BOSNIA AND HERCEGOVINA-MENTAL HEALTH INFO

"The most important factors in my recovery have been my commitment to my work in a user organization, together with the openness of my doctor to talking therapy without medication. Stigma and self-stigma have been the biggest barriers."

My first possible move away from normal behaviour, I attach to an incident when I was 7 or 8 years old. It was evening and my two older brothers teased me until I fell asleep. Later that night, I woke up crying. The lights were switched on, my eyes were open and I was communicating with my parents, but my consciousness was somewhere else. My father calmed me down by reading me stories, my parents told me the next morning. I had no recollection of what had happened.

The first time I encountered graver mental health problems was during the war, as a soldier in Sarajevo. I am Bosnian by nationality but Catholic by religion, and my fellow soldiers, who were all Bosnian Muslims, had difficulties understanding what someone called Igor (a non-Muslim name) was doing in an almost solely Muslim army. They treated me as a traitor and would say things like: ‘On the next mission you’ll be the one to die first.’ I was under constant suspicion, and this, together with the permanent threat from enemy positions in the surrounding hills, insomnia caused by guard duties and my alcohol consumption, all collaborated to strain my sanity. As a result I withdrew into myself, switched from crying to nonsensical talking and would not answer questions appropriately.

I was hospitalized for two months in a clinic in Sarajevo, where I was given injections of antipsychotic medicine. I was released after the ceasefire in May 1995, with a diagnosis of schizophrenia and psychosis in progress. Then I was released from military service and went back to my home town, Tuzla. I came home on the day of the biggest tragedy in the history of Tuzla – the killing by grenade fire of around 75 civilians at the Gate, an area in the city centre where young people hang out. I knew most of the victims.

In the autumn the military authorities declared me unfit for service, with the comment that I had been taken ill while serving in the army of Bosnia and Herzegovina, but that my illness had been in progress before I joined the army. In less than eight months, I thus went from being a completely capable individual to total disqualification. I was given the status of military war invalid, which I rejected, not wanting to be associated with people who had lost an arm or a leg in the war. To put it bluntly: who wants to be a cripple at the age of 21?

For the next eight years I worked for several different employers, mostly journalism in the electronic media. When my father died in 2003, I was unable to show any emotional reaction. I contacted a neuropsychiatrist about this, and was again diagnosed with psychosis in progress and offered some antidepressants. My situation worsened while I was working as a waiter in a local café for a few months. I suffered from insomnia and had war flashbacks due to my consumption of alcohol and soft drugs, and once again I began withdrawing into myself. In the end my family took me to an acute psychiatric care ward, where I was hospitalized for 40-odd days, and subsequently released with heavy medication. While I was in hospital, I was four-point restrained and forced to take psychiatric medicine a couple of times. The only compassion I encountered was the contextual question, ‘Are you suicidal?’

A year ago I changed doctors, since I was fed up with the superficial medical treatment I was receiving, and began looking for work again. I went round to all the private businesses and radio stations where I used to work, but found nothing. Many of the employers had heard rumours about my hospitalization and therefore refused to hire me. During this period, I joined the ‘Fenix’ Association (the Association for Mutual Support in Mental Distress) in Tuzla, and began working as a volunteer in its art studio. I was granted the status of 50% war-disabled veteran, and in September 2006 I signed a year-long contract with Fenix to work as a secretary, but in reality I am a jack of all trades. I act as a spokesperson, translator and project manager for smaller projects, and participate in the art studio and woodwork workshop when needed. In addition, I advocate the rights of mental health service users whenever I get the chance.

Fenix offers occupational therapy in an art workshop, a woodwork workshop and greenhouse vegetable production. There are a library, an Internet service and a day centre, which we are developing to stimulate the reintegration of clinically isolated service users into society. Fenix also strives to be, and partially is, a progressive stakeholder in the making of mental health policies, and in the creation of social cooperatives and social tourism.

I have changed doctors again, since the second one, too, refused to give me talking therapy and insisted on medication. My present doctor responds to my thinking and efforts with support, while giving me some guidelines that are truly effective. Nowadays I rarely take psychiatric medicine. I have no signs of mental instability and once a month I have a heart-to-heart talk with my new doctor, who is of a younger generation than the previous two.
As a matter of fact, I talk openly about my experiences to anyone who shows interest and is prepared to listen. I do this in all kinds of forums, from everyday encounters to big meetings with university students, where I go to talk about our association.

Unfortunately, my family has not been overwhelmingly supportive. I live with my mother, with whom I have quite a difficult relationship. She is overbearing, and denies any link between our family relations and my mental instability. She considers my difficulties banal, only hears what she wants to hear and plays the victim, which leads to self-stigmatization on my part. I want to improve our relationship with the help of a pedagogue–psychologist, but am somewhat doubtful of the outcome, as my mother is inclined to gossip.

