Return of the Repressed: The Second World War and 1990s Psychiatric Debates

Yugoslavia's socialist psychiatry was indeed a rich and complex field, one that combined a large variety of theoretical approaches, engaged in brave forms of clinical experimentation, and maintained a complicated and exciting network of international collaboration. However, the socialist period was marked by an important psychiatric absence—of any sustained discussions about “war trauma” and psychological effects of the Second World War on Yugoslav soldiers and the civilian population. As we will see in the following, the immediate postwar years saw an intense psychiatric exploration of war neurosis among partisan resistance soldiers, but this brief discussion came to an end by the late 1940s and was never resumed in any systematic manner. This was surprising for many reasons, not least because the Yugoslav population was exposed to extreme violence during the war, experiencing one of the most brutal occupation regimes in Nazi-controlled Europe and a bloody civil war. Moreover, the narrative of the Yugoslav people's immense suffering and courageous and ultimately victorious communist-led resistance became the most important founding block of the socialist country's political identity and the postwar regime's core legitimizing strategy. Still, it transpired that a long and in-depth engagement with psychological consequences of such suffering did not necessarily boost the national narrative, which ultimately focused on triumph, perseverance, and courage rather than distress and mental breakdown.

In 1971, Slovene psychiatrist Janko Kostnapfel spoke about the tasks and achievements of war psychiatry in peacetime and wartime at the Third Congress of Yugoslav medical doctors. In his introduction, he made a passing reference to the lingering psychological effects of the Second World War among his patients: “Memories of the horrors of the last war are still very fresh. From our patients of younger and middle generations we hear often horrible stories about the war every day.” Kostnapfel concluded that this was not at all surprising given that Yugoslavia lost about 10 percent of its prewar population, or about 1.7 million people: “Just that number tells us about the emotional difficulties of their surviving family members.”Footnote ⁴ What was surprising, however, was that Kostnapfel's reference was one of the very few mentions of any war-related emotional distress of the Yugoslav population among socialist psychiatrists. But even this extremely rare allusion to the problem was rather brief: Kostnapfel quickly moved on to discuss war psychiatry in more general terms, noting that the “negative social consequences” of the war appeared to be much worse in the rest of the world. Despite this scarcity of information, Kostnapfel's presentation offered an important (and unprecedented) insight into the workings of Yugoslavia's postwar psychiatric clinics: they were reportedly inundated by traumatic narratives of the Second World War and by patients who were still experiencing severe war-related psychological distress. But if that was the case, why wasn't there any public discussion of this pervasive issue? Why did Yugoslav psychiatrists not publish on their research into the psychological consequences of the war and their approaches to therapy and healing? Although these questions remain difficult to answer, it did appear that the socialist narrative of glorious war victory and subsequent revolutionary transformation did not easily incorporate individual and collective accounts of loss, suffering, and psychological distress. Even though Yugoslavia's “psy” professions were so systematically involved in transnational expert networks throughout the Cold War, the country played virtually no role in the international discussions on violence and traumatization from the 1960s on, and in that respect, it was no different from the rest of the socialist bloc.

In the aftermath of World War II, Yugoslavia was a ravaged country: its human and material losses at the end of the war were higher than in any of the warring countries except for Poland and the USSR. Years of brutal occupation and an even more brutal civil war, fought on ethnic and ideological grounds, left the economy in ruins, so that the immediate postwar period was marred by the scarcity of basic foods, materials, and housing options. Even more devastating than material destruction was the tremendous psychological impact of the war: there was hardly a family untouched by the mass murder and incarceration of civilians, and, well into the postwar years, many were still waiting for information on their loved ones. Tens of thousands witnessed unprecedented crimes and cruelty.Footnote ⁵ And yet, the country's flourishing psychiatric—and psychoanalytic—profession had very little to say about possible long-term psychological effects of such extreme violence, personal loss, and dislocation. At the first postwar Yugoslav neuropsychiatric congress in 1946, leading Croatian psychiatrist Bosko Niketic briefly acknowledged the immense psychological suffering (“much sadness, worry, uncertainty and fear”) to which the country's population had been exposed and enumerated the unspeakable atrocities many had witnessed—“mass shootings, hangings, slaughters … loss of almost all family members, and waging a resistance war in the most difficult circumstances imaginable.” Nevertheless, Niketic concluded his discussion of such harmful psychological disturbances and their possible consequences in the very next sentence, stating that, fortunately, the Yugoslav peoples had “persevered in their struggle” despite their suffering and that all their mental anguish had been “crowned”—and presumably cured—by the ultimate triumph of the anti-fascist forces.Footnote ⁶ Niketic and the other congress speakers then proceeded to discuss Yugoslavia's peacetime psychiatry and its future tasks.

There was, however, one particular form of mental illness that did receive more substantial public, political, and psychiatric attention because it affected the military. Toward the end of the war, the resistance army was plagued by an unnerving and mysterious phenomenon, referred to as “partisan neurosis” or “partisan hysteria,” which required collaboration with psychiatrists and psychotherapists knowledgeable about the concept of “war trauma.” The Yugoslav form of soldiers’ neurosis was soon discussed in terms of national and ideological exceptionalism: most psychiatrists and military doctors who encountered it defined it as a uniquely Yugoslav psychological disorder, fundamentally different from instances of battle exhaustion and anxiety common in the British and US armies. It was only diagnosed in communist resistance soldiers and was indeed the opposite of battle fatigue or any kind of demoralization: “partisan hysteria” was not an expression of the soldiers’ desire to withdraw from the frontlines (it appeared only at the very end of the war, once the most dangerous and deadliest battles had been finished), but in fact reflected the affected partisans’ exceptional commitment to their war tasks, their heightened willingness to fighting. The new disorder consisted of violent and potentially harmful epileptiform seizures that simulated wartime battles and attacks. The seizures could occur at any moment and under any circumstances, usually when there was audience—in the middle of a conversation, at lectures or meetings, while driving or riding a car, or in front of superiors, for example.Footnote ⁷ Two of Yugoslavia's leading interwar psychiatrists and psychoanalysts, Hugo Klajn and Stjepan Betlheim, were charged with running a clinic that specialized in caring for mentally distressed former partisans in the erstwhile psychiatric hospital in Kovin, in northern Serbia. This experiment ended quite quickly and unceremoniously, as Klajn and Betlheim could not handle the reportedly aggressive and increasingly unruly behavior of their patients, many of whom refused to obey authority or even give up their weapons and wartime mores.Footnote ⁸

Given its public, performative, and highly disruptive character, “partisan hysteria” attracted a lot of attention at the end of the war, and 1945 saw a flurry of psychiatric publications on the topic, including by Klajn and Betlheim, as well as a host of military doctors and psychiatrists. But after this initial surge of psychiatric (and political) interest, the theme of “partisan hysteria” all but disappeared from psychiatric journals and monographs. Klajn's book on the topic was shelved for ten years (considered suspicious for its “Freudianism” but arguably also because it zoomed in on severe psychological disorders and emotional difficulties of members of the victorious and heroic resistance army), and only came out in 1955, by which time Klajn had left clinical practice.Footnote ⁹ In 1957, a group of Zagreb-based psychiatrists, led by Betlheim, conducted a follow-up study of wartime neurotic patients, aiming to inquire into their adaptation to civilian life in the course of ten or so years after the end of the war. The psychiatrists concluded that in the majority of cases the former partisans had suffered from “superficial neurosis” that did not harm deeper layers of their personality, and consequently they faced no larger problems reintegrating into the postwar society.Footnote ¹⁰ In other words, “partisan hysteria” did not seem to have left any deeper wounds in Yugoslav society: the former neurotics apparently shed their neurotic condition fairly quickly and were able to adapt to the peacetime circumstances without major disturbances. Kostnapfel reiterated this view, dedicating three sentences to this major challenge for postwar psychiatry and concluding that only 1 percent of Yugoslav soldiers succumbed to neurosis in 1945.Footnote ¹¹ By the end of the 1950s, “partisan hysteria” was thus completely cured, and it was reportedly far from a widespread phenomenon to begin with. There consequently appeared to be no reason to think of Yugoslav partisans in terms of war trauma or psychological distress.

At the 1946 congress, psychiatrist Nikola Nikolić recognized the need for a new social psychiatry to help Yugoslavs make sense of the extraordinary deprivations, grief, and agony caused by the war.Footnote ¹² Although Yugoslavia did develop a formidable discipline of social psychiatry, this profession largely focused on other issues and did not fulfill the mission set out for it at this early meeting. However, Yugoslavia's postwar psychiatrists unfortunately got other opportunities to engage with the problem of war-related psychological stress in their clinical practices. In the late 1980s, Yugoslavia went through a series of political and economic crises, as the political leaderships from its six republics attempted to agree on a plan to reform and reimagine the federation. In 1990, both Slovenia and Croatia held national referenda at which a vast majority voted in favor of independence. Bosnia's independence referendum followed in 1992 with similar results. In the spring and summer of 1991, a series of conflicts broke out between the local Slovene and Croat territorial defense and police units on one side, and the Yugoslav People's Army on the other.

