General Introduction

The World Health Organisation has long stressed the need for mental health care to be decentralised and integrated into primary health care, with the necessary tasks carried out as far as possible by general health workers as an extension of the work of specialists, since existing systems for the delivery of mental health care have largely failed to meet the needs of the world population . Armed conflicts all over the world require pressing this policy of decentralisation even further, since not even well-functioning primary health care systems can be expected to cope with the vast numbers of people that are affected by this violence.
A third level of action is therefore necessary within the communities that are affected by war. A draft manual, "Refugee Mental Health" was issued in '92 by WHO and UNHCR for field testing, directed to a wide array of relief workers, community workers, primary health care workers, primary school teachers and others who provide support to refugees and the victims of disasters.

Recent experience with repeating patterns in (civil) war like in the former Yugoslavia and in Rwanda have furthermore lead to the insight, that mental health problems should not only be understood as consequences of war, but must also be considered as origins of new wars. Repressed memories and feelings of fear and hatred can and will re-emerge under difficult circumstances. If they are not confronted they will be transferred to new generations, consciously and unconsciously, thus forming the basis for an endless and dramatic chain of war. Therefore, the attack of this intergenerational transference, concentrated on the rehabilitation of children, should be designed as an essential element in the prevention of the next war, rather than as the continuation of an age old charity model that was developed to suppress the consequences of the last war.

In the winter of '91/92 a group of young adults, mostly students, from Croatia and Bosnia-Herzegovina organised themselves, supported by the Croatian peace movement and some expatriate experts, in a grassroots organisation (Suncokret)  to help refugee children. The importance of their work was instantly recognised and within months they were working in many refugee camps spread over Croatia and Bosnia. The activities, though centred on children, quickly involved mothers, grand-parents and other meaningful adults in their social environment. Young adults from within the refugee-community as well as many short-term volunteers from all over Europe joined their ranks and financial support was granted creating the necessity for stricter organisation and management. At the end of '92 over 80 Croatian and Bosnian young adults were involved in the organisation of activities for over 4.000 children and 7.000 adults. In the spring of '93, Suncokret was accepted as a partner by UNHCR, today it is recognised as an important Croatian NGO .
Of course this rapid growth lead to many difficulties in the field of management and in matters of policy .  One of the results of a period of reflection was a draft manual, "Suggestions on the structuring of Games and Activities for Suncokret"  that concentrated on the work for traumatised children. Positive reactions from workers in different circumstances as in Cambodia and the Philippines indicate that this manual may have a wide relevance.

To the WHO, the emergence of this grassroots organisation represents the necessary third level in the structural attack of war-related mental health problems that was missing up until now. The WHO wished the possibilities of this model to be investigated, as a base for development and support of similar organisations in other war-torn communities.

A second Pilot Project in Cambodia.

As in a growing number of countries nowadays, children in Cambodia of '98 were growing up in a semi-permanent state of civil war and armed conflict. This formed a threat to them in two ways, and through them to the future of Cambodia.

First there is the obvious direct threat, caused by the on-going hostilities, by the millions of land-mines that are hidden in the fields, by the economic and ecological disasters resulting from the armed conflict. Many children die  as a result of these circumstances, others loose their families and get adrift through Cambodia, usually in the direction of Phnom-Penh, were they hope to earn a living. Many of these end up begging, scavenging, stealing, being forced into child labour, or abducted into prostitution .

Second there is an indirect threat, caused by the fact that the generation that should be parenting them lost many of the necessary skills during the Pol-Pot period, in which family ties were broken down , children and parents separated, the educational system destroyed and teachers and other skilled people were systematically killed .
The result has been that a heavily traumatised generation (now in the age of 15-30) is not only transferring their trauma to the new generation, but also raising this new generation with little structure or direction .

Children are an important group in the war affected population. Their experiences are aggravated by their lack of control and understanding.  On the other hand though, they are in a natural phase of growing-up that permits them to adjust and to heal organically if only they are given the opportunity to deal with their experiences and emotions.
The mental health problems that threaten them if this adjustment does not take place will not only affect their own lifes negatively, but also will influence their capability as a generation to cope with feelings of hate and revenge, thus easily forming the base for a new episode in an endless chain of war.