I have two older brothers, who are married and have children. The older is the more considerate, but he lives in Zagreb with his family. The other one lives here in Tuzla and visits once or twice a month, when he mainly talks about his own successes and failures.
I believe much can be done to counteract the stigmatization of people with mental health problems: from the creation of affirmative expressions in Bosnian for a person who is recovering from mental distress, through the presentation to the media of positive examples of people with these problems, to the raising of awareness about the consequences of stigmatization. Having worked as a journalist for many years, I use my knowledge to criticize inappropriate reporting in the press and electronic media, for example, on suicide. I send memos to both the editors initiating the stories and the journalists writing them, to inform them about the right approach.

My work in Fenix has helped me to become aware that, although a user of mental health services, I have equal rights and responsibilities in my community. With my experience, I am useful, and there is plenty of work to do.

Today, I encounter my biggest problem with stigmatization when looking for a life partner. I do not hide who I am or what I am, and I long to fill up the empty space in my emotional life with a person who can appreciate my honesty and directness.

P.S. Since I first wrote this testimony, my life has taken many positive turns. First, I have now lived with my girlfriend for 10 months. I extended my contract with Fenix for another year, and finished my secondary schooling, which was interrupted by the war. I hope to start studying at university in the autumn.”

Response by Dr Matt Muijen, Regional Adviser for Mental Health, WHO/Europe

A central message of every story, although particularly strong in Igor’s narrative, is the split between the rich personal experience and the reductionism imposed by psychiatric treatment. Igor tells a powerful story, full of tragic and impressive experiences of family life, war, religious divide and discrimination by only his 21st birthday. To simplify Igor’s life into a label of mental illness or cripple does not do it justice, and it is doubtful whether any simplistic intervention such as medication could solve the complex consequences of such experiences on a personality. This story makes one reflect about the role of psychiatry.

What saddens me are expressions such as, “although a user of mental health services, I have equal rights”, implying that equal rights must be won, even in one’s own mind, rather than being rights. Nevertheless, Igor shows that people can demand and exercise those rights, including finding a place at university and a girlfriend.

Again, the hero of this story is Igor, who transcends all that has happened, confronting the challenges and applying his talents to great effect. I wonder whether Igor believes that these experiences have given him strength and inspiration, making him a deeper and more effective person than he would have been otherwise. I look forward to receiving a follow-up story in a year or so.

I think that until a person experiences some kind of disability, they hardly know their inner, hidden qualities. Since my mental health problems began, I have found an inner energy that was always there, but which I had no access to before. Now I use that energy for my own good and the good of my community.

I was born in 1961 in Tuzla, Bosnia and Herzegovina, where I still live with my wife and daughter. I was a soldier in the Bosnian war of 1992–1995, and experienced my first mental health problems after being seriously wounded by a grenade shell in September 1992. My prostate gland, urinary tract and intestines were damaged, as were the peripheral nerves of my right leg. I had seven operations in all, the last three in the Czech Republic, where they sent me in 1994. I still have a grenade fragment in my body.

My war wounds left me feeling anxious and distressed, and I began having nightmares and becoming disturbed by the smallest trifle. The problems grew worse and, by 1996, I had become so fearful that I could no longer go out alone. My wife had to escort me every time I left the house, I was terrified of being on my own and afraid of going mad.

At that stage, I started seeing a neuropsychiatrist, and was lucky enough to meet an understanding doctor who regarded me as a human being and not just as a patient. The fact that she did not have me admitted to a psychiatric ward but treated me as an outpatient is a key explanation to my present situation, I think. Hospitalization would have traumatized me even further but, in contrast to most of her colleagues in the region, my psychiatrist gave me individual treatment and dedicated her time to me right from the start. During my sessions with her, my strength was restored, and I regained belief in myself as a person.

But I have also been fortunate in having the support of family and friends. My wife and my daughter have played a crucial role in my recovery. During my times of hardship, they were always there for me, guiding me and giving me the strength to move on. Apart from engaging herself personally, my wife would also involve some of our friends in supporting me.

With the patience of my family and assistance from friends throughout that first year, I arrived at my present, active phase, where I am very much involved in the local mental health scene. In addition, I can boast that I have made many new friends, both privately and in my field of action.
The road has not been easy, however. Like many others I felt ashamed when I started using the mental health services, mainly because of the negative attitudes in my community (especially in the rural areas). I experienced discrimination at my workplace, where certain colleagues could not accept the fact that I was unable to work at full capacity. Along with my psychiatric problem, I have a physical disability which impedes me, and I would often hear comments like “get out of the way” or “go and see a doctor or get yourself retired”. My answer would invariably be “I shall do that when it suits me, not when it suits you”.