The Yugoslav People's Army, which intervened to prevent secession, increasingly came under the influence of the Serbian political leadership, quickly lost its multi-ethnic character, and was pitted against the other republics. In Croatia and Bosnia, the local Serbian populations refused to accept the referendum results and, encouraged and supported by the Serbian leadership, staged armed rebellions.Footnote ¹³ On Bosnian soil, this turned into a brutal conflict, in which the Bosnian Serb army, in particular, targeted non-Serb civilians with some of the most gruesome forms of violence, including the first genocide on the European territory since the end of the Second World War.Footnote ¹⁴ The wars of Yugoslav succession generated hundreds of thousands of civilian refugees and displaced persons; Bosnian Muslim civilians headed to relative safety in Croatia, Croats from the Serb-dominated territories were forced to leave their homes and find alternative accommodation, and a large number of Croatian Serbs were expelled to Serbia at the end of the conflict.

Yugoslav mental health clinicians were thus the sole generation of European psychiatrists who engaged with the problem of “war trauma” twice in their professional careers. In 1993, Belgrade's flagship Institute for Mental Health marked its thirtieth anniversary under less than auspicious circumstances. On that occasion, one of its leading psychiatrists, Jovan Bukelić, noted that the institute was first established with the help and support of the Yugoslav WWII veterans’ associations “in order to help soldiers from the Second World War get over their invisible but grave psychological wounds.”Footnote ¹⁵ Bukelić thus explicitly linked the institute to the psychiatric challenges of the Second World War, and, moreover, established a direct relationship between the two conflicts fifty years apart, as he emphasized that “history was repeating itself” and that the institute was once again setting up centers for dealing with war-related stress and trauma all over Serbia. Importantly, the institute's war-related origins had been rarely discussed in public throughout the socialist period, and it was not in any way obvious from its publications, research, and clinical projects that its work had been focused on treating the Second World War's emotional and psychological aftermath. In the 1990s, however, Bukelić spoke about the “holy duty” of psychiatrists to help cure the tragic effects of wars on vulnerable populations and effectively reformulated the institute's mission in terms of its supposedly long-standing engagement with postwar trauma.Footnote ¹⁶

This was also when interest in Klajn's and others’ research on partisan neurosis resurged: the 1990s saw a continuation of the discussion of Yugoslav soldiers’ neurosis from the 1940s in both Serbia and Croatia, as Klajn's and Betlheim's work was recontextualized in the brutal circumstances of the wars of Yugoslav succession. In my interviews with Nevenka Tadić, Ksenija Kondic, and Svetomir Bojanin in 2014, I asked each of them about their professional engagement with the concept of war traumatization among the civilian population at the beginning of their careers in the 1950s and 1960s.Footnote ¹⁷ They all responded that this was not something that preoccupied them at the time, other than indirectly through their work with orphans homed in state institutions. But whenever I raised to the issue of possible psychological effects of the Second World War on their patients, these experienced psychiatrists brought our conversations to the 1990s wars instead: it was in that moment, rather than in the aftermath of 1945, that they were called on and had an opportunity to work on war-related emotional distress and psychological trauma among refugees, children, and survivors of torture and imprisonment. It was then, as well, that the immediate post-1945 research on “partisan neurosis” attracted substantial professional attention, nearly fifty years after the fact.

In the early 2000s, reflecting on his experience of working with Serbian refugees from Croatia who were forcibly mobilized upon their arrival in Serbia in 1995, a young Serbian psychoanalyst and psychiatrist, Vladimir Jović, referred to Klajn's rather sensitive and “complex” writings. According to Jović, Klajn's explorations provided an invaluable guiding light for interpreting war trauma of the 1990s: “Following the end of the recent wars [in Yugoslavia], military psychiatrists could say that Klajn's understanding of war neurosis was of tremendous help.”Footnote ¹⁸ Moreover, for the first time since the late 1940s, the Yugoslav psychiatric community now started considering the contributions of other participants in the post-WWII discussion about war trauma or “partisan hysteria.” Klajn's nuanced and understanding analysis was juxtaposed with military psychiatrist Josip Dojc's much harsher take on the affected partisans’ medical and moral status. As Jović reported, Dojc conceived of the war traumatized in rather narrow terms—as either “hereditarily burdened” neurotics or simulants. Instead of therapy, Dojc recommended “most energetic disciplinary and pedagogical measures.”Footnote ¹⁹ For Jović and his colleagues, Klajn's interpretation certainly appeared much more relevant, not only because of its much more empathetic approach but also because it primarily relied on psychoanalytic insights to make sense of the Yugoslav soldiers’ mysterious condition. It was indeed so helpful that a 1994 edited volume on war psychiatry and psychotherapy, Stresses of War, inspired by Serbian psychiatrists’ experiences of treating traumatized soldiers and survivors of the 1990s war, reprinted the most important sections of Klajn's discussion of WWII partisan neurosis.Footnote ²⁰ For the authors of the volume, parallels were obvious and self-explanatory.

In Croatia, leading psychiatrist and coordinator of the national mental health section during the 1990s war Eduard Klain published his reminiscences about Hugo Klajn on the occasion of the latter's death in 1996 and reprinted an interview he had conducted with the esteemed Belgrade psychoanalyst in 1975. In his recollections, Klain insisted on drawing direct parallels between 1945, when Hugo Klajn worked with Yugoslav partisan soldiers, and 1995, when Eduard Klain handled the mental health difficulties of Croatian soldiers and other war-affected sections of the population. According to Klain, even though the two of them had to deal with very different types of government, “neither regime considered working with war-traumatized soldiers with benevolence.”Footnote ²¹ In the immediate aftermath of World War II, Klajn was given ample resources to develop a specialized ward for “partisan hysterics” and encouraged to practice psychoanalysis, but his resulting monograph—still a landmark study of war trauma in Eastern Europe—was published with a staggering ten-year delay because it was not immediately approved by the ideological commission of the Communist Party's Central Committee. According to Eduard Klain, the problem with the monograph was only partly in its “Freudian” approach, which was ideologically questionable in 1945. The extreme political sensitivity of psychiatric work with victorious soldiers was an equally important issue: “Both then and today it was widely considered that our warriors were heroes who could not possibly have psychological difficulties.” Apparently hinting at his own more recent problems with authorities, Klain added that “people who used to stand for certain ideas … tend to change completely when they come to power.”Footnote ²² It is unclear whether Klain felt politically constrained in any way in his attempts to publish on Croatian soldiers’ experiences and treatment of war trauma, but his belief that his and Hugo Klajn's situations were comparable was truly striking, especially given the widely divergent ideological contexts of 1945 and 1995. In any case, Croatia's leading psychoanalytic journal Psychotherapy followed Eduard Klain's piece and interview with Hugo Klajn with an English-language selection of excerpts from the latter's book. This was the first time the monograph was discussed in Yugoslav psychiatric literature since 1955 and the first time it had ever been translated into English for international audiences.

There were other, more concrete continuities between the 1940s and 1990s. It was not only that psychiatrists suddenly started discussing the Yugoslav theories of and research on the psychological effects of the Second World War. In some cases, WWII-related distress entered psychiatric encounters and consulting rooms much more directly and literally. In 1992, Vlado Jukić and Vasko Muacevic presented a case of a sixty-four-year-old patient, whom they diagnosed with PTSD in December 1991, but the diagnosis was based on the patient's participation in the Second World War (given he did not take part in any military activities in 1991). Namely, he joined the partisan resistance army in 1941 and experienced a series of highly distressing events that included imprisonment, torture, and mock execution. After that, the patient suffered from a number of psychological difficulties throughout the 1950s: “insomnia, fear, anxiety … dark, depressive thoughts, forced memories of wartime horrors,” and so forth. The most persistent symptom was a dream, in which the patient had to relive the mock execution. After intense psychotherapy in Zagreb, however, all these emotional struggles reportedly disappeared, only to get “reactivated” twenty-eight years later, when the war in Croatia began in the summer of 1991.Footnote ²³

According to Jukić's and Muacevic's description, the dream was the first symptom to return, accompanied by familiar feelings of hopelessness, anxiety, and “betrayal.” Importantly, the psychiatrists emphasized the political aspect of this PTSD reactivation: the patient reported that he “felt particularly bad when he looked at the former military barracks, which he used to visit in the past,” but which now became the symbol of the Serb-controlled Yugoslav People's Army and its aggression against Croatia. The patient apparently also felt the need to emphasize that his renewed psychological distress did not come out of any “nostalgia for the past, nor fear of the new non-communist authorities [in Croatia] (he used to be a communist, and head of the WWII veterans’ association).”Footnote ²⁴ These final political remarks served as a conclusion of sorts, as the authors added no further analysis to the case presentation. But the sense of psychiatric and diagnostic continuity between the two wars was striking: this patient's condition was seen as no different from any other cases of PTSD in soldiers who took part in the 1991 war (and, in fact, his case presentation was preceded by a much more “regular” case of a young active policeman who experienced “combat stress reaction” following a close encounter with enemy soldiers)—only its exceptional “chronicity” set it apart. But in this way, the psychiatrists constructed the patient as a loyal Croatian partisan, who, even though he used to be a communist and member of the old Yugoslav People's Army, was indeed no different than the Croatian patriots defending their state in 1991. The diagnosis of war trauma or, more universally, PTSD thus served to reconcile two different ideological poles within the Croat nation: the patient noted in the end that he was now the head of a new veteran association that included all Croatian soldiers, both partisans and home guards, who fought on the Axis side in World War II.