Most of these children, being healthy self-healing beings, do not need professional psychological treatment, provided they can deal with their stresses in a social therapeutic environment, based on some less evident but simple insights.
The base for such an environment can well be created by a nucleus of  basically trained grassroots workers involved in restructuring the social life of the war-affected community . Such activities, primarily centred on the children, should consequently have a radiating positive effect on the community as a whole.

The Cambodian Institute for Human Rights and the Khmer Buddhist Society, as well as representatives from the Ministry of Social Affairs, Labour and Veteran affairs and the Faculty of Psychology of the University of Phnom Penh acknowledged a great necessity for such a kind of grassroots-organisation in the Cambodian situation. They felt confident  that there was considerable potential among the Cambodian young adults, although at the same time they are very aware that these young people are themselves heavily affected by the Pol Pot period .

This WHO Project proposed therefore a period of 21 months, for an expatriate project initiator, to train young adults, recruited in co-operation with the above-mentioned organisations, in techniques to design and apply healing games and activities for children and to support them with their development into a well-organised NGO that can multiply itself to work in different places and circumstances in Cambodia, and, once established, can act as a partner for International Agencies that fight the consequences of war.

The goals of the project were:

1. To create a Cambodian model for the development of games and activities that allow children to heal themselves from the mental injuries they suffer as a consequence of the civil war.
2. To develop these activities as a core for a communal process inducing care and responsibility between generations.
This project was funded by the Minstry of Foreign Affairs of The Netherlands, based on the WHO-proposal.

The project was to be organised at the neighbourhood-level, starting in Phnom-Penh .
An area (neighbourhood) was selected in which 20-30.000 people live  (about 9.000 - 14.000 children under 16 years old) and in which one or more projects provide basic care for street-children or unaccompanied children .
After an initial training period, a core staff of about 10 people was formed that was responsible for the continuity and the development of the project and its activities, while at any time 20 - 30 people could be involved (part time or full time) for short periods of 1 - 2 months in  practical work in the activities with the children. These part-time workers used the project to get a basic training in the care for children, after which they return to their studies, their work and families, or they got involved in the work of the core-group. Members of the core staff proved eventually  able to develop new projects in other neighbourhoods and outside Phnom-Penh . A positive spin-off was that some of them continued activities independently on a permanent  basis because these had proven to comply with existing demand. Within the chosen area, the project has carefully extended its activities, depending upon the structure of the neighbourhood, revealing this structure and finding its natural boundaries in the proces.

The activities were directed to all the children, and not just those identified as psychologically and behaviourally disturbed. Through the children the complete population of the target area was reached . It was the intention of the project that parents, grand-parents and other adults will gradually get involved, on a voluntary base, in the activities for children. This turned out to be mainly in a passive way (as spectators), but sometimes also in an active way, as participants or getting involved in the co-ordination of activities .

At the end of the initial period of 21 months, the work of the expatriate project initiator was finished. The work of volunteers has spread over different locations in Phnom Penh, and the central location has become a meeting place and trainin centre for goverment workers, staff of NGO's, and volunteers from all over Phnom Penh. The organising young adults  have formed a dependable NGO, (Randjana Buddhi Pabhodana Mita, or, in English: CAmbokids), that that opened a second location for work in Battambang, a city in the north-west of Cambodia.

This organisation is now funded by two dutch NGO's, NOVIB (part of OXFAM), and the foundation 'Kinderpostzegels' for the period of 2000-2003.

In the light of the WHO Declaration of Cooperation on Mental Health of Refugees, Displaced and other populations affected by conflict and post-war situations, this project has a special significance. The Declaration states in Article 3:

Local regional and international policies and plans should pursue immediate and long-term mental health capacity-building, based on models that respond to the needs of the greatest number of persons affected by conflict, without neglecting those with special needs.  Therefore, community-based, psychosocial, phase-specific, cultural and gender-sensitive programmes must be given first priority when establishing or reconstructing mental health care systems.  (...)
This project shows how such projects can function, and its development in the coming years will therefore be significant.

The WHO Declaration of Cooperation