Prior to the 1990s, health components of humanitarian responses to wars and disasters were dominated by a narrowly biomedical approach, emphasizing biological and physiological needs and pharmaceutical treatments (Fassin and Rechtman 2009; Powell 2000: 19; Richters 1997; Pupavac 2004). In the last two decades, however, beginning especially with humanitarian engagements in war-torn Bosnia-Herzegovina1 and Rwanda, aid projects targeting the mental health consequences of violence and disaster—commonly known as “psychosocial support”—have become key elements of international post-crisis remediation efforts (Pupavac 2001, 2003, 2004a; Summerfield 1998, 1999). Humanitarian psychiatry, like other experiments in aid, development, and nation-building, introduces new or reconfigured social scientific and clinical rationalities into local discourse and social dynamics, producing side effects that ripple beyond program intentions. Following the theme of this issue, in what follows I briefly sketch some of the ambiguous legacies and appropriations of trauma psychiatry in Bosnia. This is my attempt to provide a case study in how social scientific theories and epistemologies can be unpredictably appropriated and adapted according to social dynamics specific to local contexts. While these phenomena remind us that the appropriation of academic knowledge for application in new projects and contexts is a basic and inevitable social process, they also suggest the tremendous challenges (for anthropologists and others) in thinking through how this process could be better anticipated, accounted for, and managed.
Advocates of building psychosocial support into humanitarian relief projects have argued persuasively that post-traumatic stress constitutes a deeply threatening “hidden epidemic,” affecting large portions—if not all—of crisis-affected populations, and thus represents one of the most urgent public health problems facing post-crisis reconstruction and recovery projects (e.g., Mollica 2000, 2008; Agger 1994, 1995, 2005; and for an influential critique, see Summerfield 1998 and 1999). Here processes of appropriation and translation are already at work: humanitarian organizations take up a culturally and historically specific clinical social science (trauma psychiatry) and adapt it (as psychosocial support) for application in new fields of transnational, transcultural intervention. The timing and philosophical underpinnings of this development can be understood historically as emerging from the 20th-century evolution of the Western mental health sciences (Pupavac 2004) and the invention and politics of PTSD in particular (Young 1995; Bracken 2002; Fassin and Rechtman 2009). The recent and remarkably large-scale incorporation of psychosocial services into post-crisis interventions means, however, that empirical knowledge of the impacts and side effects of this form of aid is only beginning to be developed (see, e.g., Abramowitz 2009, Kienzler 2010).
Such an understanding may be all the more important given the relatively brief time-scale of most humanitarian interventions. In the Balkans, for example, the rapid reduction in foreign psychosocial projects is as impressive as the original number and scale of interventions claiming a mental health component. The European Union recorded 185 psychosocial projects conducted by 117 organizations in the former Yugoslavia in 1995; projects implemented in the region in subsequent years numbered in the thousands, costing millions of dollars (Summerfield 1999: 1452; Pupavac 2003: 163). This engagement—as well as humanitarian aid and social services more generally—quickly declined following the turn of the century, even as key social and political problems in the region went unresolved.
The inclusion of psychosocial services in post-war humanitarian efforts in the Balkans was a novel event globally, and it helped to introduce a new approach to mental health in the region (Richters 1997: 72). As my fieldwork, conducted primarily in Sarajevo between 2006 and 2008, began, I expected to watch the effects of this new phenomenon play out both in local institutions and in everyday social recovery processes. What I had read prior to my arrival in Bosnia led me to anticipate substantial and obvious changes in psychiatric services and patterns of care and diagnosis. Richard Mollica, for example a renowned, globe-trotting trauma psychiatrist and the director of the Harvard Program in Refugee Program, writes proudly of his participation in ambitious mental health care reforms in Bosnia: “We were invited to Bosnia at the close of the war to provide a countrywide system of mental health care through the remaining primary health care system… We provided a comprehensive mental health training to our Bosnian primary health care colleagues so that they could successfully identify and treat tens of thousands of persons psychologically damaged by the war” (2008: 49). I quickly discovered, however, that the structural and institutional impact of international mental health and psychosocial projects in Bosnia—notwithstanding all the millions of aid-dollars spent, the hundreds (if not thousands) of projects implemented, and the ostensibly “comprehensive” character of contributions like Mollica’s—has been somewhat limited. In this regard humanitarian psychiatry bears out broader critiques of development and humanitarian aid that target the unsustainability of much international NGO work due to lack of attention to and investment in local health and welfare infrastructures (Feldman and Ticktin 2010, Escobar 1995, Ferguson 2006, Garrett 2007, Birn 2005).