PTSD and National Legitimation Strategies

The outbreak of the war in Yugoslavia appeared to have given an impetus to psychiatrists to start discussing recent developments in international classification systems in their field and to comment rather extensively on the current diagnostic standardization trends in psychiatric epidemiology. The sudden appearance of PTSD in psychiatric and political discussions in the early 1990s prompted a large number of specialist articles explaining the historical development of the diagnosis and its criteria, and the political struggle for its inclusion in the American Psychiatric Association's DSM-III in 1980. Although Yugoslav psychiatrists seemed to be superficially familiar with the description of and discussions about PTSD in the US context (as it was further developed in the revised version of DSM in 1987), their clinical practice was formally guided by an alternative diagnostic and classification system, the WHO's International Classification of Diseases (ICD), which only included PTSD as a separate nosological entity in its tenth edition in 1990.Footnote ²⁵ For those reasons, it appeared that both the lay public and the psychiatric profession needed more expert guidance when it came to understanding and diagnosing PTSD, as well as developing appropriate therapeutic strategies.

As Vlado Jukić noted in one of his articles in 1992, the meaning and relevance of PTSD were rather vague for most of the Croatian public until 1991, but he could already predict then that this would become the country's most serious psychiatric problem.Footnote ²⁶ Other psychiatrists discussed the DSM's and ICD's comparative strengths and weaknesses, but noted the importance and reliability of such international efforts at standardization and universalization, which made particular diagnoses and clinical treatments valid in different cultural contexts. At this time, it was particularly important for the Yugoslav psychiatric profession to emphasize its (thoughtful) acceptance of and participation in these global trends, by contributing to such critical professional discussions. For a group of experts used to such intense international collaboration, the imposed isolation of the war years presented an added frustration, and they invested significant efforts in maximizing their international reach and maintaining their professional contacts outside of Yugoslavia. But the intensification of their discussions of international standardization strategies at this time served another purpose: internationally recognized psychiatric entities and diagnoses validated national suffering in transnational circles and lent it scientific legitimacy. Serbian psychiatrist Marko Munjiza argued in 1994 that universal and standardized classification systems such as the ICD played a crucial role in developing a psychiatric lingua franca, which enabled “different interested parties … to understand each other, share experiences and join forces” in their efforts to improve the treatment and outcome of mental illness.Footnote ²⁷ In the context of the wars of Yugoslav succession, such goals assumed even greater significance, as the Croatian and Serbian sides, in particular, vied for the status of the victim and the international language of psychological trauma was used to substantiate such claims.

As Goran Dokić demonstrated in his interviews with Croatian psychiatrists, before 1991 PTSD was considered an “exotic disease” only encountered in textbooks and theoretical discussions. But with the start of the wars in the 1990s, both Bosnia and Croatia became prime sites for humanitarian psychiatry and international trauma advocacy and intervention programs.Footnote ²⁸ By 1994, there were already 185 such projects operating in the two countries, and a range of international humanitarian aid agencies tasked with the protection of refugees and civilian war victims developed and funded extensive psychological counseling programs for war-affected populations.Footnote ²⁹ In framing their own psychosocial involvement in the wars of Yugoslav succession, these international actors promoted PTSD as an unproblematic, largely context-less and cross-culturally applicable medical concept.Footnote ³⁰ But if the involved international aid organizations and programs conceptualized their PTSD interventions as a depoliticized expert field, the development of subsequent local discourses of war trauma in both Croatia and Bosnia was deeply shaped by, and reflected, the complex politics of war memory and national legitimation. Croatian psychiatrists rarely commented on these developments in their own writings during the 1990s—other than to note when they took part in some of these internationally funded projects—but several of Dokić's interviewees, both psychiatrists and psychiatric nurses in Croatian clinics, unofficially expressed concerns over the profession's increasing reliance on the concept of PTSD. These concerns, however, were primarily related to possible political abuses of the diagnosis or its ability to retraumatize veterans and keep them in the patient role, whereas very few addressed the issue of its cultural appropriateness in the Croatian context—possibly a sign of how well integrated Croatian psychiatry was in the universalist paradigm of late-twentieth-century global psychiatry.

In Croatia, the political usefulness of turning to the DSM and Western trauma discourses became clear early on. According to Dokić's ethnographic research in Belgrade, Serbian veterans of the 1990s believed that their Croatian and Bosnian counterparts were in a much more enviable position and that their status in post-socialist Croatia resembled much more clearly that of much celebrated post-WWII Yugoslav partisan soldiers.Footnote ³¹ Indeed, veterans of the Homeland Defence War, as the conflict was officially termed in Croatia, received symbolic and material benefits that were unparalleled anywhere else in the post-Yugoslav context.Footnote ³² The numbers of Croatian veterans who claimed disability pensions, in large part on the basis of the PTSD diagnosis, rose throughout the 1990s during the leadership of the nationalist wartime president, Franjo Tudjman. But this trend did not change with Tudjman's departure in 2000; quite to the contrary, the first decade of the new millennium saw the most dramatic leap in approved veteran pensions.Footnote ³³ In fact, in 2000 the Croatian Ministry of Defence commissioned and published a report about the incidence and most important features of PTSD among Croatian soldiers, concluding that as many as 40 percent of veterans could be suffering from some form of PTSD and that the existence and availability of effective programs of professional psychosocial support had a decisive role to play in lowering this figure.Footnote ³⁴ Disabled Croatian veterans, moreover, have had a more inclusive benefit package than their counterparts in Germany, the United Kingdom, the United States, and Israel. Their pensions have remained higher than Croatian citizens’ average income, and they have enjoyed a long list of additional privileges, such as “health insurance rights, education allowances, priorities related to university enrollment,” and so on.Footnote ³⁵

Just as socialist Yugoslavia used official histories of the partisan resistance movement in the Second World War as its core strategy of political legitimation, the nationalist account of Croatia's victorious defensive war against Serbian aggression became the foundational narrative of the post-socialist Croatian state. Croatia's Homeland War veterans, therefore, assumed their natural place in the pantheon of national heroes and were celebrated by successive political governments that sought to nurture their loyalty and support. As Vanessa and Mladen Pupavac have noted, attempts to limit the resources spent on veteran pensions, or to make the process more transparent, have on the whole not been successful, and they remained a risky political strategy.Footnote ³⁶ It is the status of war veterans as proclaimed founders of the newly independent Croatian state that made the concept of war trauma and the diagnosis of PTSD so important and prominent in Croatia's political circles. It was this global paradigm of trauma and traumatization that made it possible for Croatia to protect the key constituency of veterans from the internationally imposed demobilization and cuts to the state's military budget.

However, the explicit politicization of PTSD, multiple contradictions within the national narrative of traumatized soldiers, and mounting concerns about corruption and abuses in the veterans’ pension system complicated this discourse. Mental health professionals were still markedly uneasy about the obvious and increasing entanglements between the medical diagnosis and political rhetoric, and they observed how the medicalization of veterans’ social and economic problems could easily lead to retraumatization.Footnote ³⁷ Even those psychiatrists close to the government could express ambivalent attitudes toward soldiers diagnosed with war-related psychological problems.

In the 1990s, the earlier disagreement between Hugo Klajn and Josip Dojc was replayed, albeit in more moderate terms. On the one hand, in the Croatian public discourse, the diagnosis of PTSD (and other war-related injuries) was treated with significant respect.Footnote ³⁸ The foundational narrative of the newly independent post-socialist Croatian state, after all, rested on the military commitment and achievements of these men, as well as on the wartime suffering of Croatian civilians. On the other hand, there were very influential voices in Croatian psychiatry who reminded the public that “premorbid personality” was an extremely important factor in the emergence and persistence of pathological reactions to stress. Vlado Jukić concluded in 1993 that “according to multiple indicators, a great majority of the psychotraumatised in this war will not develop PTSD, despite having experienced traumas which went beyond ‘common human experience,’” while those who did develop PTSD symptoms would be able to overcome them within six months.Footnote ³⁹ Even though he did note that “more grave stressors led to chronic forms of PTSD,” he still argued that “predisposition” was central to the gravity of the clinical picture of PTSD and to more serious impairments in patients’ social functioning. In other words, PTSD was decidedly not a normal person's reaction to abnormal circumstances. After all, “almost 80% of patients with PTSD fulfil the criteria for at least one or two additional psychiatric diagnoses.”Footnote ⁴⁰ In that sense, PTSD for Jukić always likely signified an already psychologically impaired personality, especially if the symptoms were serious, socially disruptive and long-lasting, and marked by the patient's general maladaptation.

