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Utrecht Guidelines

Utrecht Guidelines

United Nations High Commissioner for Refugees
Draft Guidelines for the Evaluation and Care of Victims of Trauma and Violence

Dr. Anika Mikus Kos, Director, Counseling Centre for Children, Adolescents and Parents, Slovenia
Dr. Gisela Peren-Klinger, Institute of Psychotrauma, Switzerland
Dr. Mia Groenenberg, PHAROS Foundation/Mental Health Section, The Netherlands
Dr. Richard Mollica, Director, Harvard Program in Refugee Trauma, USA
Dr. Robert DeMartino, Director, International Project, Harvard Program in Refugee Trauma, USA
Mary Petevi, Senior Resettlement Office and Focal Point for Mental Health, United Nations High Commissioner for Refugees, Switzerland

Robert DeMartino, Richard Mollica, Mary Petevi

Fiona Van Den Boomen


In March 1993 the need was felt in UNHCR, in resettlement countries and in former Yugoslavia for streamlining of care and rehabilitation of victims of rape, torture and other severe traumas of war in the Republics of ex- Yugoslavia. The Government of the Netherlands and UNHCR co-funded this venture which took place in Utrecht in June 1993. The consultation was organized by “The Pharos Foundation” in Utrecht and the UNHCR Resettlement Section, Geneva in collaboration with the International Organization for Migration and the World Health Organization.

Some 25 European mental health experts, including several from former Yugoslavia, members of the European Community Task Force in Zagreb and the Warburton Committee, participated in the Consultation, as well as one from the Harvard School of Public Health, and a member of the World Federation for Mental Health, USA, who acted as one of the four resource persons.

A set of Conclusions and Recommendations was drafted to address policy and implementation regarding the mental health needs of refugees in general and those of victims of extreme violence in particular. A model for care and rehabilitation was developed on the basis of which these guidelines were drafted by some of the participants, including UNHCR, The Pharos Foundation and Harvard.

These guidelines are being widely disseminated for implementation on a pilot basis for nine months. With the resulting feedback from those who use them, the guidelines will be finalized and implemented, with the necessary cultural and other adjustments, on a worldwide basis for similar populations affected by other conflicts.

European Consultation on “Care and Rehabilitation of Victims of Rape, Torture and Other Severe Trauma of War in the Republics of Ex-Yugoslavia”
Utrecht, The Netherlands, 17-19 June 1993

1. It must be recognized that the war in former Yugoslavia is having an impact on the physical and mental health of the entire population, especially on refugees and displaced persons.

2. In order to prevent and remedy serious effects, psychosocial assistance to the refugees has to be recognized as a priority and implemented as of the emergency phase. Assistance must be targeted towards vulnerable and at-risk groups (children, unaccompanied minors, adolescents, victims of torture and sexual violence, the poly-traumatized, elderly, psychiatric patients, ex-detainees, prisoners of war, relatives of missing persons and other priority target groups which may emerge) with priority to those not yet assisted.

3. The special situation of a massive presence of refugees requires consciousness raising and special training concerning psychosocial needs and mental health problems. Related information should be provided to the refugee community, host population and professionals involved with organization of life of refugees. Specific training about dealing with psychosocial needs, reactions to traumatic experiences and pathological conditions must be organized. It must be targeted to reach mental health professionals (psychiatrists, psychologists and others) , primary health care professionals (general practitioners, pediatricians, gynecologists, nurses and others), social workers, teachers, directors of camps, volunteers, and all people engaged in organized protection and assistance.

4. Mental health professionals should organize and support outreach workers to identify acute psychosocial needs, conduct sensitive and de-stigmatizing interventions and undertake planning for longer term interventions based on the principles of community , family and individual levels. These programs should be realistic, concrete, economical, flexible, unstigmatizing, culturally sensitive and non-medicalized whenever possible. Systematic monitoring must be part of the process.

5. Socio-economic self-sufficiency should be encouraged by minimizing dependency on humanitarian assistance and encouraging reinforcement of human resources. Interventions at all levels empower refugees and displaced persons to play an active role in planning and implementing their mental health protection.

6. Early family reunification, access to communication with absent family members, and support to foster families are of vital importance to mental health and should be pursued as a priority.

7. Governments, local authorities, non-governmental organizations, international organizations and others should urgently seek ways of normalizing the lives of refugees and displaced persons. Protection and assistance are a part of this process.
8. All above-mentioned parties should ensure close coordination and rapid exchange of relevant information enhancing adequate psychosocial conditions and projects.

9. Priority consideration must be given to the refugees’ and displaced persons’ rights, interests and benefits. They must be respected during the course of any assistance project, research, mass media and other activities.

10. These recommendations can be systematically applied in other similar conflicts worldwide.

The need for practical, widely relevant guidelines for the mental health evaluation and care of refugees and displaced persons has never been greater . The current more than 100 violent conflicts around the world have produced some 44 million displaced individuals, roughly 24 million of whom remain within the confines of their own states. The twentieth century has seen over 140 million forcibly uprooted persons for whom the detrimental effects of the experience have long been recognized; some have estimated mortality in such populations to be 60 times the normal during the acute phases of displacement.

While the strong initial impetus for this work derived from the highly visible plight of refugees in former Yugoslavia, its authors recognized a deeper need to disseminate more consistently the information and measures necessary in the mental health evaluation and care of those exposed to the hardships and trauma of forced displacement worldwide. These guidelines, then, grew out of a Consultation held in Utrecht, the Netherlands, in June 1993. Contributions from a wide variety of academic and professional specialties are represented.

This compilation is addressed to all who concern themselves with the needs of traumatized, uprooted persons, be they:
1) from the medical community, working as primary health care providers, general practitioners, nurses or psychiatrists;

2) from the counseling community, as social workers, teachers or religious leaders; or
3) from the refugee services community, employed as directors and coordinators of the transit and interim refugee camps, or governmental and non-governmental staff of humanitarian relief organizations. There run distinct and common themes throughout this work:

A. In the majority of instances, individuals possess the resiliency and adaptiveness to avoid the long-term effects of forcible displacement and trauma.

B. Within a population of such individuals it is possible to recognize the full spectrum of psychosocial and behavioral responses to trauma, including “normal,” short-lived and widely occurring responses, as well as those causing significant impairment and long-term suffering.

C. An individual’s response to such experiences, for the most part, is poorly served by medicalization; that is, labeling the response as abnormal, requiring specialized intervention by the medical community.

The guidelines are intended to emphasize these themes as well as further the vision of self-empowerment, self-management and active community-oriented rehabilitation they strongly convey. The concept of prevention in the mental health field is well-worn, but cannot be too frequently or too strongly stressed here, for it encompasses the hope that, for the majority, return to full social functioning and well-being and re-integration into community life can be accomplished through intervention at the level of culturally defined social roles {persons as parents, spouses, friends, workers, etc.). As can be observed, the guidelines are not meant as a cookbook guide to evaluation and care, nor are they intended to provide a deeply theoretical examination of the field of refugee mental health. Instead, they are intended to supply practical, proven and accepted measures of addressing the mental health issues of refugees and displaced persons. By doing so, they aim for some universality, recognizing that the specific context of each situation and population will clearly influence the relevancy of any particular component of these guidelines.

Lastly, this work is seen as a first step. A simple case registry form is currently being developed, which is intended to make tracking of cases and post-intervention outcomes both more practical and routine. While there is no intention now, nor in the planned future, to provide an exhaustive volume on this subject, those who need and use these guidelines are encouraged to provide feedback regarding their accuracy and practicality, with a view to collectively improving its form and content in the future.