Various international programs—the once-ubiquitous seminars, workshops, trainings, and conferences on themes like “conflict resolution,” “non-violence,” “communication skills,” and, of course, trauma—did shift the way a number of local civil society workers understood the psychological impact of war; and a community mental health center (CMHC) reform project, led and sponsored by an array of international organizations 2, re-trained and re-assigned many local mental health professionals and social workers accustomed to a more classical pre-war system of psychiatric wards and asylums for the severely mentally ill (Lagerkvist et.al. 2003; MHPSEE 2004). The CMHCs, located in 50 Domovi Zdravlja (literally, “Houses of Health”), municipal primary health care clinics established throughout the country during the communist era, are each meant to operate with a small core staff of one to two psychologists, one to two psychiatrists, two mental health nurses, and one social worker.
Bojan Susić is a research psychologist and in 2007 was one of two employees remaining at the Sarajevo office of HealthNet International, a Dutch INGO that focuses on “the structural rehabilitation of health care systems in war and disaster areas.”3 Bojan told me that the process of setting up the CMHC units had been discontinued at the halfway point due to insufficient international funding. Even if all the centers had been created, he continued, the number of mental health professionals involved would still be tiny in proportion to potential public need. Moreover the work done at the centers is not always, or even often, related to actual post-war mental health problems. Center professionals get bogged down in fulfilling bureaucratic tasks—conducting evaluations and issuing certifications required by employers and state institutions—that provide a steadier income for the Domovi Zdravlja than longer-term mental health support and therapy. In addition, the clinics are poorly integrated with other public institutions, in particular social welfare centers, which are often people’s first point of connection to available services.
In the non-governmental sector, too, concrete institutional effects and changes produced by the short-lived post-war flurry of psychosocial work and mental health projects are limited and piecemeal, and there is little coordination between organizations with similar—or even identical—missions. In Sarajevo I found a handful of small, Bosnian-run NGOs, the staff of which, more often than not, were trained by or at least had important encounters with international mental health professionals during and just after the war. These NGOs try to adapt their sense of Western mental health science to what they perceive to be local problems and needs, often creating a disjuncture between mission statements (couched in psychological terminology) and actual practices (which tend to look more like social work and “community building”). Beneficiaries are often more interested in material assistance and guidance in day-to-day problem solving than in emotional support or psychiatric treatment. In this capacity “psychosocial” NGOs are often highly effective, if limited in the number of clients they can take on. In the end, their appropriation of the language of trauma psychiatry often has more to do with what appeals to international funders than with the actual services they deliver.
In the meantime, and despite a relative lack of sustainable transformations in actual mental health care services or treatment-seeking behaviors, “trauma” has been more enthusiastically taken up in processes of moral and political deliberation—both in the public sphere and within families struggling to get by in a harsh and unfamiliar new economy (Locke 2009; Biehl and Locke 2010). The claims and counter-claims to true victimhood that fill repetitive debates in politics and the media are increasingly underpinned by assertions of traumatization. Andrea, an international employee of the Red Cross in Sarajevo and a veteran of psychosocial programs in the Middle East and in Bosnia, shared with me her impression that, as she put it, “the term ‘trauma’ has been widely locally adopted and is used all the time. Now anyone who suffers has ‘trauma.’ The word is becoming vulgarized. It’s just used in political claims and arguments over who suffered the most. It doesn’t actually correspond to a better mental health infrastructure or to people asking for psychiatric help.” At its core “trauma” can be read as a theory of how a person becomes a victim and experiences victimhood (Fassin and Rechtman 2009); in a social world gripped by unresolved questions of how to divide and manage victims and perpetrators, it makes sense—at least in hindsight—that the concept would be appropriated as ammunition in this political process, overshadowing its clinical implications and uses.