Moreover, like Dojc, early in the war Jukić was also concerned about the highly harmful phenomenon of “rent neurosis” among Croatian soldiers and cautioned his colleagues about those “veterans” who might claim to suffer consequences of wartime suffering without ever having taken part in the war (he referred to this as “Munchausen syndrome”).Footnote ⁴¹ In fact, if soldiers with PTSD were not deemed constitutionally “burdened,” their clinical diagnosis could still betray deeper issues with their personality and ethical value system. Early in the war, Jukić and psychoanalyst Eduard Klain warned that PTSD would likely be the most common disorder among those soldiers who, at least subconsciously, experienced ambivalence regarding their participation in the war. Writing about soldiers with physical wounds and their psychological attitudes toward their impaired condition, they identified one type of reaction, which was reportedly extremely rare—“feelings of relief and exceptional satisfaction … for not having to return to the frontlines.” It was from the ranks of such soldiers—who looked forward to escaping fighting and possible death without being deserters or malingerers—that “war neurotics were most commonly recruited.”Footnote ⁴² Therefore, suffering from PTSD and “war neurosis” could indicate a soldier's lack of commitment—a conclusion decidedly not in line with the international (particularly US) diagnostic tendencies and interpretations. On the other hand, Jukić continued in the tradition of a significant group of Yugoslav military psychiatrists; at the end the Second World War, Dojc mockingly referred to partisan neurosis as Auslands-mania because those soldiers diagnosed with war neurosis were initially evacuated to the liberated territory in Italy, behind the partisan frontline. For Dojc, there was little to the concept of war neurosis than these pusillanimous soldiers’ desire to remove themselves from difficult battles.Footnote ⁴³

In a similar vein, other psychiatrists wrote of Croatian veterans’ resistance to treatment and healing, and identified their “need for compensation” as an important obstacle to therapy. Such a need was reportedly generated by “narcissistic regressive” personality changes in some veterans, who demanded “admiration and all their requests to be fulfilled.” Although this reading certainly did not dismiss veterans’ psychological disorders as malingering, it partly relied on Dojc's and Jukić's interpretations, and the authors warned that veterans’ narcissistic expectations and interests could affect therapists as well as the broader society and governmental institutions, and lead to veterans’ continued dependence on others (as was arguably already happening in postwar Croatia).Footnote ⁴⁴

This complex and ambivalent discourse about Croatian soldiers’ PTSD revealed a major tension in Croatian psychiatric discussions about the psychological consequences of the war. On the one hand, there was a strong politically motivated tendency (and pressure) to view soldiers who fought in the 1990s war as heroes of almost superhuman courage and commitment (as Jukić testified, wounded soldiers most often burned with desire to go back to fighting).Footnote ⁴⁵ On the other hand, PTSD was an extremely useful and internationally recognized concept to document the enormous suffering inflicted on the Croatian society by the aggressors. Perhaps better than any other individual debate, clinical and political discussions around PTSD demonstrated a fundamental contradiction at the heart of Croatia's official war narrative: a clash between its self-perceptions as a victim and as a glorious victor. As James Gow and other researchers have noted, Croatia sought to gain international legitimacy, sympathy, and support by presenting its state institutions and population as victims of the “barbaric” Serbian aggression.Footnote ⁴⁶ In that sense, the globally accepted framework of trauma and PTSD was perfectly appropriate to validate such claims of national victimhood and (well-documented) suffering, and it consequently permanently reshaped Croatian psychiatry. Domestically, however, the Croatian wartime and postwar government tended to eschew victimhood narratives and instead justified its own claim to power by fostering national pride in Croatia's incontestable political and military triumph in the war. Veterans embodied this irresolvable contradiction: their status as invincible national heroes was often undermined by their position as medical (even worse—psychiatric!) patients. Jukić's writings, in particular, seemed to demonstrate these unspoken contradictory assumptions very well. Moreover, given that PTSD was defined and developed in the context of the US military defeat in Vietnam, and was primarily used to describe and diagnose soldiers who, from the perspective of the American psychiatrists who designed the classification, fought an unjust and unethical war, it is surprising that it was so wholeheartedly accepted by the Croatian medical establishment. PTSD was in an important sense entirely inappropriate for the postwar Croatian medical and political context, in which the righteousness of the Croatian war effort and the virtue of Croatian soldiers could rarely be questioned.

Despite their extremely privileged and honored social position, therefore (or precisely because of it), Croatian veterans hardly evoked exclusively positive reactions, and critical discourses could take different forms. It seemed that, just like in 1945, the psychiatric encounter with war-traumatized soldiers from the 1990s wars was comparably explosive and volatile. Hugo Klajn and Stjepan Betlheim raised grave concerns about their own and their patients’ safety at the military-hygienic center in Kovin in 1945 because some partisan hysterics refused to disarm and also reportedly stole and hid knives from the hospital kitchen to assault the psychiatrists.Footnote ⁴⁷ In 1990s Croatia, psychiatrists soon started writing about the increased potential of soldiers with PTSD to cause disruption and physical violence, and exacerbate general social relations by refusing to obey medial and state authorities. Such concerns over the aggressiveness and volatility of traumatized soldiers replicated the post-WWII anxieties over the unstable figure of a neurotic hero. As many psychiatrists testified, wartime Croatian hospitals were indeed potentially dangerous places, not because they could have been attacked by the enemy forces but because of some of the ill soldiers’ reactions. At the beginning of the war, many soldiers experienced severe reactions of anxiety, fear, and panic that they would not be physically safe in the hospital and refused to give up their weapons while receiving treatment. This resulted in an explosive situation, in which anxious soldiers kept their weapons in hospital rooms, and “there was great resistance” to the order that arms could not be brought into medical institutions.Footnote ⁴⁸ Moreover, “the wounded insisted that only ‘reliable and tried’ colleagues—volunteers and professional soldiers of the Croatian Army—should guard them.”Footnote ⁴⁹ This was reportedly a drawn-out, uncertain, and intense conflict, certainly reminiscent of the post-WWII situations in Yugoslav hospitals, where psychiatrists such as Nadezda Jevtic, at Belgrade's neuropsychiatric hospital, Laza Lazarevic, blamed partisans for wreaking havoc on the hospital order and putting everyone's lives in danger.Footnote ⁵⁰

As psychoanalyst Muradif Kulenović noted in 1996, “The socially most intrusive patients are those with war-related wounds … the most challenging and difficult problem remains the case of active war participants diagnosed with PTSD, who, due to the nature of their illness, most often cause grave misunderstandings, uncontrolled aggressive incidents, and at times physical assaults on medical staff.” Kulenović recounted a colleague's experience with such a soldier in a local hospital in a Croatian small town. The soldier, who was permanently physically injured in the war, returned home and received adequate material help as well as medical care, but refused to be seen by any medical doctors and never came to the hospital himself. Instead, he demanded that a variety of analgesic (pain-relieving) medications be prescribed and delivered to him without any medical examinations or reviews. When a new doctor arrived, she initially refused to keep up this regime and demanded to see the patient first. After that, the patient visited her once in the hospital and threatened to kill her with his rifle “from his room, which was right across from her consulting room.”Footnote ⁵¹ It is also striking that Kulenović's language when referring to this soldier was also, perhaps unintentionally, mirroring the post-WWII discourses of partisan hysterics. Namely, Yugoslav psychiatrists of the 1940s increasingly concluded that “partisan neurosis” was almost exclusively diagnosed in very young, uneducated, and immature (“primitive”) soldiers, who used it to express their frustration with peacetime requirements and limitations. Although Kulenović's reading was less ideologically complex, he did emphasize the “backward nature” of the patient's home region, which was then reflected in his attitudes and educational levels: “the patient came from the interior of Croatia, which is less economically developed and backward in a social and cultural sense.”Footnote ⁵² Moreover, the patient was indeed very young, only in his twenties well after the end of the war, so he was in many ways reminiscent of the figure of the partisan hysteric from fifty years ago.

This inability of many veterans to control their aggressive impulses and establish a productive therapeutic relationship with their psychiatrists was emphasized time and again in postwar Croatia. Veterans with diagnosed PTSD increasingly became a highly problematic and disruptive presence both in a variety of social contexts and in therapeutic settings. Vedran Bilic wrote of a patient who “hated his wife so much that he constantly plotted her murder” but refused to get treatment for this destructive relationship. Another veteran nearly strangled his wife after an argument—he reportedly described in some detail how her face “had gone blue”—the woman was saved only after their daughter intervened, while others declared seemingly proudly in group therapy that their wives and other family members were afraid of them and did not dare criticize them in any way.Footnote ⁵³

Importantly, as we will see in what follows, the corresponding literature on PTSD among Serbian veterans rarely discussed former soldiers in similar terms, as potentially aggressive and disruptive patients and citizens, and only addressed this issue in general terms. Serbian psychiatrists and a number of politically progressive NGOs in fact wrote about Serbian soldiers as victims of the state's neglect, and any tendencies to aggressive or disruptive behavior were coached in terms of victimhood, lack of systemic support, and the consequent inability of veterans to readapt to peacetime circumstances.

