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PTSD in Bosnia and Herzegovina
Pandemic and Ukraine War Aggravate Suffering for Bosnians with PTSD
This page is the result of several months of journalistic research into the impact of the coronavirus pandemic, the war in Ukraine and the political, economic and social crisis in the country on individuals suffering from post-traumatic stress disorder. The material has been divided into two sections, one containing personal stories about traumas, symptoms and struggles with the condition and inadequacies in the system, and the other giving an analytical review of the situation in Bosnia and Herzegovina, covering the provision of support for individuals suffering from PTSD and shortfalls in welfare services.
Report
Life with PTSD Getting Harder in Last Three Years
For years, those suffering from PTSD have felt abandoned and forgotten while dealing with their traumas. Then the pandemic and war in Europe began, intensifying the loneliness and old nightmares which they thought to have suppressed.
The war in Bosnia and Herzegovina had been over for months, but Zlatko Ljubic was still hearing the sound of shelling. Lying in bed in his apartment, he was sure he could hear shells being fired and flying overhead. Several times he jumped out of bed and got onto the floor to protect himself. One time he sprained his ankle and ended up wearing a cast.
“At that pointed, I noticed something was wrong,” he recalled.
His friends also started noticing the changes. While he was working in tourism after his demobilisation, they got used to seeing him smiling and being chatty.
“I started retiring into myself a bit. I felt some sort of anxiety,” Ljubic said.
These were the first clearly visible symptoms, after he had ignored insomnia and unusual sweating. He thought he was simply not sleepy or that it was too hot in the apartment.
He talked to others increasingly infrequently, so his friends started asking him what was going on and if he was angry. Then he decided, with the help of his wife, to seek medical help. He ended up in hospital, where he was diagnosed with post-traumatic stress syndrome, PTSD. Now he believes that becoming a military company commander as a very young man at the beginning of the war contributed to this. He had a sense of personal responsibility for about 100 people under his command.
“I was afraid. I had no previous war experience. We learned everything as it went along and I was trying not to make a mistake,” Ljubic said.
Nearly two-and-a-half decades after the war, with therapy and support, he learned how to deal with the trauma. But then the pandemic began, followed by the war in Ukraine. He felt a great internal anxiety being triggered again.
He said he was not so much affected by the pandemic because he protected himself from infection. But the new war in Europe hit him much harder. He would turn his TV off when footage from Ukraine was being shown. He doesn’t watch the news at all now.
“It upsets me and I cannot, I simply cannot [watch]. I feel uneasy, as if I were back there on mount Majevica [during the Bosnian war]. I have stopped watching news from Ukraine. I can’t,” Ljubic said.
He often talks about this with his former comrades during group therapy at the Retirement Centre in Tuzla. These gatherings are the only places where they can talk with doctors completely openly about the condition that is making their life difficult.
Three decades since the beginning of the war in Bosnia and Herzegovina, victims’ associations and people all over the country are saying that new triggers are reactivating old traumas. It is also clear that hundreds of people with PTSD symptoms are not getting help from the healthcare system because of their fears or due to a lack of institutional resources.
Stigma
It’s a October grim day in Tuzla. The socialist-style interior of the Retirement Centre in the city is not exactly cheery, but members of Stecak Association of War Veterans 1992-95 who are being treated for PTSD are looking forward to gathering there. It gives them an opportunity to talk about their traumas in a safe environment. Since 2004, the Stecak Association has been trying to offer help to members who have been diagnosed with PTSD.
Association president Enes Dedic greeted us in front of the building to tell us about a change of plans. We had agreed to attend their group meeting, but Dedic thought that the presence of journalists would affect the situation and the association’s members would not talk openly in front of people outside their circle.
Contrary to his expectations, when we talked after the meeting, the association’s 15 members sitting around a large round table gladly started talking at once about the everyday hardships that they have to face.
They tried to explain what it means to live with PTSD and how it affects daily life for themselves and their families. The condition can affect anyone in any period of their life after witnessing or experiencing a traumatic event. It is not necessarily limited to experiences of war, although it most often affects war veterans.
This one meeting a week means a lot to the former soldiers. Recently they have mostly been talking about the economic crisis in the country and how constant price increases revive memories of the wartime and post-war period. They also have the feeling that their communities are ignoring their problems.
