RPN 24 September 1997

6. Restoring playfulness by David Tolfree

Recent years have seen a growing concern with the psychological effects of war on both adults and children. Children who witness killings, especially involving people close to them, who see houses being destroyed, who experience the fear of attack or bombardment, who become orphaned or separated from their families and loved ones, or who have to cope with the upheaval of seeking refuge away from their communities are likely to be affected in many different ways. Such experiences have a profound effect on the ways in which children perceive themselves and the world around them, on how they feel, how they behave and how they relate to other people.

Rädda Barnen (Swedish Save the Children) has become increasingly involved in working with children and families affected by war and displacement around the world. This article introduces two such programmes - Acisam in El Salvador and Hi Neighbour in Yugoslavia.

1. From clinic to community - the work of Acisam in El Salvador

Acisam (Association for training and research in mental health) was born during the most critical years of political repression in El Salvador. Initially Acisam offered counselling and psychotherapy to individuals, support to people who sought refuge from the authorities, and assistance to people living in 'marginalised communities' (temporary slum housing) in San Salvador. The primary focus of the organisation gradually shifted from clinical intervention to preventive approaches and, following the peace agreement in 1992, it decided to concentrate its energies on training and supporting volunteer Promoters in village communities whose task was to offer a range of activities broadly described as mental health promotion. The task of training and supporting Promoters is undertaken by a cadre of Facilitators, most of whom are professional psychologists.

Acisam works mainly with rural communities which have been most affected by the civil war. Many of these communities face problems and issues regarding the resettlement of people who sought refuge outside the country or who were internally displaced, as well as many emotional, inter-personal, social and economic problems resulting directly from the war. Since the peace agreement, these communities have had to face the additional issues of the demobilisation of combatants and the widespread sense of disappointment with the limited change resulting from the peace accord.

The effects of war

Acisam has increasingly come to recognise that the main effects of war on people are not so much the classical symptoms of post-traumatic stress disorder but the indirect effects: excessive use of drugs and alcohol, increasing marital violence and child abuse, authoritarian, militaristic attitudes, and a widespread feeling of despair and hopelessness. Another effect of the war was that people were so preoccupied with their involvement with the conflict that there was little time for other things. Children may have had little time for play and parents may have had little time for their children. A current trend within Acisam is to focus more directly on children and youth. They have found that young people are not only less affected than adults by the sense of hopelessness and despair but also tend to be less polarised in their views. For these reasons, children and young people can often be more readily mobilised to take action to transform their communities and to work towards reconciliation.

The role of the Promoters

Promoters are unpaid volunteers who work at community level. In some districts, the Acisam Promoters have a specific mental health role while in others their work is part of an integrated health programme. Most are young but are usually people of standing in the local community - popular teachers, village midwives, members of village committees or former combatants. The majority are women, reflecting the particular concern with problems and issues being faced by both women and children, and their lesser involvement in income-generating work.

The mental health promotion work covers a spectrum of activities. At one end is the more 'clinical' work which includes individual counselling (referred to as 'co-listening') and the setting up and supporting of self-help groups. At the other end of the spectrum is a wide range of community organisation activities which include, for example, organising sports and other activities for young people; raising awareness of issues such as domestic violence, grief and loss, and alcoholism; giving talks to schools and other groups; adult education; organising cultural and recreational activities and celebrations; identifying local needs and negotiating for resources. In addition, those Promoters who work within an integrated health framework undertake a wide range of health tasks which include, for example, treating minor ailments, advising on family planning and various health education tasks.

Acisam has developed the concept of 'community self-diagnosis'. Promoters work within the local community to engage people in examining the problems, resources and needs of the community; this leads to an action plan which specifies what needs to be done to solve the problems identified and to improve the overall health and wellbeing of the community.

Working with Young Promoters and child and youth leaders

Acisam also deploys Young Promoters, who are usually older adolescents or young adults Their role is broadly similar to that of adult Promoters, with two exceptions: they do not undertake the more clinical work such as co-listening, and they have particular responsibility for reaching children and adolescents in their communities. By using sports and other recreational activities to gain the interest of young people, they often then try to progress into other areas which may include, for example, workshops (on topics such as alcoholism, health issues, sexuality, grief and loss) and the development of modest economic activities. Under their leadership, young people are also involved in community self-diagnosis. The compilation of village maps (which identify resources and resource gaps, community problems and so on) is a practical and enjoyable exercise which contributes to this process.