“Trauma” and Erased Memories of the War in Serbia

According to Zeljko Spirić, a psychiatrist based at the chief Belgrade military hospital and editor of a rather extraordinary collection of psychiatric essays on Serbian 1990s veterans’ war trauma, this 2008 volume was the first Serbian publication to explore specifically psychological disorders of Serbian soldiers who took part in the wars of the Yugoslav succession. Although there were other monographs and articles that addressed the concept of PTSD in general terms, or the psychological difficulties of children, refugees, or torture victims, they generally strove to maintain the focus on civilians’ wartime suffering—perhaps because this topic was significantly less controversial and more likely to elicit universal agreement and sympathy. Military veterans and direct participants in the wars in Slovenia, Croatia, Bosnia, and Kosovo, on the other hand, assumed a much more complex and awkward position in Serbian society and public discourse. Their own status, social support, and any material benefits they were likely to draw from their years of military service were directly related to the Serbian society's collective memory of the wars and the political leadership's preferred memory narratives. But because Serbian government officials as well as leaders of the right-wing nationalist opposition maintained throughout the 1990s that the country never took part in the wars, the position of veterans who needed mental health care became increasingly complicated. Moreover, the outcome of the wars—negative from the official Serbian point of view—made their situation even more difficult. As Spirić noted in his analysis, “In a majority of (victorious) states, veterans enjoyed public support and sympathy, served as an important source of national pride, and were glorified.” On the other hand, in Serbia, veterans from the 1990s became an unwelcome reminder of the national defeat (which was never officially proclaimed as such) and an “obstacle to the process of forced repression of the [collective] memory of war losses.”Footnote ⁵⁴

Spirić described Serbia's official disregard of its war veterans as akin to the behavior of defeated states throughout the twentieth century, and this was one of the rare moments when Serbia's participation in the wars was referred to as an outright defeat. As Spirić and his fellow contributors suggested, postwar Serbia was a troubled society that never declared either victory or defeat, never even recognized its own participation in military activities in neighboring states’ territories, and, even more importantly, never articulated its political (and ethical) attitude toward its soldiers’ wartime behavior. This final concern was perhaps the most important: Serbian veterans were also perpetrators of some of the gravest war crimes (including genocide) on the European soil after the Second World War, and a more involved political and psychiatric debate on the psychological consequences of the war would need to at least in part reflect on this highly uncomfortable fact. As Serbian journalist Ljiljana Mitrinović argued, “It has not yet been said [in Serbia] whether this war, for whose victims we are supposed to build a monument, was a war of aggression or a defensive war; who the heroes and criminals are; whether it has been worth it…. We live in a country in which we are increasingly forced to listen to the truth from others because we don't want to speak about it ourselves.”Footnote ⁵⁵ Quite shockingly, it was only in 2007 that the Serbian Ministry for work and social politics approved the first research project aimed at evaluating systematically the mental health status and needs of war veterans from the 1990s in order to (finally) design a long-term health-care plan for this population.

In fact, the exact number of war veterans has not yet been ascertained in Serbia—researchers who engaged with this problem have estimated that there could be anywhere between 400,000 and 800,000 former soldiers.Footnote ⁵⁶ The state's marked disinterest in counting and recording the names of all participants in the wars of Yugoslav succession was further reflected in most veterans’ inability to claim social security support and any material benefits except in a small number of cases when long-term medical disability was medically proven. Moreover, for many disillusioned veterans, the glaring absence of symbolic acknowledgment was even more harmful, as the entire political leadership that entangled the country in a series of wars now renounced its responsibility for both the conflicts and those who fought in them: “Contrary to the general opinion that veterans were only interested in material rewards, most veterans’ narratives revolved around the loss of dignity and the lack of any symbolic recognition.”Footnote ⁵⁷ According to Dokić, who conducted interviews with members of a veterans’ association in Belgrade, one of his interviewees admitted that he felt ashamed of his veteran status and felt very clearly that “everybody despises us.”Footnote ⁵⁸ As Belgrade psychoanalyst Branimir Stojanovic noted, “Veteran is another name for absolute exclusions and invisibility … as long as veterans’ status remains unrecognised, the state will be able to pretend there were no wars.” For that reason, Dokić was also able to conclude that “when compared to Croatia, PTSD was practically non-existent” in Serbia's official political discourse.Footnote ⁵⁹ Veterans’ claims remained on the political margins, and in this sense, the Serbian experience of the 1990s was markedly different from the state policies and attitudes toward partisan veterans in the 1940s, who became celebrated as heroes and founders of the new socialist state.

But whether they were heroes, war criminals, or awkward reminders of Serbia's traumatic and unsavory recent past, Serbian veterans were a sizable group whose needs and health difficulties were virtually invisible to the rest of the society for the most part of the postwar decade. This did not mean that such needs and difficulties did not exist: in fact, it appeared that the very experience of invisibility confounded veterans’ attempts at recovery and reintegration. As several psychiatrists and psychologists testified from their own clinical experience, the extreme political and military events of the 1990s left an indelible mark on various sections of the Serbian population, and soldiers and veterans were among the worst affected in terms of psychological health and recovery. At Belgrade's Institute of Mental Health, psychologist Vladimir Jović and his colleagues were, by the mid-1990s, seeing dozens of traumatized veterans every week (and that excluded any active military officers, who reported to a separate military hospital).Footnote ⁶⁰ According to Spirić, even though the intensity of relevant “war stressors” had diminished radically in the years after 1995 (or 1999), “the number of patients treated for PTSD did not decrease significantly.”Footnote ⁶¹ Moreover, PTSD often went hand in hand with additional chronic and debilitating psychiatric and somatic disorders. As we will see in the following, Spirić's narrative thus painted a grim picture of mass suffering endured by neglected and marginalized veterans, whose symbolic and material status in Serbian society was simply too politically difficult to resolve.

Milanko Čabarkapa, a Serbian military psychologist who dedicated his career to researching Serbian soldiers’ PTSD, wrote about the psychological and social dangers of untreated and unacknowledged war trauma in war participants: in addition to significant impairments of individual emotional, professional, and familial functioning, long-term effects of unprocessed and neglected PTSD included a “diminished capacity for democratic orientation and democratic dialogue,” that is, an erosion of those social and individual capabilities that “enabled people to enter into associations and create their own better future.”Footnote ⁶² In other words, the widespread experience of PTSD in the veterans was more than a clinical problem, and it seriously compromised Serbian society's ability to move forward. In a similar vein, Spirić warned about the broader societal “dangers stemming from the [psychological] consequences of the war” suffered by Serbian veterans, who, ten years after the end of their military engagement, experienced severe difficulties in their social adaptation (their inability to maintain family and personal relations and to take part in normal economic and professional activities did not bode well for the development of Serbian society in general).Footnote ⁶³

Although Čabarkapa's own clinical research went a long way toward shedding light on the nature of psychological difficulties of Serbian veterans, it never seriously delved into the complex ethical aspects of their war conduct and possible psychological consequences suffered by perpetrators of extreme violence against civilians. Čabarkapa interviewed hundreds of Serbian soldiers—members of the Yugoslav People's Army who took part in the wars in Slovenia and Croatia in 1991—and aimed to determine which events and experiences had the highest potential to cause traumatic reactions. In his 1996 dissertation and his subsequent publications, Čabarkapa focused on the difficult and extraordinary circumstances in which Yugoslavia's regular army found itself at the beginning of the war, when it faced open hostility from the local population in both Slovenia and Croatia, and went through a torturous process of dissolution along ethnic lines in the midst of an escalating armed conflict.Footnote ⁶⁴ In his analysis, Čabarkapa thus zoomed in on the negative psychological effects of such overall political and military conditions, describing in detail the disorientation of Serbian recruits who had to witness “a mass desertion of both regular soldiers and commanders,” as well as what Čabarkapa referred to as the “betrayal by the military command and the political leadership of the country” as the army was ordered to withdraw from Slovenia.Footnote ⁶⁵

In his discussion of the responses of soldiers in Croatia, however, Čabarkapa noted that the second most traumatic experience was “seeing massacred human corpses,” whereas one of the most significant “events” described by his interviewees was the “destruction of all moral values and disrespecting personhood and the value of human life.”Footnote ⁶⁶ These statements were vague enough and could be read in a variety of different ways; that is, they did not necessarily mean that the interviewed soldiers spoke of their own army's and comrades’ responsibility for the massacres and unethical behavior. Nevertheless, Čabarkapa never clarified their implications, and they remained the only somewhat ambiguous references that did not construct Serbian soldiers and recruits explicitly as victims of their circumstances. In his own research conducted in 2005, Spirić listed “death of a large number of civilians” among the most intensely stressful events in the war as reported by his Serbian interviewees: the characteristically ambiguous formulation (which civilians, and how were they killed?) was not elaborated on any further.