“All doors are closed, there is just a wall. Only here, among these colleagues, can we share it, we can say anything and we can knock on the door at any time. You can see it for yourself, everything is expensive. We have no support from our authorities,” said one of the association members.
Most of them are struggling to find jobs for themselves or their children. One of them is disappointed because his two sons have moved to Germany, leaving the country for which he fought in the war. These days the PTSD sufferers feel stigmatised and think that no one understands them except their doctors.
“What we have, what we carry inside of us, that is ours and our problem, but these groups help us get it out of ourselves and understand each other, respect each other,” said one of them in the room, which is thick with cigarette smoke.
Group workshops help them deal with the condition that they see as a psychological injury sustained during the war.
“We didn’t think about the post-war period – whether we would achieve something or not and what the war would bring us, we only tried to stay healthy and alive,” association president Dedic said.
When the war ended, Dedic thought he would be able to work, so he started a job in a salt mine.
“However, it started happening slowly. I would lie down and start seeing images of all the soldiers who had been killed. The images of all my killed and injured soldiers came to me, everything came to me and it felt as if they were sitting under my bedroom window,” said Dedic, whose weight dropped to just 65 kilogrammes at one point.
Recalling what happened during wartime, Dedic, who was 32 when the war began, said he had a close brush with death when a sniper was shooting at him for nearly an hour. He thought he would be killed.
With the help of his wife, Dedic sought medical help for his condition, but initially he was hesitant.
“I was ashamed to go there. The stigma is the worst thing, and people… if they saw you go there… I would sometimes run, I would run down there across the asphalt, I would put on a cap so they could not see me from the bus,” he recalled.
All of the veterans said they think that getting support and understanding from their family is an important part of facing PTSD. Outside their families, they have a hard time getting any support from others, said Borislav Mlinarevic from Ljubuski.
“Many people don’t believe us. Most people are still sinking deeper, as they see we can’t get much help. The state isn’t really helping us,” he said.
Mlinarevic, who first had two strokes and then developed epilepsy, says that PTSD sufferers have to deal with a lack of understanding and even ridicule.
“People know that we meet there for coffee before our sessions and they watch us a bit mockingly, they look at us as weirdos. ‘Those people with PTSD are meeting up again, they are gathering. There, look at them.’ That is how it is, we have to live with that,” he said.
Social stigma also appears when they try to find a job. Employers reject on them when they see PTSD written in their medical reports, Dedic said.
Symptoms
The rain is falling through the trees in a park in the village of Slatina, near Laktasi, where Mara Milankovic is sitting on a bench, adjusting her jacket before the camera starts rolling. She has spoken about her experiences and the problems she has faced because of PTSD countless times, attempting to raise awareness about the condition and to encourage others to seek help.
Her story is very much out of the ordinary.
She was 26 when she was wounded while serving in the army in September 1992. Her sister was also killed that day. She then spent a lot of time in hospital before getting married and giving birth to two children.
“The PTSD started in 1997 after the birth of my second child, combined with postpartum stress,” said Milankovic. She said that she had carried the trauma since the beginning of the war.
“But I didn’t know that. The trigger was the fact that my baby, my second baby, wasn’t sick as such but had to have a complete blood transfusion,” she recalled.
The first symptom she felt was irritability.
“Everything got on my nerves. When we left the hospital, I started being bothered by my baby crying. I was bothered by people, I was bothered by voices. I couldn’t sleep. I was just unable to function. My life was turned upside down. Actually it had been turned upside down before, but that was when it all came to a head,” she explained.
As she petted a dog sitting at her feet, she said that at first she had a combination of heart disease symptoms, so she ended up going to the emergency room every night, but didn’t get long-term treatment.
The memory of the day when she was injured and her sister was killed kept coming back to her, both in her dreams and while she was awake. It took her years to get back to some kind of normality.
“At the very beginning, I visited various psychiatrists. Various psychologists. The psychiatrists gave me medications. None of those medications suited me and one day, I took those medications with me and I went to the river and threw them in. I said to myself: ‘Either I’ll live as a normal person or not at all,’” Milankovic said.
“As well as the therapists, my family, my children have given me great support during my recovery. They have kept me alive,” she explained, adding that some people around her could not deal with the consequences of trauma, so they sought relief in alcohol or gambling.
Milankovic was not ashamed to ask for medical help. “I am not ashamed to speak about it at all. Because I don’t blame myself for being sick. The condition was the caused by the circumstances,” she said.