A relatively new departure is the identification of, and training and support to, child and youth leaders. The idea is to identify young people with leadership potential to undertake a number of functions in respect of children and youth in the community, such as the organisation of sports and recreational activities, workshops on various topics, and the promotion of awareness of mental health issues among the young and the organising of community events. Another facet of their role appears to be that of providing a role model to other young people in communicating attitudes and values conducive to good mental health and community development.

Conceptualisations of health

Acisam's approach is highly significant in moving away from individualised concepts of mental health and recognising, for example, the importance of identifying the effects of war in community terms. A striking example of this was found in one village which, every year, celebrates the return of its people from exile in Honduras. Previously an individualistic and fragmented community, this village achieved a strong sense of community and a high level of community organisation as a result of traumatic experiences in the war and subsequent experience of exile. An Acisam Promoter suggested ways in which the community might celebrate their return and the village committee decided to re-enact the circumstances leading to flight into exile. This involved large numbers of adults and children and not only preserved a highly significant part of village history but also served therapeutic purposes in encouraging people to talk about traumatic events within the context of the whole community. Significantly, this village seemed relatively free from problems such as drug and alcohol abuse, and it seems likely that the sense of community solidarity is an important reason for this.

An interesting feature of Acisam's experience is that it has not found it useful to respond to the reactions of individuals and communities to their experiences of war and conflict in isolation from other issues being faced in rural communities. The specific effects of conflict and violence, and the implications of the peace accord, are inextricably intertwined, making it necessary to respond to the totality of people's experiences and not to any one particular aspect of those experiences.


Perhaps one of the most remarkable features of Acisam has been its ability to adapt as circumstances within El Salvador have changed: from a concern with the immediate psychological effects of war to the problems associated with peace. From a largely clinical perspective, it has moved to prevention and then to promotion of mental health as its major focus, with community reconciliation as an important and challenging task.

2. A special form of social integration - the work of Hi Neighbour in Yugoslavia

In 1992, a group of developmental psychologists based in the University of Belgrade in Serbia became concerned about the effects of war on children in the Former Yugoslavia and in particular about the issues facing the growing number of children and families seeking refuge in the Federal Republic (FRY). In order to assess the impact of war on children generally (not specifically refugee children or those with direct experience of the war), they did some work with children attending pre-schools and observed a number of particularly striking factors:

- a preoccupation, sometimes almost an obsession, with war

- a dramatic effect on the colours used by children in their drawings, with flowers and suns coloured black

- in their play, children displayed their reactions to war but their playing tended to be rigid and lacked the vital ingredient of normal play: the elaboration of their experience and not merely reactions to it

- increased aggression in play

- children perceived the end of the war in terms such as 'extermination' rather than reconciliation, peacemaking or conflict-resolution, suggesting that adults have not given children different ways of thinking about the war and the possible ways in which the conflict might be resolved

On closer contact with children in the Collective Centres, they found that many children were simply unable to play, having experienced violence, sudden uprootedness and separation, as well as facing an uncertain future in a very constrained living environment. They also found that many parents displayed a reduced level of parental competence as a result of their experiences; adults were also isolated and experienced difficulties in making social contacts outside the Centres. It was apparent that the refugees felt a loss of individuality, personal identity and 'personal space'.

Hi Neighbour workshops

The Hi Neighbour approach(1) is based on the belief that all refugees are deeply affected by their experience but, by avoiding labelling people as 'traumatised' or as 'having problems', they are able to work in a way that builds on people's strengths rather than weakness. No attempt is made to 'solve' problems or to suggest action which they can take. Rather the aim is to provide a special form of social interaction and the 'tools' with which people themselves can discover and build on their own and each other's personal resources.

The project consists of weekly workshop groups in selected Collective Centres. Two or more psychologists are deployed in each group and there are usually one group for children, one for adolescents and one for adults operating concurrently, with periodic joint workshops for all ages. The groups are open and refugees are free to join and leave at will.

Each workshop group involves a wide variety of different activities. They usually begin in a large circle, with an activity focusing on the theme of personal names, personal signs and faces which serves to emphasise personal identity and individuality. Workshops also end with participants in a large circle with some sort of experience which, often in a ritual-like manner, draws the workshop to a conclusion.

Media such as drawing and painting, clay modelling, story telling and performing, movement and human sculpting, creative and expressive games and exercises all facilitate individual and group expression and exploration of the reality in which they find themselves and its emotional significance for them.