In the rest of his research and analysis, Čabarkapa focused on a variety of factors which in no way touched on the issue of Serbian responsibility for war crimes and crimes against humanity: the death and wounding of other soldiers; sudden, unexpected, and stealthy attacks from the enemy side (fellow Yugoslavs until recently); lack of military and fighting experience; unclear war aims and contradictory information regarding commands and course of action and so forth.Footnote ⁶⁷ In fact, Čabarkapa reported that most of his interviewees did not feel hostility for the “enemy side,” defined as Slovene and Croat territorial defense organizations, local police units, and civilian population who opposed the Yugoslav People's Army in 1991. To the contrary, almost 60 percent of the soldiers in Čabarkapa's sample testified that they had not seen these organizations as “enemy” at the beginning of the conflict, and that, moreover, they had at times had very good relations with their representatives and the local population. In the author's reading, the absence of any hostile emotions paradoxically led to further psychological difficulties as Serbian soldiers experienced deep confusion and ambivalence, and were, moreover, poorly motivated to fight.Footnote ⁶⁸ On the other hand, their relatively positive disposition toward the enemies, claimed Čabarkapa, made it unlikely that they would struggle with aggressive impulses or feelings of hatred, or behave destructively during the conflict. In a similar vein, another group of mental health clinicians concluded that their research subjects—a group of Serbian POWs who had been tortured in Croatian camps and prisons—still expressed an exceptionally “mature” form of patriotism “without hatred or any revanchist feelings towards the nation from which their torturers hailed.”Footnote ⁶⁹ Not even such profoundly traumatizing experiences and unspeakable cruel treatment at the hands of their enemies could provoke hatred and aggression in Serbian soldiers.

Other psychiatrists largely joined the denialist trend: Spirić noted in passing that war veterans in Serbia experienced “satanization,” “stigmatization,” and “disrespect” for their service coming from certain unnamed media outlets and organizations.Footnote ⁷⁰ These reportedly drew on unsupported conclusions about the entire veteran population on the basis of some “incident situations (violence, crimes, murders, suicides) in which individual soldiers took part” and because of the ongoing war crimes trials of “individual veterans.”Footnote ⁷¹ In that sense, the belated discussion about Serbian soldiers’ PTSD almost completely eschewed the issue of the psychological and moral status of perpetrators, and failed to explore the psychological and moral burdens of a society that needed to reintegrate such perpetrators.

Moreover, even though Serbian psychiatrists such as Spirić and Čabarkapa generally presented their own profession as a victim of broader social and political circumstances, which made it impossible for mental health scientists to plan and conduct systematic research into Serbian soldiers’ PTSD, the situation was indeed much more complex than that. In the midst of extreme social divisions and political crisis in 1990s Serbia, those psychiatrists who worked with patients suffering from war stresses played an active role in shaping the dominant political narrative. Discussions about PTSD and “reactive psychological disorders” were omnipresent in psychiatric and medical journals throughout the war and also dominated post-1995 psychiatric discourses. As mentioned, the focus was on civilian victims of the wars—children, survivors of torture and prison camps, civilian refugees—and such partial psychiatric analyses relied on the perceived universal scientific value and appeal of international diagnostic categories (such as PTSD) in order to reinforce the narrative of (Serbian) innocence, victimhood, and even generosity (they did not hate the nation from which their torturers hailed, their patriotism was devoid of such destructive feelings). In his analysis of the applicability of the WHO's International Classification of Diseases, 10th revision (ICD-X) to the Yugoslav context, Kaličanin noted that “the real circumstances in which we live in themselves constitute a stressor to which our entire nation is exposed.”Footnote ⁷² In that sense, such international classifications validated the suffering of the Serbian people as a whole, serving as the ultimate proof of its unjust victimization, and there was very little discussion of the cultural applicability of the PTSD discourse in the Serbian context.

Still, Čabarkapa's, Spirić's, and others’ work on the diagnosis of PTSD served as a powerful and uncomfortable testimony to the sheer magnitude of Serbia's and Serbian citizens’ involvement in the wars in Slovenia, Croatia, and Kosovo, and as a reminder of the heavy psychological burden such participation imposed on Serbian society. Again, psychiatric debates became an unexpected forum for discussing highly controversial political issues and concerns that could not be addressed elsewhere. According to Spirić's analysis of more than 200 questionnaires filled in by war veterans in Serbia, the military conflicts in former Yugoslavia dramatically cast a long and troubling shadow, and still dramatically shaped the lives of its participants. For instance, Spirić assessed that more than 40 percent of the veterans “probably” suffered from undiagnosed PTSD, which limited their postwar adaptation and severely impaired their efforts to rebuild their own social networks. Importantly, on average nearly 60 percent of the interviewed veterans still thought about the war frequently (a decade after its end), and that number rose significantly, to 70 percent, for the subgroup with PTSD symptoms (who were experiencing intrusive memories and flashbacks). Moreover, nearly 30 percent of PTSD veterans now regretted their participation in the war, and a significant number developed a fairly negative assessment of their wartime activities.Footnote ⁷³ Finally, the veterans’ overall physical health, the quality of their social and family relations, as well as their ability to provide for themselves and their families deteriorated dramatically, while systematic state policies to address these problems were sorely lacking. Nearly 30 percent of veterans described their own physical health as bad, and a shocking 78 percent believed that their material situation was bad or exceptionally bad. Veterans were also much more likely to underperform at work, to get fined or fired, and were promoted much more rarely than before the war. In fact, unable to find solid ground in a society undergoing major structural transformations after the change of regime in 2000, they often labeled themselves “losers of the transition.”Footnote ⁷⁴

Vladimir Jović was one of the very few mental health clinicians in Serbia who raised the issue of the collective memory of and ethical responsibility for war crimes and human rights abuses when addressing his own experiences with treating PTSD.Footnote ⁷⁵ He noted, furthermore, the similarity between the situation of Serbian soldiers and that of Vietnam veterans in the United States, especially with regard to the Serbian leadership's “confusion about the wars’ political aims” and the Serbian society's negative attitudes toward war participants. Through this comparison, Jović introduced the issue of war crimes and veterans as perpetrators, whose psychological problems were in large part caused by their own violent or destructive acts. This concern with responsibility for war crimes was likely a result of the main focus of Jović's research: the suffering of Serb refugees from Croatia and Bosnia, who were recruited against their will immediately upon their arrival to Serbia and sent back to the frontlines, usually after having been exposed to torture and harassment at one of the semi-legal “military training camps” in the country.Footnote ⁷⁶

According to Jović and most of his colleagues, although all Serbian veterans found themselves in difficult and unfair circumstances after the end of the war, this was obviously a particularly badly affected subgroup of soldiers, whose grievances, memories, and psychological difficulties were extremely difficult to overcome. By zooming in on these refugees turned soldiers, Jović's research raised the issue of the Serbian state's complicity in civilian suffering almost naturally: there was no way of eschewing a discussion of the Serbian military (and paramilitary) formations’ crimes against civilians and international humanitarian laws. Moreover, he explicitly referred to the Serbian military groups’ most heinous crimes outside Serbia, on the territories of Bosnia and Croatia, such as the shelling and destruction of the Croatian town of Vukovar and executions of its civilian population, the shelling of the historic city of Dubrovnik, the mass murder of civilians in the eastern Bosnian town of Srebrenica. In his analysis, Jović critiqued the absence of any “societal self-reflection on a national level” in Serbia, any reassessment of Serbia's status following a series of mass crimes, military defeats, and humiliations, or “any steps whatsoever towards reconciliation with the other nations against which we waged wars.”Footnote ⁷⁷ Instead of taking a hard look at itself, Serbian society continued to deny its own role in the post-Yugoslav carnage by ignoring the needs and even the very existence of its veterans. Jović even compared the Serbian public to bystanders in the Holocaust, who knew about but remained indifferent to the fate of concentration camp inmates, even though they did not personally commit any crimes.