While many of the people I encountered during my fieldwork did indeed employ what Andrea calls a “vulgarized” concept of trauma to legitimate claims to true suffering, others had found in PTSD a tool for rebuilding identity and social ties and for accessing psychiatric care and other forms of support—pragmatically blending, in other words, the diagnosis’s clinical and political applications. In the fall of 2008, for example, I visited an organization for traumatized war veterans in the northeastern provincial center of Tuzla. The organization—called Stećak, after the massive, intricately engraved medieval tombstones found in remote areas of the Bosnian mountains—was formed in 2004 to provide a safe space and social support network for ex-soldiers who had been diagnosed with PTSD. Proof of the diagnosis, and of military service in the war, is required for membership. The vets meet in a former JNA (Yugoslav National Army) office near the town center—a small conference room dominated by a long table, around which members sit to smoke, drink coffee, and eat simple meals donated by the municipality. Stećak started with 76 members and had around 300 at the time of my visit. Upon joining, new members are issued membership cards bearing an image of a human brain made to look like a hand grenade, complete with detonating pin. Stećak’s leader at the time, Alija, told me that the image is meant to convey that traumatized vets are like “walking time bombs:” prone to breakdowns, suicide attempts, and violent outbursts at any moment.
The veterans’ stories had a common narrative shape: anecdotes of extreme wartime experiences, followed by a post-war period of relative normalcy, then the sudden and bewildering onslaught of what they now understood to be symptoms of PTSD—nightmares, anger and acute irritability, outbursts of violence and rage directed toward family members, alcoholism and blackouts, suicide attempts, and intense feelings of alienation, isolation, and despair. While the onset of symptoms was often connected to the increasing intolerability of day-to-day economic and social circumstances, dramatic emotional crises usually provoked families or local authorities to direct veterans to Kreka, the local psychiatric hospital, for therapy, group support sessions, and strong psycho-pharmaceutical treatment.
In 2007 a young Bosnian filmmaker, Aldin Arnautović, made a documentary about Stećak. He called it Fantasija (“Fantasy”), a title inspired by group meditation and visualization sessions led for the vets by professionals from Kreka. The film follows a handful of Stećak members through their daily lives—interacting with family, trying to find employment or apply for government assistance, walking the streets of Tuzla, and sometimes narrating for the camera their experiences during the war, their struggles to adjust to life afterwards, and the process of being diagnosed with and treated for PTSD. When I spoke with Aldin in 2008, he seemed unaware of the millions spent on psychosocial services by international organizations during and after the war—the men in Tuzla, certainly, had never encountered or benefited from such services. “I made the film so that somebody will react. Doctors Without Borders or somebody like that. Because our authorities won’t do anything.” Medecins Sans Frontieres (MSF) had, in fact, been very involved in psychosocial projects and mental health care reform in Bosnia in the years just after the Dayton Accords. It is telling—confirming doubts about the long-term impact and sustainability of psychosocial intervention—that in 2007 Aldin and Stećak were trying to get MSF’s attention, as if, in fact, the organization had yet to take notice or intervene at all.
As Aldin emphasized—“our authorities won’t do anything”—veterans struggling with post-traumatic stress also have little luck extracting aid from state and local authorities. The Bosnian government recognized PTSD as an official war injury, rendering those with the diagnosis eligible for disability benefits, in 1999; but the legislation passed at that time required the diagnosis to have been received prior to December 1997. This rule excludes the vast majority of veterans claiming PTSD—most of whom received the diagnosis after 1997—from the possibility of applying for assistance. Stećak members have campaigned to change the law. “We are war invalids without visible wounds,” Alija argued to me, as much deserving of public recognition and support as those veterans physically disabled by wartime injuries.
