ࡱ> Y YbjbjWW ;==Q:]  ,,,@@@@8xT@'(D(lllGGG>@@@KL"L#'$(~*G',GGGGGG',,llG,l,l>@@,,,,G>|,,>l4)5<@@, 3. Transforming Local and GLOBAL Discourses: Reassessing the PTSD movement in Bosnia and Croatia Paul Stubbs 1. Introduction The wars of the Yugoslav succession, beginning in 1991 and culminating in the still unresolved Kosovo crisis, have seen large-scale killings and forced population movement as explicit major war aims, often euphemistically referred to as ethnic cleansing. In this chapter, the dreadful realities of the wars and their wider socio-political contexts are less directly the focus than the ways in which these realities were reproduced and connected in specific, more or less coherent, discourses. These discourses were embedded in particular movements, which constructed ways of addressing and understanding the consequences of the conflicts on particular affected populations, and, most importantly, thereby delineated particular kinds of responses to ameliorate these consequences. Above all, the paper attempts to unravel the ways in which forms of psychosocial assistance, primarily defined in terms of post-traumatic stress disorder (PTSD), came to attain an important position within emergency responses to refugees and displaced persons in Croatia and Bosnia-Herzegovina. The text builds on arguments which, together with Baljit Soroya, and based on research undertaken in Croatia from October 1993, I have advanced elsewhere regarding the problematic aspects of the dominant psychosocial discourse, particularly in Croatia (Stubbs & Soroya, 1996; Soroya & Stubbs, 1998). It is a reassessment, however, written some three years after I last focused, directly, on questions of PTSD and is much more a contribution to a sociology of organizational and professional responses to war and forced migration, in which the discourse and movement is addressed much more directly and viewed as more fractured and contradictory than previously. In addition, and consequently, critiques themselves, of which I was a part, are themselves understood as discourses and movements which may have had effects which were either unintended, problematic or both. Perhaps even more importantly, the text is a reconceptualization of an emerging critical orthodoxy that sees the PTSD movement as a new form of humanitarian intervention (Parker, 1996) in which Western understandings and approaches are imposed, by aid agencies, on unsuspecting non-western populations. Whilst this argument has its merits, it is too sketchy and all-encompassing an explanation, neglecting the active role of key individuals and agencies and, even more importantly, the difficulty of Western professional discourses attaining a dominant global position without some form of connection with more locally specific discourses and practices. A close attention to discourses and movements suggests that emancipatory forms of analysis and practice are more likely to be prefigured by an examination of complexity and contradictions than by a simplistic either/or approach, and in which crude dichotomies between global and local, and indeed, between Western and non-western forms, are seen to have only limited explanatory value. The next section provides a more detailed exposition of the Who and What of the dominant PTSD movement in Bosnia-Herzegovina and Croatia, from its establishment in late 1992. The section also attempts, somewhat tentatively and speculatively, to address How and Why the movement attained the importance it did and, in particular, to look at its relationship to other discourses and movements. The third section of this paper addresses the critique of the PTSD movement and its demise, and suggests ways in which a more nuanced understanding of the discourse of which it was critical, could have led to some different emphases. A brief concluding section looks at other approaches to refugee mental health based more on anthropological understandings of exile experiences and, on this basis, draws some brief lessons from the case study of relevance to practice and research, and more importantly, to emerging connections between the two, in the future. 2. The PTSD Movement: meanings, mobilizations, and modalities This unexpected European war ... is probably the first war ever where not only the body and the material needs but also the soul and the psychological needs of the traumatized has (sic) been taken seriously on a large scale. (Arcel, 1994, emphasis in original.) This quote comes from a book of proceedings from a conference, held in Zagreb, in April 1994 on Psychosocial Care of Traumatized Women and Children: need for new methods and aims? and it is a clear statement of the innovative nature of the approach by one of its leading proponents. By the time of the conference, the psychosocial approach, dominated by a particular understanding of PTSD, framed such a wide range of interventions, from a variety of agencies in Bosnia and Croatia, as to be clearly identifiable as a movement. By this time, four key agencies, and five key individuals, were playing a key role in its amplification: The European Community Task Force (ECTF) and its psychosocial consultants Libby Arcel and Inger Agger. The ECTF was established at the EU Summit in Birmingham in October 1992 as the implementing body of the EU aid agency ECHO. In addition to its more usual aid and logistical operations, and