In that sense, Jović's article was about the PTSD diagnosis of the entire society, not only the surviving soldiers. Those who identified with the Serbian “national interests” and criminal leadership still inhabited a gray zone and remained dependent on a political ideology that would enable them to “distance themselves from any considerations of war crimes” and their own moral responsibility for them. For such people, the chances of psychological recovery were rather low in Jović's diagnosis. But the problem was even larger than this group of people, and here Jović continued the practice of relying on psychoanalytic interpretive frameworks to explain the political effects of the war. A majority of Serbian citizens, regardless of whether they supported Milosevic's belligerent regime, found it impossible to integrate the destructive experiences of the war (poverty, extreme fear and helplessness, humiliation) into their memory and meaningful sense of self, so they utilized the strategy of “externalization,” “denial,” and “projection.” In other words, a strong delineating line needed to be maintained between those who participated in the war formally and those who did not: “the group which was associatied with any references to the war had to be held at enough psychological distance” that any negative war-related memories or feelings could be symbolically “deposited” in such figures and expunged from the national space. Veterans, as “contaminated” by the war, were either expelled from the public discourse or vilified. It was very difficult for psychiatrists like Jović to overcome society's efforts at externalizing veterans’ experiences, precisely because this strategy hid the most difficult truth: in a society of morally complicit bystanders, everyone was traumatized.Footnote ⁷⁸

Jović's analysis came closest to articulating ideas central to what Allan Young defined as the category of “self-traumatized perpetrator”—a diagnosis based on the notion that perpetrators could harm their own mental health through committing acts of extreme violence and could experience psychological suffering and develop psychiatric illnesses comparable to their victims’. Jović never addressed this explicitly, and his argument primarily concerned Serbian society as a whole rather than individual soldiers, but his focus remained on the destructive impact of self-inflicted moral and psychological wounds among perpetrators. In his 2002 article, Young argued that “self-traumatized perpetrator” was a “transient mental illness,” which emerged due to some very specific social and political circumstances in the United States in the 1970s and 1980s, and was likely to fade away as the broader context changed. Young did hypothesize that this category might reappear in the aftermath of the Yugoslav wars, given the large number of perpetrators and the exceptional influence of the PTSD discourse in the 1990s Balkans, but this has so far not happened in the mainstream psychiatric context and Jović remains the only practitioner whose research indirectly touched upon this theme.Footnote ⁷⁹

But Young's analysis of the American discussion around “self-traumatized perpetrators” does help us understand possible reasons for the category's absence from the Balkan context of the 1990s—as we saw previously, neither the Croatian nor the Serbian psychiatric profession was prepared to discuss veterans’ psychological difficulties in the context of responsibility for committing war crimes, just as the two societies were reluctant to discuss their respective soldiers as perpetrators of destructive acts against civilians. Serbian psychiatrists might have warned against the victimization/stigmatization of veterans upon their return, but they almost never engaged in any antiwar activities and rarely criticized the Serbian army's conduct against civilians. In that sense, the absence of any broader discussion of the category of self-traumatized perpetrators in the Serbian (or post-Yugoslav) context confirms Young's thesis—that this mental health classification was dependent on a specific constellation of social and political circumstances and influences, which were simply lacking here. Even though the Serbian state and the broader Serbian public reportedly often expressed negative attitudes toward Serbian veterans, this was rarely due to any widespread belief that those veterans had engaged in morally questionable activities during the war. Veterans and veterans’ associations, moreover, never spoke of their own wartime involvement in terms of violent crimes against civilians and individual responsibility—this was certainly not part of the mainstream political discourse in Serbia—so their potential assumption of the role of self-traumatized perpetrators would most likely turn them into veritable social and political outcasts.

On the other hand, there was a group of psychiatrists and psychotherapists in Serbia, largely working with children, who regularly presented themselves as neutral and even-handed observers of the war. In their research, which primarily focused on the mental health of Serbian refugees from Croatia and Bosnia, they regularly referred to the wars of Yugoslav succession as civil wars among three equally brutal sides, emphasizing that in this conflict “nobody was innocent but children.” All three warring parties were said to be characterized by “religious exclusivism, which [led] us into an anachronistic medieval situation of ruthless religious wars.”Footnote ⁸⁰ In one article, Yugoslav writer Ivo Andrić was evoked and quoted in the middle of a clinical analysis of child refugees and their psychological disorders in order to make sense of the current political developments and the violent dissolution of the country. In these citations, the psychiatrists used pronouncements of a variety of Andrić's literary characters to argue that the “spirit of the Balkan man” was hopelessly and permanently tied to inflicting and suffering violence and that the “four faiths” coexisting in the region had since time immemorial thrived on the feelings of hatred and intolerance toward one another.Footnote ⁸¹

In this reading, the 1990s war and its consequences, even though they were referred to as “man-made” or “man-intentioned,” were in fact constructed as akin to natural disasters, caused by timeless and inexplicable forces of destruction. This also by necessity meant that there was no individual responsibility to speak of and very little individual agency, especially since everybody involved was reportedly equally morally bankrupt. The practical political implications of this line of thinking were obvious almost immediately: describing the case of a girl refugee, who spent some time in besieged Sarajevo before making it to Belgrade with her family, the psychiatrists noted that her boyfriend was killed by a sniper in one of the “street fights” in the Bosnian capital.Footnote ⁸² In that way, the responsibility for this murder was removed from the Bosnian Serb army, which kept the city hostage and killed and wounded more than 16,000 civilians. Instead, the reference to street fights once again implied that the burden of guilt was completely diffused and shared among all participants.

Beyond attempts at diagnosing war participants and interpreting the origins of the war in psychoanalytic terms, therefore, psychiatrists used their clinical materials and experiences to make direct political pronouncements about what was going on in the war-affected areas of the former country. In Serbian psychiatry, in particular, the idea of establishing equal responsibility of all three ethnic “sides” was very common, most likely because it undermined the narrative focused on Serbian aggression and the growing international condemnation of the Serb armies’ and paramilitaries’ crimes against civilians.Footnote ⁸³

Psychoanalysis as a Tool in Political Warfare

In 1993, Serbia's leading psychiatrist and a prominent participant in debates about war trauma among the Serbian population, Predrag Kaličanin, gave a speech to his colleagues at the Institute of Mental Health in Belgrade, in which he protested the economic sanctions and political isolation imposed upon Serbia by the United Nations in response to the Serbian leadership's direct participation in the wars in Bosnia and Croatia. Interestingly, Kaličanin framed the sanctions as foremost a psychiatric problem, as they reportedly led to a “grave impairment of the health of all citizens of this country” and to “tragic mass consequences…, which inflicted enormous suffering on the already ill, and resulted in further illnesses and deaths of the innocent.” Moreover, Kaličanin used this opportunity to appeal to the international community to prevent the “satanisation of the Serbian nation” in medical and psychiatric journals, in particular.Footnote ⁸⁴ Kaličanin had in mind a specific expert publication based in Croatia—the new Croatian Medical Journal, whose first issue came out very soon after the start of the hostilities, in 1992, and which was published only in English, presumably because it was primarily intended for international audiences. In its first year, particularly in its two “war supplements” from 1992, the journal ran several articles by distinguished Croatian (and former Yugoslav) psychiatrists and psychotherapists, who attempted to apply a variety of psychoanalytic concepts to understand the origins of war, violence, and aggression on the Yugoslav soil. Kaličanin objected vehemently to such interpretations and their reliance on psychodynamic theories to demonstrate that, in Kaličanin's words, “the Serbs were a criminal and genocidal people with cannibalistic impulses.”Footnote ⁸⁵

The Croatian Medical Journal caused a major international stir with its early psychiatric publications, although it never published anything similar to Kaličanin's aforementioned quote. On the other hand, a group of psychiatrists and psychoanalysts, caught up in the horrific realities of war and aggression on the Croatian territory, did utilize a host of psychoanalytic principles and theoretical frameworks in rather dubious ways to diagnose the supposed sources of that aggression and pathologies of the Serbian psyche. This first of these principles came to the attention of their Serbian colleagues in 1992, when they contacted the journal's international advisory board and other international medical organizations to complain about the “unscientific derivation of generalizations based on psychoanalysis” and “the disqualification of whole nations … through psychiatric or rather psychoanalytic diagnoses.”Footnote ⁸⁶ In the Serbian-language version of the letter, they criticized the “reductionism and superficiality” of such psychoanalytic interpretations and warned that “psychoanalysis developed from studying individuals, so that its application for the purposes of understanding cultural phenomena could never be scientifically rigorous.”Footnote ⁸⁷ The Croatian Medical Journal reluctantly published the Serbian psychiatrists and medical doctors’ letter of complaint—apparently at the insistence of some of its own advisory board members—but the editor apologized to the journal's readership for “burdening” them with such an inappropriate and, he implied, inaccurate text.Footnote ⁸⁸

The peculiar case of the Croatian Medical Journal, and the bitter political conflict fought on its pages, signaled a tragic breakup of what used to be a formidable and internationally renowned psychiatric and psychotherapeutic profession. But it was striking and very surprising that, as these former friends and colleagues were busy realigning their medical and political loyalties with the perceived interests of their respective ethnic communities, they decided to conduct their political discussion in almost exclusively psychoanalytic terms. In the 1990s, by which time psychoanalysis had in other parts of the world largely been banished from medical practice to literature and history departments, the fractured Yugoslav psychiatric community still held on to it as the core interpretive framework to make sense of the extreme violence plaguing their former country.