Bosnia’s authorities are reluctant to expand the list of those eligible for disability benefits out of a concern to prevent uncontrollably ballooning costs. With an estimated 70 percent of Bosnia’s yearly GDP already going to fund the country’s dysfunctional government institutions, and with perennial budget shortfalls regularly requiring controversial cuts to other social services, state acknowledgement—or lack thereof—of the needs and problems of demobilized soldiers is as much (or more) a matter of cost and resource triage as it is of symbolism and fairness. Proposals to cut or reduce benefits for war veterans tend to provoke angry street protests from the latter, as well as intense political pressure from influential veterans’ associations connected to the nationalist parties that dominate Bosnia’s elected bodies. The debate over PTSD fits, thus, into a larger dynamic pitting state institutions—interested in controlling costs and limiting services—against a vocal array of politically significant groups (especially veterans) demanding recognition and compensation for specific wartime losses and injuries.
The veterans I met in Tuzla were clearly in very real, and often very severe, emotional pain. The danger in their conversion to a PTSD-centered form of identity and citizenship is that they and others will come to understand that pain as stemming exclusively from their wartime experiences, rather than also—and importantly—linked to their experience of war’s aftermath: the way in which, that is, they had come to feel abandoned, neglected, and misunderstood by their communities and public institutions. As in other situations of medicalization chronicled and critiqued by anthropologists (e.g., Young 1995, 2007; Petryna 2002; Scheper-Hughes 1992), here the process of coming to inhabit a clinical, “traumatized” subjectivity seems to foreclose more possibilities for care and public engagement than it opens up: the veterans’ trauma-based appeals for broad social support from state institutions, that is, have very little currency or effect. This is a painful irony, as the veterans come closer than most to appropriating and using “trauma” according to the original hopes and intentions of psychosocial projects.
Although my comments here have focused on appropriations of psychiatric knowledge in a postwar context, the relevance to anthropologists—especially those working at the fertile intersection of medical anthropology, psychiatry, and humanitarianism—is clear. Anthropologists routinely and productively blur disciplinary lines between these fields and make crucial contributions to the application of Western psychiatric models in other cultural contexts. Physician and medical anthropologist Annemiek Richters, for example, worked with MSF on its early psychosocial programming in Sarajevo for several months in 1994, helping to expand local health professionals’ “medicalizing approach” to mental health problems (1997: 72). And scholar-activist-caregivers like Arthur Kleinman and Byron and Mary-Jo DelVecchio Good have long combined critical scholarship with advocacy and support for building mental health service capacity in a range of international settings (e.g., Kleinman and Good 1985; Kleinman 2009; Lemelson et.al. 2007; Jenkins 1996). In this vein, the Goods’ recent psychosocial needs assessment work (2010) in post-conflict, post-tsunami Aceh is particularly noteworthy.
While trenchant theoretical critiques of humanitarianism and humanitarian psychiatry by anthropologists (e.g., Fassin and Rechtman 2009, Fassin and Pandolfi 2010, Feldman and Ticktin 2010, Pandolfi 2010) continue to be indispensable, the mixed legacies of humanitarian psychiatry in Bosnia seem to confirm that critical distance alone is not enough. Rather, a dynamic balance between critique and practical engagement—sustained over time as on-the-ground realities evolve—is called for if we are to fully accept and take responsibility for the complexity and unpredictability of how social scientific knowledge is appropriated by the populations we aim to serve and the institutional reforms we hope to support. Helping to install comprehensive mental health services in ways that are sensitive to the cultural, political, and economic particularities of a given context is, in this view, an important initial contribution that we can make. Given resources and receptive audiences (big hypotheticals, to be sure), anthropologists can also help to monitor unexpected appropriations and side effects over time and advocate for appropriate adjustments. In the case of postwar Bosnia, this might involve working toward renewed attention to and investment in Bosnia’s faltering social service and health care infrastructures—so that regardless of the political uses and abuses of the “trauma” concept, those who need clinical treatment and/or more holistic forms of social support can actually obtain it.