As for people who are not ready to speak about their condition, she said she thinks they are still suffering and having a hard time dealing with their trauma.
Therapy
It was a sunny October day when we arrived in the city of Ljubuski, where we were met by Borislav Mlinarevic, president of the Association of Disabled War Veterans of the Homeland War Treated for PTSD in Ljubuski. As we got to know each other over a coffee in the garden of a café, he told us that since the war, his memories of the bloody conflict have remained fresh.
He still remembers faces and names, screams and gunshots, sounds that were going round and round in his mind. But he did not seek treatment, nor did he tell anyone about his problem. He admitted that he may have been ashamed to talk about it or that he found it uncomfortable to tell someone about what he was experiencing.
“Sometimes I dream of those situations, I dream about those people, those events [during wartime]. Dreaming about what happened and about being injured is only one part of it. Another one is irritability, hypersensitvity. Everything bothers me. If my wife says something, it starts right away. I have a tingling sensation and my blood pressure goes up,” Mlinarevic said, describing the tensions at home.
Later, in the Association’s small office, he talked about the importance of seeing people socially, but also about his walks along the river near his home as one of the ways of dealing with his PTSD. On his estate several kilometres out of the town, he proudly shows us his garden and fruit trees. He explained that he spends time there every day. He shows us a promenade by the river Trebizat, a place where he relaxes.
Immersing himself in nature helped him forget about a dream he used to have four times a week about being injured in Kupres in 1994. For years he says he lacked the strength to go back to the place where he was hit.
“I wanted to visit it again, but there was some fear, some repulsion, some kind of feeling that was preventing me from doing it,” he recalled.
He spoke about it with doctor Marko Romic, who comes to Ljubuski once a week for group therapy sessions. Romic told him he had to confront his fears or he would suffer for the rest of his life.
“I decided to go. I visited the place where I had been wounded. After that, I visited it once more and I no longer had that problem. I’ve completely broken free of it,” Mlinarevic said.
He now receives support through the group therapy sessions that he worked hard to organise through the Association. Although 30 years have passed since the start of the war, he said that the stigma of PTSD continues to dissuade sufferers from joining the therapy group.
In the town of Derventa, it was difficult to get even five people to attend the initial group therapy sessions held by the local Association of Disabled War Veterans, recalled Mara Milankovic, who works with the organisation and helps PTSD sufferers through various activities.
“That was a great success,” she said of the first session.
But she added: “When group work was about to start, they left the room, because they were not ready to open up and share their troubles in front of others.”
She and other sufferers say that work and occupational therapies help with their treatment and recovery. However, they are not always available to everyone.
Zlatko Ljubic said that the association in Tuzla, of which he is a member, does not offer group therapy.
“We are unable to do it, as we lack space and conditions,” he explained.
He has participated in group therapy before with another association.
“I can tell you that it relaxed me,” he said.
Diagnosis and treatment
Unlike the group therapy, medication has not helped Ljubic with his continuing insomnia.
Borislav Mlinarevic was searching for medication that suited him for a long time. He tried several types, but they numbed him to the extent that he could not go to the toilet on his own.
Now there is better medication for treating PTSD, but they are not on the list of essential medications provided by the state. Sufferers say that, in order to obtain these medications, they must go through a special procedure each month to get the cost refunded. The time-consuming procedure adds another level of distress.
The same goes for the frequent reviews of their disability status in Sarajevo and Mostar. Mlinarevic complained that due to the fact that the maximal level of disability on the grounds of PTSD is rated at 30 per cent, the most they can receive per month in benefits is 52 Bosnian marks, around 26 euros.
“I have given up on that, I have given up on the disability benefit. As a result, I have been deprived of the rights of a disabled war veteran. They have called for a review four or five times,” he said.
Mlinarevic said that for his friend who has to take several types of pills in order to get to sleep and is not capable of working, having to go through the review process so often brings the trauma back.
“He was once given a 70 per cent disability rate on the basis of PTSD and injuries. They have now reduced it to 30 per cent. He now receives the 50 marks. He has to go to court again. The court sends him back to the first-instance court and then he goes through the same process again. That has been going on for years. He is sinking deeper and deeper. Such cases happen often,” Mlinarevic concluded.
Transfer of trauma
Mirela Osmanovic does not remember the war, but she is convinced that PTSD has made a mark on her life. She was born two years after the Srebrenica genocide in which her two brothers, who she never met, were killed.
