In October 1997, I visited a high school in Vogasca, Bosnia-Herzegovina. It was my first visit to this Sarejevo suburb, occupied for four years by Bosnian Serb forces.
I found myself facing a classroom of young people, awkwardly trying to start a group discussion. The familiarity of many complaints was reassuring: the teachers were too strict, they had too much homework and not enough got tickets to see the U2 concert. In many ways, they seemed like ordinary teenagers.
Other comments suggested extraordinary struggles. "Our curriculum isn't practical enough in the economic realm"-in other words, they had no idea what work, if any, they would be fit for after completing their educations. "We haven't enough opportunities for sports or large social group activities"- implying that there were few possibilities for being together in communality.
At least half of them were internally displaced families from Srebrenica, and most had lost their fathers and older brothers to General Mladic's atrocious mass murder in July 1995 (Rohde, 1997). Many had missed more than three years of school.
My Bosnian psychiatric colleagues reported to me that there was the usual adolescent stew of identity crisis among them: delinquency, drugs and sex; but also much, much more.
I asked the students, "What do you suffer from?" Lack of opportunity was mentioned most often. A few said that they wanted someone to talk with when it all got to be too much. They welcomed the new school-based initiative of the adolescent mental health clinic in Sarajevo.
To my question, "How do you keep from breaking down?" they replied, "Our Bosnian spirit keeps us strong and positive." It was hard for them to find the words, but I already had some idea what they meant.
Like others in trauma studies, I have been trying not only to find ways to understand the traumatization of individuals and their societies, but also to find paths of recovery.
There were things the students wanted to know. How are the Bosnian students in the United States doing? What kind of future do they have? Have they forgotten about Bosnia?
The questions brought back memories of a national meeting of Bosnian students in Maryland. Those students had survived ethnic cleansing and siege, and were now apart from their families, pursuing their education in America. "We are not survivors like those in Bosnia. We are just students." By all reports they were exceptional students: flourishing at high schools and colleges across the United States and highly committed to advocacy work for Bosnia and its youth. Yet there was also homesickness, sadness and many questions about what the future would bring for them, their families and their country.
I am trying to understand what the traumas of ethnic cleansing have done to these youths, how we can help them, what they can teach us about surviving, and perhaps opposing, political violence. Understanding Posttraumatic Stress Disorder (PTSD) helps to address the first issue, but alternative paradigms are necessary to respond to the others.
It is also necessary to let go of the image of adolescent development that many of us were taught: "Peter Blos meets Valley Girls." Against a background of stability, privilege and conformity comes falling in love, rebellion against parental authority and involvement with cliques and clans. That is not the reality of today's youth from Bosnia, where adolescents and the family as a whole have survived communal violence. Their society offers little in the way of socioeconomic opportunities for advancement, and the existing sociocultural milieu offers a shattered ethic of peace and pluralism. Progress in mental health and human rights requires articulating new concepts of adolescent development to fit with these realities, which will in turn promote new ways of providing effective interventions.
Several years ago I joined with the Bosnian Student Project, a program conceived by Fellowship for Reconciliation. This group was responsible for bringing more than 100 Bosnian students to the United States during the years of ethnic cleansing. To their credit, they thought that systematic attention should be paid to the Bosnian student's mental health and they actively sought psychiatric consultation for them.
Initially, I was called upon to help students with overt trauma-related problems. No one was sure how severely students with less obvious symptoms had been traumatized and might be affected. Some U.S. students who got to know the Bosnians claimed, "They do not look traumatized." We knew that many had endured ethnic cleansing, but there was also the sense that most might have gotten out of Bosnia before the worst had happened. With the help of the program staff and students, a survey was developed and distributed in order to better characterize and respond to the trauma mental health needs of the Bosnian students.
We sent questionnaires to all the students enrolled in Bosnian student programs throughout the United States and got responses from a majority. We found that there was a considerable rate of trauma and mental health consequences in the students: they had an average of six months exposure to the traumas of ethnic cleansing, more than two out of three met symptom criteria for PTSD, and the group averaged a moderate level of PTSD symptom severity (Weine et al., 1996). We compiled a detailed report on trauma mental health in the group and provided it to all the students and others working with the program. We shared all the data, analyses and interpretations with the students and described in detail individual coping techniques, mental health treatment plans and other information pertinent to students, families, teachers, administrators and mental health professionals. We also held large and small discussion groups for the students during which they could share their traumatic memories and their own strategies for living in the present.