following the Warburton report on rapes of women in Bosnia, it added the aim to develop, improve and coordinate the contribution of the European Union in the psychosocial field (Martinez-Espinez, 1994). As usual with ECHO, it did not work directly with governments but, rather, funded a wide range of projects in the psychosocial field, mostly led by member-state NGOs, in Bosnia and Croatia. The World Health Organization (WHO) and its Mental Health Consultant Soren Buus Jensen. Within a broad rehabilitation of war victims project, Jensen headed a mental health unit concerned both to protect the mental health of populations in Former Yugoslavia and to prepare national mental health services for post-war development (Jensen, 1994), which involved research, training and support primarily to governmental agencies and to local experts. The United Nations Childrens Fund (UNICEF) and its psychosocial Advisor Rune Stuvland. In parallel with WHO, UNICEF also focused on research, training, and project support, with a particular emphasis on children as victims of war, and with a wider range of initiatives including some work with local NGOs, again throughout Former Yugoslavia. The United Nations High Commissioner for Refugees (UNHCR) and its Regional Social Services Officer Marcia Jacobs. Perhaps less important in stressing PTSD than the other agencies, UNHCR was a major funder of NGO psychosocial projects working with refugees in Croatia and Bosnia. The main link is, however, through Jacobs co-authoring of a core theory and practice text on what defines a psychosocial project with two others in the movement (Agger, Jensen, and Jacobs, 1995), which they described as a truly collaborative effort. Designating these organizations and individuals as a movement may be less accurate than seeing them as an epistemic community or a network of knowledge based experts. Certainly, there are strong epistemic and related links between four of the five, three being from Denmark, two of whom (Agger and Jensen) were, at the time, married to each other, and a fourth, Stuvland, from Norway so that a Scandinavian perspective is apparent, instantly, as dominant. All sought explicitly to link theory, research and practice and were very conscious, as the quote from Arcel demonstrates, of the pioneering nature of their intervention. The innovative organizational core, in many ways, for the group, is the ECTF, in terms of levels of funding, extent of dissemination of analysis, and the development of new approaches. ECTF as an implementing body of ECHO, itself at that time a relatively new humanitarian actor, can be considered in terms of its two key aspects - as a European and as an emergency aid agency, hence already, almost a priori as it were, tending to exclude any non European and developmental approaches. Seeing ECTF as a key part of the way in which humanitarian intervention substituted for political intervention is only part of the story. At the onset of the refugee crisis in Bosnia, with large numbers of refugees arriving in Croatia, itself with large numbers of displaced persons, a major theme was the systematic rape of, primarily Bosnian Muslim women. It was on this basis, with Libby Arcel herself playing a leading role, that psychosocial support redefined in terms of vulnerable women and children, was added to ECTFs mandate. In other words, a politicized context helped to set up a relatively autonomous and explicitly depoliticized professional psychosocial field, more or less free to develop explanations, analyses, and projects, provided these did not impinge upon or threaten wider power relations or other aspects of the European Unions interventions. 2.1. The psychosocial Field In retrospect, notwithstanding differences of emphasis, the psychosocial field was established on the basis of three core elements, which, in shorthand terms, can be labeled essentializing trauma; talking up the numbers; and justifying intervention. All of these are, of course, highly problematic and, in other circumstances, would certainly be questioned by some or all of the individuals involved in establishing the field, aware as they surely were of an emerging general critical psychological literature. Taken together, they amount to a very questionable argument that PTSD is a relatively unproblematic diagnostic category; that large numbers of refugees and displaced persons in Croatia and Bosnia-Herzegovina suffer from it; and that massive psychological assistance, including from internationals, is required to treat it. It is as if, to establish such a field, and to convince a number of influential publics, a crude, and lowest common denominator approach had to be installed in the core before more nuanced understandings could be introduced. In some ways, this is a kind of classic moral entrepreneurship in which a moral panic approach to a social problem frames a limited range of solutions. Each of the core elements, as strands in the discourse, can be noted briefly here. 2.1.1. Essentializing Trauma Throughout the public presentations of the work of ECTF, there was an essentializing of the concept of PTSD as a set of symptoms which follow a trauma outside of the range of usual experience and which contained a number of essential features. (Arcel, 1994) The term trauma tends, therefore, to be used to describe an event or series of events, a symptom or series of symptoms, and a condition, so that, in a key elision, people become their symptoms and their experiences, and can be referred to, unproblematically, as traumatized children (Stuvland, 1994) or, simply, the traumatized (Agger, Jensen and Jacobs, 1995). In the same literature, however, there are the beginnings of a much more nuanced approach, in terms of the importance of strengthening psychosocial protective factors and decreasing psychosocial stressor factors (Agger, Jensen & Jacobs, 1995) which should have opened the door to much more reflection on the broader social, political and cultural dimensions of lived experiences. This insight is never pursued, however, so that the essentialist perspective on trauma, delinked from any wider structures, retains a core position. 