Osmanovic belongs to a generation of young and educated people who are aware, more than their parents are, of how all that they endured during the fall of Srebrenica affected their mental health.
While she was still in elementary school, she noticed that people treated her differently after finding out where her parents came from.
“I wouldn’t know if it was compassion, but there was always a reaction I didn’t like. At that time, I figured out that people somehow thought that what had happened to my parents had also happened to me, that I was a part of that story too, whether I wanted that or not,” Osmanovic said.
She is now much more aware of the extent to which she has been shaped by transgenerational trauma, the term used for the complex phenomenon of the transference of trauma between generations, which has still not been sufficiently explored in Bosnia and Herzegovina.
Although she was born in Sarajevo in 1997 and still lives, works and attends master’s studies in the capital, her Srebrenica background is part of her identity. Her childhood was unusually quiet and the family did not listen to any music for a long time, for so long that it became normal to her. Her parents refused to be cheerful and considered loud laughter to be wrong.
Her mother has never told her what actually happened on the day when her sons Ahmedin and Velid, 15 and 17, were taken from her arms. Osmanovic only knows them from a few remaining photographs that have never been put on open display at their home.
These days she is trying to understand how her mother feels.
“She says she spends the whole night somewhere. She is somewhere with someone the whole time. When she goes out in front of our house in Srebrenica, she sees everything differently, she absolutely does not see the yard as I see it, she sees something else. She sees her children, she sees something else absolutely,” Osmanovic said.
When people tell her that she looks like her younger brother, she often wonders what her mother thinks when looking at her, if she reminds her of her son, and if that makes her happy or sad.
“Although I did not go through that myself, it has definitely affected me indirectly,” Osmanovic said.
Osmanovic initially said she was ready to speak about the transfer of trauma. However, as the lights for the interview shoot were switched on, we could hear nervousness in her voice.
For a moment, it seemed she would not be able to speak, but after a break, and with a confident smile, she said we could start filming. She decided to speak about the transfer of trauma because she hopes that people with similar experiences will understand the importance of talking about it.
“After all they have gone through, there is absolutely no way that my parents don’t suffer from PTSD. They have never sought medical help for it. I have a feeling that their mental health was the furthest thing from their mind at the time,” she said.
She is sorry that society failed to offer support when the victims needed it most. Her mother sometimes stays up all night. This cannot be normal, Osmanovic thinks.
“They can no longer speak, nor could they do this before, but it is extremely important that we don’t stop talking. Imagine how it would feel if our life story stopped here. No one would know any more why they were killed, why my father has spent his life this way, why my mother has survived in this way,” she said.
Trauma triggers
When the coronavirus pandemic made life stand still in the spring of 2020, for most people it seemed it was the end of the world as they knew it. For PTSD sufferers, everything reminded them of the onset of the conflict nearly 30 years ago. Empty streets and closed shops brought Enes Dedic back to the year 1992.
“Two years later, the Russian invasion of Ukraine happened. It hit us so hard. It was the same as here back in 1992. Starting in 1991 and 1992, we could see shops slowly running out of goods. That is how it all started in the city of Tuzla and the whole of Bosnia and Herzegovina,” Dedic said.
He followed all the news and watched reports from Ukraine, but not for long, as it brought back images of what he had been through during the war.
As well as the images from Ukraine, which remind him of his wartime experiences, loud sounds remind Mlinarevic of artillery explosions.
“I shudder, I get scared, that is inevitable. It cannot be helped,” he said.
Irritability is not uncommon for PTSD sufferers.
“We who have trauma from the war, injuries and PTSD, we’re like that. We’re emotional. We don’t need much. A token of attention, a passer-by greeting you or smiling at you, having coffee together, talking to each other,” Dedic said.
Analysis
Lack of Doctors and Social Support Make Life Harder for Sufferers
How the pandemic and invasion of Ukraine have exposed failure of Bosnia and Herzegovina to strengthen the system of support and treatment of PTSD sufferers nearly three decades after the end of the war.
It is an early October sunny morning in Ljubuski while a group of former soldiers is waiting for psychologist Marko Romic.
Once a week he comes from Mostar to hold therapy sessions with PTSD sufferers, because a psychologist of the local health center in the small Herzegovina town doesn’t hold a group treatment license.