“We may state freely that war is often started by sick political minds that have created a sick collective political consciousness and culture,” wrote Zagreb-based psychiatrist Miro Jakovljević in his article about “psychiatric perspectives on the war against Croatia.”Footnote ⁸⁹ This tendency to view the political conflict in 1990s Yugoslavia as an issue of collective psychopathology set the tone for the two war supplements of the Croatian Medical Journal. According to Vladimir Gruden, from Zagreb University's Department of Psychological Medicine, the sources of the war lay with the Serb nation's “enormous aggressive energy” and “regressive psychic tendencies,” understood in the Freudian sense as “[closeness] to [one's] own uncontrolled impulses” and “diminished capacity for sublimation.” Gruden and most other contributors to the war supplements [?] diagnosed pathology in Serbian folklore, national mythology, political choices, as well as everyday life and customs: “In Serbs, regressive tendencies can be recognized in their inclination toward oral and other bodily pleasures … Their business partners are frequently surprised by this regressiveness when attempting to establish the usual business communications with them.” On the other hand, Croatians—as representatives of the superior Western civilization—were characterized by an excellent ability to sublimate, and this ability, it was said, provoked the Serbs’ hatred, envy, and guilt. In addition, the Serb nation was diagnosed with a collective “paranoid condition” and described as existing “at the level of the schizoparanoid position in the development of personality” as a result of a deeply embedded regressive orientation.Footnote ⁹⁰ The Serbs’ disintegrated self was then projected onto the Croats, which explained the Serbs’ violent and destructive impulses toward Croatian territories and citizens. Eduard Klain argued in a similar vein, that, in relation to Croats, “Serbs often have aninferiority complex, because they are aware of their lower level of civilization and culture.”Footnote ⁹¹ Psychoanalytic theories and concepts were thus mobilized to demonstrate the Serbian nation's supposedly deeply ingrained propensity to violence, destruction, and irrationality.

But Croats (and other Yugoslav peoples) could also, on occasio, find themelves collectively diagnosed on the pages of the Croatian Medical Journal, although these diagnoses were generally framed in more positive or neutral terms. Unlike Gruden, Klain noted regressive psychological tendencies in the Croatian nation, too, but argued that they did not encourage violent or aggressive forms of behavior because they were “closer to the depressive position.” For that reason, Croats were psychologically inclined to feelings of guilt and religious sentiments rather than to destructive reactions and “paranoid projections.”Footnote ⁹² In Jakovljević's reading, Croats developed narcissistic psychological mechanisms in the aftermath of the first free elections in 1991, in which a noncommunist political option won. But this narcissistic tendency did not indicate anything particularly damning about the fundamental characteristics of the Croatian collective—it led to “benevolence and naivete”--as the Croats strongly identified with “the great democracies of the world” and underestimated the dangerous “barbarism and primitiveness” of their Serbian enemies.Footnote ⁹³

In these discussions concerning the psychological roots of the Yugoslav wars, psychiatrists utilized yet again their discipline's evolutionary narrative of primitivism, “barbaric” societies and modernization. From the very beginning, the psychiatric profession in Yugoslavia framed its tasks and broader societal project in terms of a “civilizing mission.” Throughout the twentieth century, they aimed to take an active part in discussions about Yugoslav society's cultural, political, and social modernization, emphasizing their own expertise in the mechanisms of human psyche and behavior, and promoting their own role in modernizing the population's mind. In different historical and political contexts, the meanings of such a psychiatric civilizing mission could change quite radically, but this narrative of the profession as the prime national modernizer remained a constant. It is hardly surprising, then, that it got its final twist in the psychiatric-political discussions of the 1990s, when Yugoslav psychiatrists discussed their former colleagues and entire national groups in Yugoslavia in terms of (ireedemable) backwardness and primitivism. In the Croatian Medical Journal's war supplements, in particular, the civilizing mission of psychoanalysis was explored to its fullest potential.

Although Gruden certainly had very few affirmative things to say about the collective Serbian psyche, in the spirit of self-criticism he did note that Croats shared part of the blame for the way in which the Yugoslav conflict had evolved over the preceding months. Relying on developmental psychology and psychoanalysis, he established that the Serbs, as a regressive collective actor,comparable to a child,could not help themselves without the guidance of “persons or a group who have achieved a certain degree of sublimation,” and who were on a higher level of civilizational development. It was up to the Croats to perform this corrective function and aid their Serbian neighbors (as well as Croatia's Serbian citizens), who were “incapable of achieving maturity” and needed to be led out of their infantile phase into collective adulthood. Unfortunately, wrote Gruden, instead of taking this educational and civilizational process seriously, and acting with “strictness and resoluteness” toward the Serbian child-nation, the Croats “respected [Serbs'] regressive demands” in both Yugoslav states.Footnote ⁹⁴ Gruden also faulted Serbian leaders, many of whom were psychiatrists and as such aware of their nation's need for maturation, who still failed to act in a responsible manner.Footnote ⁹⁵

***

In the 1990s, the Yugoslav psychiatric profession faced unprecedented challenges, which both undermined its revolutionary socialist legacy and temporarily boosted its local political significance. As the country saw extreme violence unfolding on much of its territory, the notion of war-related psychological trauma rapidly rose to significance in both political and psychiatric contexts, and the diagnosis of PTSD became the primary framework through which to discuss the memory of the war and its broader social consequences. In that sense, psychiatry was again at the very center of some of the most sensitive political debates, and fractured psychiatric narratives closely reflected a range of social, political, and cultural tensions, anxieties, and controversies—related to the status of war veterans and postwar recovery, collective memory of the war, and responsibility for war crimes. As we saw in this article, the silence that quickly settled around discussions of war trauma in the aftermath of the Second World War was finally broken in the early 1990s, when psychiatrists in different parts of war-torn Yugoslavia began reflecting on the psychological consequences of the extreme violence and dislocation of the 1940s and considered at some length the Yugoslav population's experiences from nearly fifty years ago. Some of the most important publications from the immediate post-WWII era were revisited in the 1990s, partly as an attempt to find professional precedents and guidance for dealing with large numbers of soldiers and civilians who had lived through extreme experiences, and partly to draw (politically expedient) parallels between the 1940s and the 1990s.

And while psychiatrists’ work on trauma and PTSD strangely reenergized the mental health professions and brought attention to their political significance in the newly formed, ethnically delineated post-Yugoslav states, the breakup of the socialist country had a devastating effect on the overall status of this group of experts. Yugoslav socialist psychiatry was a formidable, rich, and highly innovative clinical and research field. The profession and its practitioners were renowned in the European and global contexts, and they developed diverse and extensive networks of international contacts, which crossed the conventional Cold War political boundaries and enabled dynamic, experimental, and revolutionary developments. Yugoslav psychiatrists thus had regular access to Western techniques, institutions, and schools of thought; moreover, what made the profession stand out was that many of its practitioners were actively involved in the highly original project of integrating Marxism with Western psychoanalysis and psychotherapy, and worked to turn their discipline into a tool for political and social emancipation. They also played an active role in global debates around psychiatry and decolonization, critiquing some aspects of colonial legacies and racialized thinking in postcolonial transcultural psychiatry and developing a role for socialist “psy” disciplines in the decolonizing world.Footnote ⁹⁶

With the outbreak of the war, psychiatrists almost everywhere in former Yugoslavia experienced a long period of professional isolation. Unable to travel or access international psychiatric literature, they looked for other ways in: several psychiatric journals in Serbia and Croatia decided in the early 1990s to publish all of their proceedings in English in an attempt to make their research more accessible to international audiences, and they strove to include foreign colleagues on their editorial boards. In some ways, they succeeded, and this was also the time when some international mental health practitioners grew increasingly interested in Yugoslavia and internationally funded trauma advocacy programs offered local clinicians some limited opportunities for transnational collaboration and international exposure. But overall, these engagements amounted to little more than a shadow of their erstwhile achievements, reputation, and influence. Even more importantly, what they wrote in their new English-language journals was not as innovative and internationally relevant. In many ways, psychiatric discussions of PTSD reinforced dominant nationalist political narratives and justifications, reflected collective ethical blind spots within their respective national groups, and often served to substantiate political constructions of national victimhood.

One important legacy of the socialist period remained, however: throughout the 1990s, psychoanalysis remained an exceptionally important analytical framework for analyzing the origins of violence and ethnic hostilities and for exploring the mechanisms of broader group dynamics and interactions in Yugoslavia. In one of the most memorable examples of this tendency, Eduard Klain explained the rise of anti-communism after Tito's death as the “devouring during the totemic meal of the father who left them without offering them some fixation or referential point of support.”Footnote ⁹⁷ Serbian psychiatrist Radomir Samardzić ended his article on PTSD in Serbian prisoners of war and victims of torture in Croatia with an extended discussion of Freud's and Einstein's 1932 exchange on the origins of the human propensity for aggression,Footnote ⁹⁸ and a 1993 issue of the Croatian journal Psihoterapija opened with Freud's response to Einstein.Footnote ⁹⁹ Even if their methods and some of their conclusions were questionable, this development was remarkable and constitutes perhaps the only original contribution of post-Yugoslav psychiatry. After the end of the war, psychoanalytic paradigms remained influential, and post-Yugoslav clinicians relied on them to discuss and treat the lingering psychological consequences of the war (particularly notable in this context was the prominent Balint group gathered around Zagreb's Muradif Kulenović) or to make sense of post-Yugoslav societies' inability to acknowledge their own moral responsibility for violence and war crimes.