In subsequent travels I met many Bosnian young people who were pursuing their studies either at home or in exile, and I felt compelled to look transnationally at the Bosnian students and compare their experiences across different social contexts. An international collaborative study between psychiatry departments of the Universities of Sarajevo, Zagreb and Illinois at Chicago looked at a sample of 111 female students ages 18 to 23 (Weine et al., 1997). The Sarajevo sample consisted of 52 students and the exile sample (Zagreb and the United States) consisted of 59 students. The subjects completed anonymous questionnaires that asked about general information, traumatic events, traumatic stress symptoms, general functioning, school satisfaction, coping with traumatic memories, cultural identification and alienation, all drawn from standardized assessments.
The average rate and severity of PTSD was similar across all three settings. With the exception of alienation, the other remaining factors suspected of playing a mitigating role in the trauma response were also consistent across the three settings. This suggests that these settings are more alike than different in terms of factors likely to be involved in determining trauma-related psychiatric consequences.
The severity of PTSD was found to be related to the intensity and frequency of traumatic events and to alienation. Alienation appears to be related to avoidant cluster symptoms (and not to re-experiencing or hyperarousal symptoms), with which it shares many phenomenological qualities. PTSD severity is also related to quality of life at school and psychosocial functioning, although it would probably be wrong to assume simple unidirectional linear causality. The cases in which PTSD is more severe can be attributed to higher trauma exposure, whereas the cases where quality of life at school was lower were found to be related to higher PTSD diagnosis and symptom severity, and higher trauma exposure and alienation.
This study indicated that PTSD has an impact upon the school experience of these traumatized refugees. In those students who are having school difficulties, more severe PTSD may be present, warranting an assessment and appropriate treatment. Screening for trauma exposure could be helpful as a simple means of identifying students who are at higher risk for PTSD and school problems. On the other hand, a positive school experience could serve as a protective factor against the development or worsening of PTSD symptoms.
Needs assessments of traumatized youths are a start, but they are not enough. They reveal that Bosnian youths have experienced substantial trauma, that many are suffering from symptoms of PTSD and that it appears to affect their school experience. Yet we know that only a very small minority have received mental health services. Too often, services are either not available or not accessible. It is imperative that we use innovative approaches in developing new service activities involving schools, social groups and community organizations when treating these young people for trauma.
Another central issue that emerged through working with the students, and in academic and professional contexts, concerned the possibility that trauma does not only yield suffering and psychopathology, but perhaps also a knowledge base for affirmative growth. It resonates with Erik Erikson's observation, made during a lecture delivered in 1968 at Cape Town University: "In all ages it has been intellectual youth which has kept open a bridge between privileged insights and the needs of the era's underprivileged, thus maintaining avenues to future ethics"(Erikson, 1975). Do the legions of young people caught up in today's transnational problems of communal violence and cultural change contain not only suffering and misery, but also a knowing which can be the nucleus of a new public ethics? Some of us believe so. But to really know we will need biographical studies of intellectuals, artists and activists among young people, who show extraordinary capacities for socially redemptive work in the face of communal violence and social suffering.
We need not only to study these achievements, but to join with these young leaders and support them in their push for an international human rights movement.
This has been happening in and around the International Society for Traumatic Stress Studies (ISTSS). Several meetings have been held to convene youth survivor/activists and leading international trauma mental health professionals from around the world. There is a deliberate effort to steer the dialogue away from PTSD and toward a broader social, cultural, psychological and ethical dialogue on political violence and human rights. ISTSS is now in the process of defining its mission, organization and fundraising.
Frank Ochberg, M.D., of the Dart Foundation, has said that trauma mental health professionals "could and should be mentors to a new generation of youth human rights activists, and could find new outlets for their own ambitions to end cycles of violence."
Among some 2 million refugees, many of them youths, there are extraordinary opportunities for service, research and advocacy. In that they implore us to think anew about who we are and what we do as psychiatrists, these youths could hold the keys to a future in which we find a new role for our profession-to aid the survivors of human rights violations.