2.1.2. Talking Up the Numbers A key text, referring to an unpublished WHO study co-authored by Jensen, suggested as early as late 1994 that more than 700,000 people in Bosnia-Herzegovina and Croatia ... suffer from severe psychic trauma (Agger, Jensen & Jacobs, 1995), with Jensen, in an influential New York Times article in January 1995, quoted as stating that there is no doubt in my mind that post-traumatic stress is going to be the most important public health problem in the former Yugoslavia for a generation and beyond (Kinzler, 1995). The WHO study, which I have not seen, appears to estimate these numbers on the basis of a series of statistical assumptions about the existence of severe trauma in peacetime and in war time conditions, including a figure of 20% of all refugees and displaced persons, which is not only, itself, questionable, but, of course, relies on what was, at the time, a rather questionable figure of forced migrant numbers (Spirer, 1995). Preliminary data from 1974 people in one psychosocial project in Zagreb concluding that a great number of people ... had considerable losses, deep traumatic experiences and needed urgent social support (Arcel, 1994) and from a screening of children in 28 schools in Croatia (Stuvland, 1994) are, perhaps, more valuable but also suffer from a number of methodological flaws and, above all, little validity as representative samples. Guesswork seems to have been more important in amplifying the nature of the problem as well as contributing to an illusion of planning, not least since most psychosocial projects were being implemented in the relative safety of Croatia and most suffering, even according to the assumptions of the WHO study, was in Bosnia where 78% of the affected population was said to be based, people who were receiving very little support (Agger, Jensen & Jacobs, 1995). 2.1.3. Justifying Intervention The sentence quoted above about the large numbers suffering from severe psychic trauma ends with the words and need urgent and qualified assistance (Agger, Jensen & Jacobs, 1995). Local professionals were estimated to be sufficient to meet less than 1% of the needs for psychosocial assistance of the traumatized, therefore, both international assistance, and a wider range of interventions including those by para-professionals and non-professionals, were seen as needed. In typical moral entrepreneurship, failing to act would have disastrous consequences for at least the next two generations, in terms of increases in alcohol and drug addictions, suicides, all kinds of violence (criminal and domestic) and psychiatric illness and, in addition, unresolved traumatic experiences are likely to ignite new hatred and new wars (ibid.). The balance between international and local staff, and between professionals and non-professionals, tended to be discussed somewhat abstractly, if at all. The argument that local mental health professionals were likely, in significant numbers, to be traumatized themselves, so that internationals, as well as prioritizing training, should reserve their practical work for this group served, as Derek Summerfield has commented wryly, to aggrandize the status, knowledge and indeed health of the foreign expert (Summerfield, 1996). The crudity of the lack of any kind of social or cultural awareness amongst members of this epistemic community, perhaps best exemplified by Inger Aggers infamous phrase when I arrived in the former Yugoslavia (Agger, 1995), is also reflected in a number of telling phrases and articles which suggest that, in large part, their main point of contact was other international humanitarian aid workers, all of whose longing for Sarajevo (Agger, 1995) was mediated through this framework more than any others. 3. Legitimating Connections Given the problematic nature of all of these strands of the discourse, the success of the PTSD movement can be considered as less a product of its internal coherence and much more a result of a series of real or imagined connections with more progressive discourses, themes and movements which, in shorthand terms, I shall call gendered perspectives, human rights, and civil society. 