Romic knows all too well the war traumas of his patients with whom he works every Thursday. But recently he has noticed something he did not see before.
“I had a chance to see close people crying while watching footage from Ukraine. Not saying anything. And it lasts for hours,” he said.
“It was a shocking experience for me,” says the experienced psychologist.
After two years of the pandemic and one year of the Ukrainian war, he has noticed that a significant number of people visit him and his mental health expert colleagues, because the war scenes remind them of what they had gone through.
But due to lack of staffing and money and poor commitment by politicians, Bosnia and Herzegovina is experiencing difficulties in adjusting its system of support to mental health to new trauma triggers, such as the pandemic or the biggest war in Europe in the past 80 years.
Besides that, the analysis by Balkan Investigative Reporting Network of Bosnia and Herzegovina, BIRN BiH, shows that over the course of nearly 30 years since the end of the war, Bosnia and Herzegovina has not set up special centers for post-traumatic stress syndrome sufferers, nor does it have clear and uniform data on the exact number of sufferers and their needs, expecting nongovernmental organizations to complete a substantial portion of field work with sporadic financing without clearly developed strategies.
“There is support to treatment from the institutions. The question is whether it is sufficient. I would say no,” says Romic.
The organization of PTSD sufferers had to strive to have him visit Ljubuski. At present, the Cantonal Health Insurance Institute pays for the therapy costs to the local association gathering 57 former soldiers.
It seems that the cases like Ljubuski, where there is a lack of doctors specialized in treating PTSD, is the rule of small towns in Bosnia and Herzegovina rather than the exception. A doctor also visits Vitez once a week, despite the fact that the number of sufferers has increased by ten percent in the last three years.
Not all small communities have received financial support, so the nearby mental health center in Travnik says that they have never received special resources for working with PTSD sufferers. Dozens of queries and interviews by BIRN BiH journalists reveal a disparate financing and work with sufferers.
While in some areas of war legacy, such as demining or search for the missing, Bosnia and Herzegovina has established specialized bodies which are now sharing their experiences and knowledge with their colleagues in Ukraine and other countries, the state has never founded an institution or agency specialized in helping and researching PTSD as a significant consequence of traumatic wartime experiences.
“The state takes no action,” says Borislav Mlinarevic, president of the Association of Disabled War Veterans of the Homeland War Treated for PTSD in Ljubuski.
He explains that the Association was registered at the state level.
“They don’t care about us at all. For them, we don’t exist. All we have comes from the canton and municipality,” Mlinarevic said.
In the state budget, PTSD is barely even mentioned. Romic considers that the previous wrong approach has caused long-term consequences. After the war, a number of sufferers retired in their 30s, he explains, which led to another problem because “those young people just sat there, drinking and gambling”.
“Instead of directing the money to creating new jobs, they bought peace by giving those people some benefits,” Romic said.
In the state budget, items containing support for PTSD are rare and refer to several thousand KM of support to nongovernmental organizations dealing with sufferers. Cantons allocate a bit more money, but those amounts range up to several dozen thousand KM, while direct work with sufferers is most often being transferred to nongovernmental organizations such as veteran associations.
The Ministry of Veterans of Posavina Canton says they allocate money for PTSD sufferers through support to associations, adding that the exact amount allocated for PTSD sufferers is not known.
Responses to queries, which BIRN BiH sent to dozen institutions that might allocate money for PTSD sufferers, as well as budget analyses, show that budget allocations are small and differ from area to area.
In the past three years, the Ministry for Veterans’ Affairs of Herzegovina-Neretva Canton has allocated KM 48,000 per individual requests referring to treatment costs and state of social need, and another KM 77,704 for grants to relevant PTSD associations.
By contrast, the Mental Health Center, which is a part of the Health Center in Travnik, says that they have never received financial resources specifically intended for treatment of PTSD sufferers.
The data collected by BIRN BiH demonstrate that cantons allocate a thousand or up to several thousand KM per year as support to associations, as is the case in the Western Herzegovina Canton where they set aside KM 1,800 to support the work of the Association of War Veterans Treated for PTSD.
Just like in the Federation, in Republika Srpska the money is channeled to associations. Former minister of labour, war veterans and disabled persons’ protection of Republika Srpska Dusko Milunovic explains that the Ministry has no legal obligation to allocate resources specifically for former soldiers suffering from PTSD.