I am a building technician by trade but, owing to a lack of jobs in the construction sector, I was retrained as a shoemaker. After being wounded in the war, I was on sick leave until 1996, when I went back to work at the shoe factory. Because of my physical and mental disability, I could no longer work in production, however, and was given a less demanding job in a warehouse. I retained the same income as before, so in that respect I was not discriminated against. After four years I retired, since the work was too physically strenuous for me in the long run.

Since then, I have had more free time, which I use to help my wife decorate the surroundings where we live. I also try to express my culinary abilities by being active in the kitchen.

I have an invalid pension, as I was disabled in the war, which means I receive more or less the minimum monthly amount to cover my basic needs. This makes me more fortunate than most of my fellow users of the mental health services in Bosnia and Herzegovina. The majority of them do not even receive the bare social minimum.

When I began getting involved in the user movement, I must admit I had some difficulties in explaining who I was and what I represented. One experience that helped me was an informal conversation I had with the former head of Tuzla Municipality and governor of Tuzla Canton, Mr Selim Beslagic. After I had introduced myself and asked for support for my organization, Mr Beslagic told me: “You must be persistent and tug me by the shirt collar! If you want to succeed you have to be annoying!” That experience contributed greatly to the fact that I communicate freely with the decision-makers at local community level today.

The association I work for is called ‘Fenix’, or the Association for Mutual Support in Mental Distress, in Tuzla Canton. It was founded on 1 April 2000, with the support of, amongst others, the Hamlet Trust in London. For the second time running, I am the president of the Association.
Fenix advocates in favour of user interests and the empowerment of the user movement, and is known and recognized for the creation of mental health policies in our local community and beyond. With financial aid from foreign donors and support from the local community, Fenix has implemented many projects. We have our own place where our members can meet. We also own a van, a wood processing workshop and a greenhouse for vegetables. Apart from informal socializing, we offer a range of services and activities such as legal aid, art and wood processing workshops, social skills learning, and the publication of books and brochures. We cooperate with many other nongovernmental organizations, some of which have legal departments, where we may seek support.

One of our main objectives is to raise awareness about mental health and the problems encountered by mental health service users. To this end, we organize press conferences and roundtables, participate in local radio and television shows, and publish public information. Each year we mark International Mental Health Day and focus on the topics recommended by WHO. In 2007, we concentrated on an interesting topic, namely suicide prevention. We were overwhelmed by media representatives from all over Bosnia and Herzegovina who wanted to hear about our Association and the problems we live with.

The user movement is still far from developed in Bosnia and Herzegovina, however, and basic human rights are often breached. Users are gravely stigmatized by medical professionals and civil society for example, and the conditions in closed psychiatric institutions are by no means adequate. The whole community can help in fighting these discrepancies and diminishing discrimination against mental health users, but I think the crucial role should be played by the user organizations and the users themselves.

There are positive changes taking place, in my view. We can sense it in the psychiatric institutions, where there is an improved relationship between users and doctors, and the whole atmosphere is becoming more human. We need to be both optimistic and realistic, however, and accept that we cannot change the environment we live in overnight. But, since members of the user organizations have begun to talk openly about their problems, more of us have become engaged in socially beneficial activities and the issue of mental health has begun to take its rightful place in public awareness."

How can Vahid's story influence policy making for mental health?
by SEE-MH-INFO on Fri 27 Jun 2008 - 13:06

All across the WHO European Region, people with mental health problems are working to raise awareness, tackle stigma and support each other. Vahid could well be forgiven for resenting the attitudes he encountered in his fellow workers, mental health staff and the community after his war-time experiences. Instead, he used the negative messages for campaigning.

Vahid decided to set up his own campaigning organization, called Fenix (Phoenix), a very well-chosen name. The activities are strikingly positive: supporting others but also informing the public and working with the press and television. The community’s apparent receptiveness to Fenix’ activities is also impressive.

Vahid received a lot of support from his family, particularly his wife, whose great efforts kept him out of hospital. Families must cope with the tough reality of living with a mental health problem, including the stigma and discrimination. This is a success story, including the many friends Vahid made. He seems to have followed the advice to be “persistent and annoying”, and has attracted the necessary resources to create a wonderful enterprise. I hope he keeps going, and informs us about progress.


Response by Dr Matt Muijen, Regional Adviser for Mental Health, WHO/Europe
SEE-MH-INFO
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