3.1. Gendered Perspectives In some ways, the relationship with gendered perspectives was unsurprising given the origins of the psychosocial field in EU investigations, including the Warburton Commission, into rape as a weapon of war in Bosnia-Herzegovina. Given this fact, it is the way in which the psychosocial discourse makes virtually no mention of the connection, which is rather more remarkable, substituting instead a notion of women and children as vulnerable groups. It is certainly true that the response to systematic gendered violence, particularly by womens groups in Zagreb, some of whom had their origins in proto-feminist movements of the 1980s, and some with more nationalist agendas, did see trauma as a major issue to be dealt with, as part of a wide range of humanitarian, counseling, support, and political interventions. Indeed, some of the theoretical impetus for this may well have come from Judith Hermans Trauma and Recovery (Herman, 1992), making connections between domestic violence and political violence, and which circulated widely amongst activists and, indeed was translated into Croatian by the Zagreb based Womens Infoteka. 3.2. Human Rights In some ways, the gender perspective fed into a wider human rights framework, not least because of the emphases of Inger Agger, herself the author of The Blue Room (Agger, 1994), a pioneering study of gender, human rights and testimony in Chile which was also, interestingly, translated by Womens Infoteka. Indeed, having suggested that (the) overall purpose of psychosocial emergency assistance is to promote mental health and human rights (Agger, Jensen & Jacobs, 1995, my emphasis), one would expect to find copious references to how this could be done. In fact, apart from vague references to the importance of memory in peace building, there is little elaboration of the importance of testimony in terms of the International Criminal Court and wider questions of justice. Again, it is as if the dominant psychosocial field would be stretched too far if human rights were to be anything more than a rhetorical device. However, simply by mentioning one of the dominant leitmotifs of global ideoscapes (Appadurai, 1996), there is a sense in which a progressive intent, more imagined than real it must be said, is hinted at. 3.3. Civil Society The space opened up in terms of civil society also contributed to the progressive appearance of some elements of the PTSD movement but this is far more complex, given the split between ECTF and, to an extent, UNHCR, which primarily funded NGO-led projects, and WHO and UNICEF which, by and large, promoted initiatives with the governmental sectors. Nevertheless, and notwithstanding the vacuity of notions of civil society which are undertheorised, insufficiently concretized in terms of specific practices, and rarely subject to critical scrutiny (Stubbs, 1996a), by promoting a wide range of NGO activities, ECTFs funding of the psychosocial field did expand the space open to innovative projects. Some of these were, indeed, led by, or at least involved, local groups, activists and movements, including those who framed interventions more in terms of gender-based and human rights approaches. Whether the psychosocial shape was bent to include some of these projects or vice versa remains disputable, but the space opened up in a society where there had been very limited civil initiatives before the war, and where the state tended to monopolize health and social services, certainly could, in itself, secure support from those wishing to see an expansion of non-governmental activities. In some ways, what was much more important was the way in which NGO-led psychosocial projects, based on the assumptions of the PTSD movement, multiplied in 1993 and 1994 as more and more agencies, including many significant donors, tended to follow the trend. Particularly important in what can, perhaps, be termed the second wave of projects were those supported by USAID which included two multi-million dollar programs, one an Umbrella Grant for Trauma and Reunification through the US NGO The International Rescue Committee (IRC), which became the biggest local NGO support program in Bosnia and Croatia, and the other through a partnership between Catholic Relief Services (CRS) and the Croatian NGO The Society for Psychological Assistance (SPA) to implement a large-scale program on Trauma Recovery Training. 4. Aspects of the psychosocial Shape Clearly, the defining of the psychosocial shape in terms of the need for new local NGOs benefited Croatian, and to an extent, Bosnian, psychologists and psychiatrists who became very much flavor of the month - some forming their own NGOs, others involved in a range of supervisory, sessional, and consultancy work. In large part, of course, their market-value rose in response to the obvious critique of the failure of international organizations to understand refugees language and culture and the importance of working with local professionals. There developed, in fact, a very complex relationship between international and local professionals, which has to be seen in the context of the history of the mental health training and practice infrastructure in Croatia and Bosnia before the war. This was very well developed with good connections with the international mental health community. Within this local infrastructure, very diverse approaches to mental health tended to co-exist alongside each other, with less explicit antagonism than might be found in Western Europe, for example. A generally over-empiricist and labeling medical model, therefore, rested alongside some heavily Vienna-influenced psychoanalysis and an emerging discourse, certainly in Slovenia and parts of Croatia, in the 1980s, of anti-psychiatry, gestalt and other celebrations of self-awareness