As he says, they have financially supported the work of associations of PTSD sufferers by co-financing the Jedinstvo project by the Republic Organization of Soldiers and Civilians Suffering from PTSD.
Enes Dedic, president of Stecak Association of War Veterans Treated for PTSD in Tuzla, says they often get promises for systemic solutions of the problem, but the support is weak when it comes to fulfilling those promises. He points out that they have good collaboration with the Mental Health Center and Psychiatry Clinic.
“The only support we have is financial support by the Tuzla City. Also, we have support from the department of veterans and disability protection,” he said.
The Ministry of Health of Sarajevo Canton says that they have so far not allocated money for PTSD, pointing out that in the next year they are planning to incorporate it in a screening program that will be included in the budget.
Lack of evidence makes it harder to monitor trends
Out of the ten ministries for veterans’ affairs and health, which BIRN BiH has contacted, the majority have answered that they do not keep statistics on the number of PTSD sufferers, because they either have no legal obligation or they lack resources.
The lack of data makes it hard to follow the trends and an increase in the number of sufferers.
Since the onset of the pandemic and Ukrainian war, trends at the cantonal level have differed. In Tuzla they have registered a significant increase in the number of sufferers over the past three years. The Public Health Institute of Tuzla Canton had records about a thousand PTSD sufferers back in 2019. During the two subsequent years the number was doubled, according to data available to the Institute.
According to records kept by the Mental Health Center in Vitez, during the past three years the number of PTSD sufferers has increased by ten percent.
In other areas, which have answered BIRN BiH’s queries, no increase in the number of cases has been observed. But, the actual number of sufferers might be higher. So, in Bosnian Podrinje Canton they assume that the real number of sufferers is significantly higher than the one recorded by Svjetlost Drine Association, whose work is supported by the Ministry for Veterans’ Affairs.
According to the said data, 80 patients have been recorded in that area, but it is assumed that around 150 more sufferers don’t want to turn to professional help due to stigma.
The Association of Disabled War Veterans of the Homeland War Treated for PTSD in Ljubuski says they often witness to that. The Association, which was founded more than 20 years ago to enable war veterans and sufferers to exercise their rights, currently has 57 members. According to Mlinarevic, that is a small number, while many people don’t want to join, be it out of fear or lack of trust.
One of the reasons for not knowing the exact number of PTSD patients in Bosnia and Herzegovina is because people fail to report it and seek medical assistance, most often for fear of being negatively labeled.
“A great number of people have never reported it for sure. They are running away, denying the problems they encountered,” says Goran Cerkez, assistant minister for public health with the Federal Health Ministry.
He cites stigma as the main reason, but also says that it exists in other countries too in relation to mental health. He mentioned assessments according to which every seventh person in Bosnia and Herzegovina suffers from PTSD, irrespective of specific traumas causing it.
According to neuro-psychiatrist Amra Delic, the results of a research on prevalence of PTSD in general population in BiH indicate the presence of PTSD symptoms in about 30 percent of respondents even twenty years after the war.
“The obstacles due to which traumatized persons fail to seek professional help are either lack of knowledge or insufficient awareness that their symptoms are linked to a traumatic experience, as well as concern that they will be stigmatized due to a psychiatric diagnosis.
At the same time, it should be stressed that post-traumatic stress disorder is a normal reaction to an abnormal situation,” Delic explains.
PTSD is a disease that can affect practically anyone who goes through a traumatic experience that falls outside their usual experiences. What is particularly specific for PTSD are forced images and thoughts, meaning recollections of painful experiences with which sufferers are struggling constantly.
Considering the intensity of the war and estimated number of individuals suffering from PTSD, it seems that explorations of its influence on the society and individuals in Bosnia and Herzegovina are less frequent than expected. Some of them that can be found through online search were prepared by nongovernmental organizations and experts outside the official system with sporadic financing from the budget.
As a country that had come out of the war, Bosnia and Herzegovina invested considerable resources and sought international help to establish the Missing Persons Institute and BHMAC agency specialized in demining. With all the difficulties those organizations were facing, they helped BiH speed up the process of finding the missing persons and demining. Experts from those institutions help other countries develop specialized institutions of that type.
But, despite PTSD being yet another considerable legacy of the war, BiH has never had a national strategy for helping sufferers and exploring how the disorder affects the entire society and its economy.
Not a single institution that has responded to BIRN BiH’s query said that they had developed a strategy specifically intended for PTSD.
