘my best days’ (three to four drawings). After several lessons, children are once more asked to draw on a ‘free’ topic. After several such free topics, the number of children who reflect their traumatic experiences in their drawing decreases considerably. It is important to ensure that, after actualization takes place during the drawing process, the children are then directed towards something good, kind and positive, either recollecting it from the past or transferring it to the future.
3. Music
Musical folklore appeals to the age-old mechanism of music’s complex psychophysical effect (music, text and rhythm). To a certain degree, these effects are predictable, stereotyped and leave less space for individualized associations. Each lesson starts with songs with a sad component (10-15 per cent of the time); then songs with more neutral content (up to 20-25 per cent); and at the end come songs and dances with an optimistic, happy component (60-70 per cent).
4. Sport
Sport yields less possibility for directed intervention into children’s psychogenic problems but has more impact on behavioural problems. In general, this section uses team sports such as relay race competitions; the results are improved emotional health, rehabilitation and interpersonal relationships. The games also create favourable conditions for addressing personal characteristics such as withdrawal, egocentrism, depression and frustration.
Application
This method of complex mass psychosocial rehabilitation of IDP children can be applied on three different levels with the use of various specialists:
Level 3: This involves two specialists: a psychiatrist (or psychologist) and a professional group leader whose background corresponds with the section profile (theatre producer, artist, etc). The psychiatrist designs a play scenario for the work of the section; the group leader implements this plan, making it attractive and interesting for children. Medical-psychological, social and to a lesser extent pedagogical interventions are applied.
Level 2: This involves one psychiatrist (or psychologist) and four to eight social workers. The latter are trained in the basics of intervention methodology. The work of the psychiatrist is confined to ‘difficult’ children and supervision of the social workers. (A common mistake is a tendency on the part of the social workers to focus on either the most talented or the most deprived children.) Mainly social-pedagogical and to a lesser extent medical-psychological types of interventions are applied.
Level 1: This involves social workers only, though they still require training. Intervention is implemented on the social-pedagogical and, to a much lesser extent, the medical-psychological level (mild neurotic reactions spontaneously decrease).
What level to choose will depend on the following:
- stage of psychosocial rehabilitation
- occurrence of psychogenic disturbances among children
- availability of psychiatrists/psychologists with experience in group psychotherapeutic and rehabilitation work and familiarity with the ethnic and regional environment in question
- financial resources
Results assessment
Assessment should indicate:
- whether the work brings tangible benefit
- which types of psychosocial assistance and interventions are the best with the different groups and ethnic-cultural compounds of IDPs (children, adults, elderly, women, urban, rural, etc)
- which types of psychosocial assistance are the most suitable in the work on different stages of displacement
- which activities social workers should choose in order to bring maximum benefit to IDPs
We would like to comment on the statement in the article by Anica Mikus Kos and Sanja Derviskadic-Jovanovic (2) that “…time is the most important healer. The state of mental health and psychosocial functioning improve in the majority of children without psychosocial intervention”. Our experience does not support this statement. Comparative evaluation of the children who took part in our activities and those excluded from them shows a significant difference among them.
Lessons learned
- Psychosocial rehabilitation, especially with children, should be done as a combination of both the therapeutic and the social, based on examination.
- Depending on the presence and character of psychotrauma and the individual reactions of children, there should be a range of psychosocial activities in the following sequence: from medical-psychological and social-pedagogical to purely social and educational (extracurricular education).
- All these activities can be organised attractively and educationally for children through games in ‘sections’. This avoids creating prejudices in the community. Many people in our culture, as well as in many others, still think that accepting any type of assistance with a ‘psycho’ word in it implies one is crazy.
- Intervention through games attracts children in large numbers and allows them to interact in mixed groups.
- Freedom of choice of section by children tends to ensure the most suitable type of activity and therefore the most appropriate form of intervention for each child.
- Depending on needs and resources, psychosocial rehabilitation can be done by the combined team of psychiatrists (psychologists) and social workers or alternatively by the trained social workers.
- Of key importance in the three levels of psychosocial rehabilitation is the training of social workers from among the inhabitants of the camp, transferring to them the role of ‘rehabilitationist’.
Based on fieldwork experience and the results of examination, we came to the conclusion that the best way to progress in psychosocial rehabilitation is to move from the medical-psychological complex to activities with purely social-pedagogical and educational components. All this should be done with the same group of children, in the same community, especially if their life in the camps spans a long period of time.
Nazim Akhundov is a psychiatrist, Associate Professor of the Medical In-service Training Institute and Medical Coordinator of BUTA Children’s Humanitarian Foundation. Email: nazim@intrans.az
BUTA is currently preparing a book including the main principles of the above methodology plus concrete recommendations about standardized games for use in interventions. Contact BUTA at Najaf Narimanov St, 5A, Apt 17, Baku, Azerbaijan. Tel/fax: +994 12 627432. Email: nazim@intrans.az
- Moreno J L The Essential Moreno: Writings on Psychodrama, Group Method and Spontaneity, 1987, Springer Publishing Co. ISBN 0826-15820X.
- Forced Migration Review, issue 3, December 1998