and identity which, in a dominant political framework which was perhaps over social in its orientation, could attain quite a radical import, even if they rarely impacted on day-to-day professional practice. Sometimes, individuals combined these diverse approaches and, when psychosocial work predominated so that all kinds of training courses were being offered, it was not unusual to see different, and from a Western gaze incompatible, approaches, being implemented together within the same project. I have argued elsewhere that, in fact, this flexibility, rather than any newly invented strategy, contributed to the ability to say different things to different audiences, thereby strengthening the discourse and movement rather than weakening it (Stubbs, 1997). In addition, as already noted, an apparent tension within the movement was the fact that ECTF largely worked with NGOs and some other agencies, particularly WHO and UNICEF, worked with governmental agencies and academics, engaging much more with the existing mental health system. Indeed, to one critic of privatized, unregulated and multi-mandated NGO-led projectization, UNICEFs remarkable psychosocial program was seen as a prototype for a cross-line institutional support and adaptation policy (Duffield, 1994). In reality, this supported a psychological elite, particularly in Croatia, whose clinical approaches to PTSD tended to be reinforced rather than challenged. In any case, the categories of governmental, research and NGO provision tended to become blurred somewhat with members of this elite skilled in being involved in a wide range of initiatives. Even more importantly, despite Duffields assertions, it was primarily in Croatia that this work was undertaken, so that the effects on Bosnian services, still at the time in war conditions, was only limited. Indeed, the ways in which the crisis allowed this local, though internationally connected, elite, to join the ranks of a global elite and, even now, to claim competence as the best placed to work with Kosovan refugees in Macedonia and Albania, is particularly instructive. Overall, the effects of the emphasis on psychosocial approaches was much less to open up the field to a wider range of perspectives than to reinforce traditional hierarchies, between academics and practitioners, between professionals and non-professionals, between psychologists and members of other disciplines, and indeed between Croatia and Bosnia, and urban and rural areas within these countries. The extended amplification of these hierarchies further marginalized any attention, above and beyond rhetoric, to user involvement, community-based services, and that over-used term empowerment. Indeed, as the PTSD movement began to be critiqued, it was the work of NGOs, largely unsustainable because of their reliance on emergency foreign funding, which contracted, leaving the field to be dominated even more by the core, now closer to mainstream government-controlled services, in which prestigious projects, based on clinical, medicalizing, and pathologizing approaches, came to dominate. 5. Critical Perspectives Reassessed It is very difficult, from the perspective of someone involved from the inside in opposing the PTSD movement, to assess what the impact of the critique was. It cannot be disputed, however, that by mid-1996, there was much less emphasis, certainly within priorities for funding of NGOs, on projects connected with trauma questions. In part, this may have been a rational response to changing circumstances and needs, and to initial evaluations which tended, at best, to be inconclusive about the value of the most costly, expert-led, approaches. In some ways, in the post-Dayton situation of Bosnia-Herzegovina, questions of refugee return and of democratization became more pressing, and with other, newly formed, epistemic communities showing almost no interest in trauma questions - the limited impact which Inger Agger had when she moved to the OSCE in Bosnia is, perhaps, an indication of this. In addition, in Croatia, issues of the reintegration of Eastern Slavonia, of refugee return, and of support for a more balanced third sector also took precedence in the context, in any case, of declining international financial support. Nevertheless, in the trend-based world of humanitarian aid and development, in which priorities are developed and sustained according to crude sound bites as much as rational planning, the critique probably was important in challenging what had been up to that point, a more or less unshakeable belief in the psychosocial approach. Two anecdotes are, perhaps, relevant here. As early as the middle of 1995, I was approached by Jadranka Mimica, a Croatian psychologist working as assistant to Inger Agger in ECTF, who had been asked by ECTF in Brussels, to explore community development approaches. Finding common ground, we expanded our analysis in a text published in the Community Development Journal which stated that, in Croatia, the psycho- has dominated at the expense of the social (Mimica & Stubbs, 1996; 286) and outlining a developmental agenda in which changes in communities not just in individuals could be promoted. Whilst it is hard to be certain, this perhaps signified, at least, a crack in the support for the psychosocial approach within the EU. In addition, in June 1996, I was asked to speak at the