While a special National Center for Psycho-Trauma has been established in Croatia, with three regional centers particularly caring about patients with post-traumatic stress disorder, PTSD, and other mental disorders associated with participation in the war, Bosnia and Herzegovina doesn’t have a special institution of that sort, so work with the diseased is fragmented, and so is the complicated state government system.
“Relationship to traumas from the 1990s war to date and difficult economic situation in which the transition is taking place leave a mark on individuals. The issue of public health should therefore have been a priority for institutions long ago. But we have ended up in a situation of complex structures of entities, cantons and Brcko District, and competences. That field has actually been given over to only and almost exclusively nongovernmental organizations, which are narrowly focussing on those issues,” Dino Abazovic, professor at the Faculty of Political Sciences in Sarajevo said.
Cerkez explains that BiH has not decided to form special centers for PTSD patients, like some other countries. Instead, it has developed a decentralized system with more than 50 mental health centers throughout the country. These centers deal with a series of mental diseases, with PTSD being just a part of that spectrum. At present most of them are facing staff shortage and insufficient financing.
“Is the number of professionals sufficient? I think that, for this state, it isn’t. This state should have much higher standards and much more professionals to deal with mental health of children affected by transgenerational trauma,” Cerkez said.
Praising the efforts of health workers, he admits they are facing problems. In the Federation, the centers are financed from cantonal health insurance funds via health centers. Directors of the centers decide how much attention will be paid to PTSD patients based on needs. In practice, in addition to money-related challenges, they are also facing staff shortage while balancing the needs.
As a part of the official system and doctor working with PTSD patients on a daily basis, Romic says, from his own experience, that domestic institutions don’t have sufficient capacities to cope with the problem.
“I think we don’t have sufficient resources, meaning primarily human experts who are sufficiently motivated and qualified to deal with that,” he said.
Delic has noted a growing interest in specializations in the field of mental health and increasing number of psychologists, psychiatrists and social workers educating themselves in psychotherapy. Their education is expensive and lasts long, and on top of that, Bosnia and Herzegovina is facing the outflow of educated staff.
Cerkez is worried about the growing mental health crisis, while we have one psychologist, psychiatrist and social worker, and four nurses on 60,000 people. They are certainly “not enough and they don’t keep the situation under control”, he says.
“Let alone do something more than that. Because with each new day, the number of sufferers increases. We often say that there was not as much trauma during the war. This is a delayed trauma,” Cerkez said.
Nowadays, with the spiraling inflation after the pandemic and the war in Ukraine, the pressure on the health system demonstrates the importance of being committed to mental health.
“The coronavirus pandemic has really caused a huge damage in the field of mental health, especially in individuals suffering from PTSD,” says psychologist Romic.
Data available to the World Health Organization, WHO, suggest that the coronavirus pandemic has seriously affected the mental health of the population, which is particularly pronounced among those with already deteriorated mental and physical health.
Romic is of the opinion that the political situation in the country has a negative impact on persons suffering from PTSD, because it generates tensions and conflicts, so people live in a state of tension.
Due to extraordinary measures during the coronavirus and the war in Ukraine, many people had to correct the therapies they were using.
Zlatko Ljubic from Tuzla says that seeing the scenes of war on TV upset him, so he had to correct his PTSD therapy.
“So, since the onset of the war in Ukraine, I have increased the dose. My doctor told me to increase the therapy, because I told him I could not watch that, so he gave me a stronger dose,” Ljubic said.
The Public Health Institute of Tuzla Canton says that, between 2019 and 2021, there was an increase in consumption of drugs acting on the nervous system.
“The mental health problem, not only PTSD, is on the rise and that is a global trend. It is estimated that due to COVID only, depression and anxiety have risen by 27 percent. Those are very serious issues,” Cerkez said.
He says that mental health centers react to the increase, but they struggle with capacity shortcomings.
Symptoms characteristic for PTSD include flashbacks of images and thoughts, as well as memories of painful experiences, so sufferers struggle constantly.
Delic says that the war happenings in Ukraine and pandemic have led to considerable mental or anxious reactions in persons with PTSD, which are reflected through the state of hyperarousal.
“The images of war happenings and constant exposure to information from battlefronts, fear from shortage of food and other supplies, may act as reminders and triggers for reliving the traumatic experiences. In everyday practice, most patients, irrespective of their diagnosis, complain about anxiety, concern and distress,” Delic explained.