Workshops are planned in advance. The project has developed a large range of flexible workshop 'scripts' grouped in 'pools' of topics; some reflect such themes as feelings, faces and self-expression, identity, self-esteem or personal space in a way which provides opportunities for participants to use those experiences as they find appropriate, without necessarily being directed towards particularly poignant issues facing them. Other scripts reflect themes and issues of more immediate pertinence to refugees. New workshops are devised around particular issues which emerge within the Collective Centre or which refugees themselves request; one recent request was for a workshop on the emotive issue of 'revenge'.

The objective of the workshops (referred to as the 'prolonged workshop effect') is to help refugees to change the pattern of interaction among themselves - for example, in encouraging the expression of feelings, in achieving a high level of caring and tolerance, and in developing non-violent means of resolving conflict.

Social interaction programmes

Although the workshops have a significant impact on the quality of social interaction within the Collective Centres, many refugees still experience problems and anxieties in social interaction with people in the local community. The range of activities designed to improve such interaction has several components:

- meetings with refugees from other Collective Centres

- a range of outings and cultural visits

- encouraging refugees to act as hosts to other people

In such activities, the role of Hi Neighbour has been to encourage the refugees themselves to articulate their own wishes and needs and then respond by providing resources: transport, funds and personnel where needed.

In addition, refugees requested opportunities for taking part in traditional activities such as craftwork. The project responded by deploying an artist to design clothes and other craft items, provide materials, train refugees to train others in traditional skills and to begin to find ways of marketing the goods produced so as to provide a modest income for refugees. This provided not only a range of purposeful activities for adult refugees, mainly women, but also brought them into closer interaction with each other; this social function was considered to be as important as the activity and the modest material gains resulting from it. All three benefits enhance their sense of self-esteem and self-respect.

Originality and innovation

Hi Neighbour operates on a multiplicity of levels. At a basic level, it provides simple friendship and cultural and recreational activities which are valuable for their own sake. At another level, it offers a conceptually complex approach to child and human development which calls for very precise, purposeful and sophisticated work but which is implemented in a relaxed, friendly and non-confrontational manner. The work is highly professional yet avoids many of the typical characteristics of professional relationships, such as professional distance and inter-personal formality. The willingness of the psychologists to work within the real-life situation of the Centres rather than withdrawing people into a 'special' group situation is also a hallmark of their work.


Although this programme is built on a particular child development framework rather than specifically pursuing the concept of resilience, the two approaches have much in common. The idea of facilitating social interaction, of enabling young people to develop cognitive, social and emotional competence, and of promoting self-esteem and a sense of mastery over difficult life experiences - all these objectives have much in common with programmes aimed at enhancing resilience. Both have as their starting point the belief that people have a wealth of personal resources to bring to bear on even overwhelming difficulties. The task is to support these capacities rather than to provide 'treatment'. In particular, the Hi Neighbour approach builds on the great capacity of children for creative and imaginative play, through which difficult issues can be explored, feelings can be expressed and a sense of hope can be found.

The following story was written by a group of children in a workshop called 'my personal sign':

In the field of flowers a boy was wandering. He was holding tight to his heart a boomerang of kindness, uncertain what would happen to his boomerang if people received it. Would it come back to him as boomerangs always do? The boy took a chance. He threw his boomerang of kindness to people. Kindness went all the way to the sun and was coming back at people together with sunshine. The boy was looking into the blue sky and waiting. His boomerang came back to him as boomerangs always do. Kindness of people was with him, mingling with sunshine around his heart. The boy was certain, now and for ever, that boomerangs do come back to those who send them out to others.

This story is significant, not just because of the extraordinarily powerful imagery but because it resulted from the creative imagination of children. Here was a group of children surrounded by the horrors of a war which adults had imposed on their lives yet, despite everything, they were still able to perceive their own and other people's capacity for kindness and peace.

David Tolfree is a social worker and independent consultant. He is the author of Restoring playfulness: different approaches to assisting children who are psychologically affected by war or displacement from which the above article is extracted. Restoring playfulness is published by Rädda Barnen and is available in English and Spanish. 1996. ISBN 91-88726-46-0. 212pp. SEK 190. Contact: Rädda Barnen, S-107 88, Stockholm, Sweden. Tel: +46 9 698 9000. E-mail: info@rb.se

Hi Neighbour is a not entirely satisfactory translation of the Serbian Zdravo da ste, a traditional form of greeting which is more accurately translated as 'I wish you good health'.

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October 1997