Third Anniversary meeting of the IRC Umbrella Grant. My text, translated into Croatian, was published soon afterwards in the political weekly Arkzin where I again criticised an over emphasis on so-called psychosocial programs heavily reliant on professional, labour intensive, and expensive psychological approaches to trauma, and reinforcing the cult of the expert, at the expense of much broader based social and community development approaches, going on to suggest that the supposed emphases of some of these projects on self-help, empowerment, and such like, is little more than a smoke screen meant to hide the essentially pathologizing and hierarchical nature of service provision (Stubbs, 1996b). Perhaps even more significantly, a short time later, a proposal which I had helped a local NGO to develop, for a community development project in a deprived area of Zagreb serving a socially excluded Roma population alongside refugees and an ageing and impoverished local community, which purposefully never mentioned psychosocial or trauma, was funded by the IRC Umbrella Grant. It was also praised as a prototype for the future at the same time, indeed, as the trauma element of the Umbrella Grant was dropped from its name. In some ways, this was the culmination of over two years of pressure based on research, activism and practice in Croatia, in which I had advocated for social and community development frameworks which, in the midst of the dominance of psychosocial approaches, had seemed to be largely absent in Croatia. Collaborating closely at the time with Nina Pe nik, a founder of the grassroots NGO Suncokret and also a psychologist and Lecturer in Social Work at the University of Zagreb, we had drawn a division between three discourses: Figure 1. Contrasting Features of Humanitarian Aid, psychosocial Projects, and Development Projects (Pe nik & Stubbs, 1995). HUMANITARIAN AID  PSYCHOSOCIAL PROJECTSDEVELOPMENTAL PROJECTS Dependency Patronizing Demeaning Distorting of National Economy Needs of Donors Not Recipients Divisive Disrespectful Emergency Undermining Local Communities Distributive Effects - ? Reinforcing Inequalities Unaccountable Self-Maintaining Business Part of a War Game/Reproduces War Disempowering Unjust Fosters Mistrust Prevents Local Solidarity ActionsExpert Pathologizing Medicalizing Distanced Professionalizing Inflexible Prestigious For Workers Not Users Needs Defined by Experts Not Communities Disconnected from Community Needs Self-Maintaining Disempowering Labeling e.g. PTSD Creates Elite Foreign Experts - Unaccountable Local Experts Accelerated Promotion and Salary Self-Fulfilling Evaluation - Narrow; Quantitative Uncoordinated Temporary Duplicating Flexible Empowering Engaged/Social Movement Community Based/Localised Integrating Transformative Links/Connects Different Levels Human Rights Develops Skills Democratic Civil Society Action Research Long-term Planning Our work was, certainly, sustained by a series of international connections that suggested that we were not alone in being profoundly suspicious of the PTSD movement and had, perhaps, even underestimated its increasing global impact. I first became aware of Derek Summerfields work, for example, during a visit to Belgrade in November 1994 where a worker with Oxfam which, astonishingly given its own social development profile, had initially prioritized work on trauma, gave me an unpublished text which had been crucial, for her, in questioning this emphasis. Later, Summerfield was instrumental in ensuring that a core critical text, co-written with Baljit Soroya, and which had circulated widely in the region, was finally published after having been rejected by another journal on the basis of criticisms from two referees both involved in the PTSD movement (Stubbs & Soroya, 1996). At the same time, he himself published a highly influential article, which used some of the same material in mounting a far more rigorous critique of psychosocial projects (Summerfield, 1996). Also influential was David Ingleby, first encountered through my brief subscription to an e-mail discussion group on post-traumatic stress, and who invited me to a conference on health care for migrants and refugees (Balledux & de Mare, 1995) where, again, a wider range of critical perspectives were elaborated. In retrospect, then, the critique of the PTSD movement in Croatia and Bosnia-Herzegovina moved, rather quickly, from the margins to the mainstream, in which it has now become something of an orthodoxy to state that PTSD is a highly disputed category, that estimates of numbers affected, and assumptions of the necessity of treatment, are problematic, and that the ways in which people express and embody and give meaning to ... distress is largely dependent on context - social, cultural, political and economic (Boyden & Gibbs, 1997). What had seemed like a very difficult target turned out not to be so at all, and to be so discredited that it has now become very difficult to get any international funding, certainly in Croatia, for innovative therapeutic work even though distress and longer-term consequences can be demonstrated. In some ways this is an argument that the critique was simply too all embracing and unfocused, based on the assumption of separate discourses and, of course, on the progressive nature of social and community development. Rereading the texts for