Shortfall in achievement of status and rights on grounds of PTSD
Besides social problems facing those diagnosed with PTSD, a great portion of them cannot achieve the disability status due to legal and date limitations.
Under the Federal Law on Fundamental Rights of Veterans, in order to determine the disability percentage, the circumstances under which disabled war veterans got bodily injuries due to psychosomatic damage and disruption and the manifestation of the injuries prior to December 23, 1997 are taken into consideration. That means that, after that period the diseased cannot file requests for help on grounds of this disease.
“Manifestation of the disease past the said deadline is irrelevant for achieving the rights according to the existing laws,” the Service for War Veterans and Disabled Persons’ Protection and Protection of Civilian Victims of War of the Brcko District Government explained.
According to the Law on Rights of War Veterans, Disabled Veterans and Families of Fallen Soldiers of Republika Srpska, as of 2012 it has been possible to achieve the status and rights on grounds of this disease.
For years the Stecak Association has been trying to initiate the removal of the date line up to which it was possible to achieve certain rights on grounds of disability. The Association has sent several letters to the Federal Parliament, requesting the removal of the date line, but they are kept in drawers, says Dedic.
“We asked that they introduce the term ‘war injury’ instead of ‘disease’ and requested them to move the date line,” he said, explaining that they asked them to move the line for ten years, i.e. until 2007, although war trauma can appear even after 20 years.
Sociologist Esad Bajtal explains that the institutions must help sufferers to overcome the difficulties they are facing.
“If all that is missing, or if there is no law, or if the law is not implemented, that person or the whole group feel abandoned and helpless, while their dissatisfaction naturally comes forward,” Bajtal said.
Insufficient capacities to fight against PTSD
Romic also cites problems facing the families of sufferers, adding that they are always the victims of PTSD and get hurt to a greater or lesser degree.
“Due to being non-functional, that person cannot be a good husband. He cannot be a good father either. So, that person has failed in a certain way. Such persons often start seeking cure in a wrong way, which sometimes turns into addiction or damaged relations due to aggression,” Romic explained.
Delic says that persons suffering from PTSD often have difficulties in fulfilling their family roles, while some complain about marital disputes or more frequent quarrels, a lack of understanding, difficulties in maintaining close relations, problems in intimate sphere, loss of interest and satisfaction in joint activities, sense of alienation.
“In some cases, violence can be present, both within family and in relations with others. Persons who have developed PTSD as a consequence of interpersonal violence, like for instance, physical abuse of children, torture and rape, lose confidence in other people, become vulnerable and hypersensitive in relationships with others, so during the treatment for PTSD it is very important to also work with the family of the diseased person,” Delic considers.
Such unresolved and accumulated problems leave consequences on families. In a report on progress of Bosnia and Herzegovina in the implementation of the Beijing Declaration referring to an increase in equality of women from 2019, it is stated that the issue of persons suffering from PTSD is not properly treated legally and socially, having a great influence on families.
Children as inheritors of trauma
The traumas that parents experience during their life, especially if they have not been treated, are transferred to other generations, i.e. children.
This phenomenon is known as transgenerational transfer of trauma, which has also been recorded in Bosnia and Herzegovina.
Delic explains that symptoms of avoidance and emotional numbness directly affect children who can misinterpret them, thinking that their parent is not interested in them or doesn’t love them. As he said, persons with PTSD usually have a high level of anxiety and arousal, which is manifested through sleep disturbance, reduced concentration, timidity, easy irritability and undue concern for own security and security of family members.
“For this reason, parents with PTSD can be overprotective. Irritability and reduced level of tolerance of frustration make the parents seem hostile or distanced, which also makes children reassess parental love because children don’t understand the reasons behind those symptoms,” Delic explained.
Social community should take the mental health problem more seriously, Cerkez said.
“We’ll witness an increased number of suicides,” he warns.
“Over the course of the last two or three years, we have seen an increase. It can be associated with multiple traumas, as each trauma reminds you of a previous trauma. The floods took many people back to the war period. The COVID crisis and the lockdown have surely taken many people back to that period and reactivated their traumas,” Cerkez said.
If you are in Bosnia and Herzegovina and you think you might have some of the symptoms of PTSD and want to get expert help, you can contact your local mental health centre for assistance or get in touch with a PTSD association near you. To see contact details for health centres, follow this link.