this paper, I am struck by how little they are focused concretely on the complexities of local and global discourses, much less on the differences between discourses, individual agents, and practices within particular projects. Whilst stating that the intention is not to deny suffering and distress but, rather to demonstrate the ways in which people are reduced to cases, expressions of hurt to symptoms, and processes of healing to treatment, there is a cumulative tendency to throw the baby out with the bathwater, and to argue for a complete rejection of one approach in favour of another. There is little real analysis of the complexities of diverse refugee experiences and responses, between those from Croatia compared with those from Bosnia, between urban and rural populations, between different ethno-religious and other identity-based groupings, and so on. There is also no real confrontation with the specific nature of the atrocities which came to be termed ethnic cleansing, much less any call for more research on this. Perhaps unsurprisingly in the context of the period, there is little attempt to understand the How and Why of the psychosocial approach, to treat it as a complex set of ideas and practices, nor to engage with more progressive approaches from within. A number of initiatives which sought to combine trauma healing with peace building, for example, are conveniently ignored. Above all, the existence of different global and local constituencies, and the possibility of linking critical mental health perspectives within post-Yugoslav countries with those outside, was not really engaged with. With the benefit of hindsight, of course, social development discourses proved to be no less problematic and, on numerous occasions, equally divorced from social, political and cultural realities. Above all, a naive faith in grassroots approaches resulted in almost no engagement with the project planning process and a refusal to take seriously the question if you had these funds, what would you do? In short, an opportunity to break down a number of boundaries which obviously were problematic in terms of services for refugees in distress: between disciplines; between theory, research and practice; and between different knowledges-in-use from different global and local contexts, was missed. 6. Conclusions: refugee mental health or an anthropology of exile? In some ways, my current interest is in seeking to refocus a connection between what might be termed refugee mental health questions, which have, of course taken on a more critical edge recently, and an anthropology of exile which starts with forced migrants lived experiences but which can and should, seek to extend its methods to explore interactions with so-called helpers. Both, in their different ways, are increasingly concerned with complex concepts of cultures, identities, and forms of belongings and losses and, clearly, in terms of policy and practice development, there are many important benefits likely to come from cross-fertilization between the two approaches. Whilst Parker, one of the first to argue for this connection, is right to warn of the dangers of social anthropologists culturalizing violence (Parker, 1996), recent attempts to develop anthropological understandings of the global production of locality (Appadurai, 1996) and of diverse kinds of travel encounters (Clifford, 1997) are signposts towards a very different conceptual framework. A collection of texts from a conference on War, Exile, Everyday Life, organized by young anthropologists from the Institute of Ethnology and Folklore Research in Zagreb (Jambreai Kirin & Povrzanovi, 1996) is a clear example of the possibilities here, and, elsewhere, Malkki s work on Rwanda (1995), is also highly instructive. In turning  war and exile ... into domains of anthropological scrutiny (Povrzanovi & Jambreai Kirin, 1996), producing a  multivoiced ethnography of war (Jambreai Kirin, 1999), and combining  critical abilities ,  emotional commitment ,  moral indignation and  political analysis (Povrzanovi & Jambreai Kirin, 1996), the approach is suggestive of a new set of research questions, which may help to reorient critical perspectives on refugee mental health. In lieu of conclusions, then, I want to state what seem to me to be some of the most pertinent questions for debate and discussion: How can ethnographic understandings of war and exile as diverse processes and meanings influence what appear to be short-term, and quite narrow, agency-led psychosocial frameworks? What do the testimonies of refugees tell us of their encounters with diverse helpers and how might these be used to reorient policy and practice? What processes may be at work in the ascription and achievement of certain labels, including that of trauma, amongst diverse refugee communities, and how do these labels affect roles, status, and access to resources? In the encounter between project communities and refugee communities, who play the roles of intermediaries and interpreters, and how important are these in terms of processes and outcomes? What factors in the response of diverse local communities to diverse refugee communities promote integration and healing? How do wider policy contexts affect these processes? Whilst more research is, of course, needed, perhaps of equivalent value will be a re-examination of existing material, and support for testimony to be seen as an important part of the response to refugee emergencies, not only in the name of justice, but also healing. Above all, I am arguing that what Peter Loizos has termed allocation-words (Loizos, 1996), which I would reframe somewhat as allocation processes, including the labels from within refugee mental health, are relevant directly to breaking down the split between a post-modern ethnography of fracture, disjunction, experience of suffering, and resistance (Loizos, 1996) and socially worthwhile collaboration with planners and policy makers (Loizos, 1996). These connections will not appeal to all and, indeed, too close a rapprochement is less likely to promote new perspectives, much less those which may be sustainable and genuinely progressive and in the interests of diverse refugee communities, than attempts to debate and discuss across these divisions. references Agger, I. (1994) The Blue Room: Trauma and testimony among refugee women - a psychosocial exploration. London: Zed Books. Agger, I. (1995) A longing for Sarajevo: understanding the trauma of humanitarian aid workers. In: Agger, I. (ed.), Theory and practice of psychosocial projects under war conditions. Zagreb: ECTF, 27-33. Agger, I., Jensen, S., & Jacobs, M. (1995) Under War Conditions: what defines a psychosocial project?, In: Agger, I. (ed.), Theory and practice of psychosocial projects under war conditions. Zagreb: ECTF, 11-26. Appadurai, A. (1996) Modernity at Large: Cultural Dimensions of Globalization. Minnesota: University of Minnesota Press. Arcel, L. (1994) War victims, trauma and psychosocial care. In: Arcel, L. (ed.), War Victims, Trauma and Psychosocial Care. Zagreb: ECTF, 11-22. Balledux, M. & de Mare, J. (eds.) (1995) Ouder- en Kindzorg voor migranten en vluchtelingen (Child Health Care for Migrants and Refugees). Assen: Van Gorcum. Boyden, J. & Gibbs, S. (1997) Children of War: responses to psychosocial distress in Cambodia. Geneva: UNRISD. Clifford, J. (1997) Routes: travel and translation in the late twentieth century. Cambridge: Harvard University Press. Duffield, M. (1994) Complex Political Emergencies: an exploratory report for UNICEF. Mimeo, University of Birmingham. Herman, J. (1992) Trauma and Recovery. New York: Basic Books. Jambreai Kirin, R. (1999) Personal Narratives on War: a challenge to women s essays and ethnography in Croatia. Estudos de literatura oral 5, 73-98. Jambreai Kirin, R. & Povrzanovi, M., eds. (1996) War, Exile, Everyday Life: Cultural perspectives. Zagreb: IEF. Jensen, S. (1994) Psychosocial stresses and protective factors in families under war conditions and peace building in former Yugoslavia. In Arcel, L. (ed.), War Victims, Trauma and Psychosocial Care. Zagreb: ECTF, 72-79. Kinzler, S. (1995) In Croatia, minds scarred by war. New York Times, 9 January. Loizos, P. (1996) Perspective from an earlier war. In Jambrei Kirin, R. & Povrzanovi, M. (eds.), War, Exile, Everyday Life: Cultural perspectives. Zagreb: IEF, 293-301. Malkki, L. (1995) Purity and Exile: Violence, memory and national cosmology. Chicago: University Press. Martinez-Espinez, F. (1994) Opening Speech. In Arcel, L. (ed.), War Victims, Trauma and Psychosocial Care. Zagreb: ECTF. Mimica, J. & Stubbs, P. (1996) Between Relief and Development: Theories, practice and evaluation of psychosocial projects in Croatia. Community Development Journal 31, 281-290. Parker, M. (1996) The Mental Health of War-damaged Populations. IDS Bulletin 27, 77-85. Pe nik, N. & Stubbs, P. (1995) Croatia: from dependency to development? Rural Extension Bulletin 8, 35-39. Povrzanovi, M. & Jambreai Kirin, R. (1996) Negotiating Identities? The voice of refugees between experience and representation. In Jambreai Kirin, R. & Povrzanovi, M. (eds.), War, Exile, Everyday Life: Cultural perspectives. Zagreb: IEF, 3-19. Soroya, B. & Stubbs, P. (1998) Ethnicity, forced migration and psychosocial work in Croatia. Medicine, Conflict and Survival 14, 303-313. Summerfield, D. (1996) The Impact of war and atrocity on civilian populations: basic principles for NGO interventions and a critique of trauma projects. ODI Relief and Rehabilitation Network Paper 14. London: ODI. Spirer, L. (1995) Report from the Hague, December 8-10, 1994, for American Statistical Association Committee for Human Rights and Freedom Newsletter.  HYPERLINK "http://www.virtualschool.edu/mon/news/UnWarTribunal" http://www.virtualschool.edu/mon/news/UnWarTribunal Stubbs, P. (1996a) Nationalisms, Globalization and Civil Society in Croatia and Slovenia. Research in Social Movements, Conflicts and Change 19, 1-26.  HYPERLINK "http://www.stakes.fi/gaspp/ps_cv.htm" http://www.stakes.fi/gaspp/ps_cv.htm Stubbs, P. (1996b) NGO Development in Croatia: definitions and dilemmas (Croatian language version), ArkZin, 69, July. Stubbs, P. (1997) NGO work with forced migrants in Croatia: lineages of a global middle class? International Peacekeeping 4, 50-60. Stubbs, P. & Soroya, B. (1996) War trauma, psychosocial projects and social development in Croatia. Medicine, Conflict and Survival 12, 303-314. Stuvland, R. (1994) School-age children affected by war: the UNICEF programme in former Yugoslavia. In Arcel, L. (ed.), War Victims, Trauma and Psychosocial Care. Zagreb: ECTF, 111-126.  Paul Stubbs, Institute of Economics, Zagreb, Croatia.  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