Keywords

1 Introduction

In post-war Bosnia and Herzegovina , there has been a noticeable increase in the number of people, especially young people, who face behavioral and emotional problems. The problems are wide ranging: they run from anxiety, depression, and withdrawal, through social problems, attention problems, difficulties thinking, somatic problems without clear medical causes, and even to problems of rule violation, aggressive behaviors, various types of addiction, learning disabilities, and more severe psychiatric illnesses and disorders.

Often the problems begin with a person having difficulties in the social environment in which they live. The prevalence of young people with emotional and behavioral disorders ranges from 13% to 22% of the total population in our Bosnia and Herzegovina [1]. This is a clear indication that many young people are in need of assistance and counseling. The problems are amplified by people fearing that they will become labeled if they decide to engage with one of the regular mental health institutions. Young people in particular assume (perhaps not unreasonably) that by attending an institution they will get “stuck” with a label. The result is that, hesitating, their problems get worse.

This is where we found in our work an ally in the virtual world. Given the fact that we now live to a large extent in a virtual world, in which all of our needs are satisfied through the basics of online communication, we recognized the need for adopting a similar approach in establishing new and improved access to mental health services for children, young people, and adults. We changed our approach to access and moved to allowing our users to get the help they needed (whether socio-educational, psychological, or psychiatric) through their computers, laptops, and phones, and from different parts of the country or indeed the world, and all without going near a clinic.

The online platform we developed with our partners (see Acknowledgments) offers a “World Without a Label.” It is the first counseling center of its kind in Bosnia and Herzegovina, and it is also a platform for the future in the wider world. It brings together in one place experts in behavioral, psychological, and psychiatric problems. Its approach is both evidence-based and values-based: it was created, on the one hand, on the basis of long-term preparations and research into the effectiveness of virtual interventions consistent with strategies for promoting and preserving young people’s health in general; and on the other hand, on the basis of careful assessments of the needs of the people—especially the young people—that the program is intended to serve. The result is an online platform that offers specialist counseling for young people (including with their parents’ permission, underage children) and for adults. An online counseling service is also available to parents who want to support their children in overcoming life difficulties. The approaches offered are socio-pedagogic, psychotherapeutic, and psychiatric, including behavior modification treatments with primary and secondary prevention.

The platform lives up to its name—it is a “World Without a Label” —in that all treatments are delivered in the virtual environment through Skype’s online platform. Those who need help are required to visit the site “onlinesavjetovaliste.com” and fill out the form. After the application has been sent, the multidisciplinary team makes a real-time triage of the problem and sends the patient to an appropriate online expert. The intervention is again done through Skype and is completely anonymous.

The story that follows illustrates how the program works to provide a world without a label, allowing clients to access help without fear of prejudices against mental health, by providing an expert service within a virtual environment and with full confidence anonymity.

The boy concerned (who is clearly above-average computer literate) refuses face-to-face therapy (at least in the first instance) but then engages successfully with our innovative online service.

The anonymity of online counseling services gives users a sense of control, and users simply open up because there is no possibility of first contact.

2 Adnan’s Narrative

Adnan was a young teenager, born in 2002, who first attended our Child and Adolescent Clinic accompanied by one of his parents. The concern was that he had been showing behavioral problems —extremely poor social interaction with peers; and spending most of his free time on his computer playing video games. He came reluctantly and only at the urging of his parents.

Adnan was an only child living in a complete family with both his parents. He attended the local elementary school, was in the final grade, and an excellent student. At school, he had very little communication with peers and no best friend. In the early years of his schooling he was occasionally mistreated and bullied. He later responded to this bullying physically—he bullied the bullies back and after that they stopped mistreating him for good. But subsequently he expected only the worst from other people and constantly thought he was being attacked by others for no reason. Most of the time he was a very calm child though always ready for self-defense. Since preschool, he had spent a lot of time on his computer mostly playing war-related video games. He had always been fascinated by the war itself, by the arts of killing, and he dreamt about being a professional soldier when he grew up. When he was 7 years old, he started following internet sites for military training.

Adnan’s mother had a history of psychiatric illness : she had been treated in the Day Hospital of a local psychiatric clinic where in group psychotherapy she recalled her own war-related rape trauma; she experienced this in her early 20s, where soldiers of the opposing army systematically raped their captives. Adnan’s father was a former member of their national army and he himself suffered many war traumas. Adnans’s parents met after the war. They knew all about each other’s war-related traumas but they never talked about them in front of their son.

Our formulation was that unconscious transgenerational transmission of the parents’ war trauma (see below) had led to a specific formation of Adnan’s personality traits reflecting his lack of confidence and fascination with war. The boy refused group therapy but engaged well with your on-line programme.

3 The Transgenerational Transmission of War Trauma

War trauma is in many ways specific: it causes destruction, death, and wounding of a large number of people; it has occurred from the enemy’s hand; and it leaves feelings of helplessness, loss of trust in others, and a sense of humiliation. Hate, prejudice, and negative feelings are among the well-recognized common reactions to war trauma. Less well recognized is “transgenerational trauma transmission” where the victim transmits trauma to their children with the result of keeping it alive for the generations to come.

Importantly, trauma of this kind may be transmitted unconsciously and even where, as in Adnan’s story, the original victims try to avoid passing on their trauma by not talking about it in front of their children. We have seen this following the war in Bosnia and Herzegovina in the 1990s when systematic rape of Bosnian women was for the first time in history characterized as a war crime. It is believed that more than 20,000 women were raped in the war in Bosnia and more than a thousand children were born afterward origin [2, 3]. Such children are born into a world that may lack the basic prerequisite for normal mental development, the availability of a primary object (mother) to become a good content of the child’s personality, or what Winikot has called a “good enough mother” [4]. The processes involved in this are in part but importantly unconscious. For example, work on facial mirroring has shown interactions that, organized through constant regulation and experiences of mutually coordinated and synchronized responses, form the basis for the affective development of the child [5, 6].

What picture then could the child who was born out of rape get from their mother’s eyes? How could a mother laugh or look forward to giving birth to that child knowing how she became pregnant? And how will her feelings affect her child’s emotional development? The result is trauma which becomes transgenerationally transmitted influencing the formation of identity and self-image of children [7].

4 Beyond Direct Transmission to the Generations to Come

We seek to tell the story of children now in their 20s who were born as “war-time children of rape” in an attempt to publicize and acknowledge the existence of these so-called “invisible children,” or Bosnian war children.

Such unspoken secrets have the effect of creating messages within the environment in which the Bosnian war child is growing up, messages affecting his or her sense of inadequacy, of feeling guilt about the emotional state of the mother who was raped, and a sense of disgust because rape is stigmatized in society and its origin does not belong anywhere. These messages are not confined even to those directly affected but (as with our story above of Adnan) may spread indirectly to the children of those affected. The result is a process of transgenerational trauma that becomes self-sustaining spreading to the children of the victims of war and from them to the next generation, to the children of these “invisible” children themselves.

Silence and closeness with their attendant guilt and shame keep these children, now young people, imprisoned in their personal worlds without as they see it hope of exist. Paradoxically, society’s acknowledgment that such children exist, and are in and around us all these years, often brings massive disbelief and sometimes outright rejection. It does not surprise us, precisely because of this, the need for online privacy counseling. Such a service offers a safe space for acknowledgment bringing with it not rejection but support and understanding. That is why simply writing about these children and their stories can be helpful. Acknowledging what happened, difficult as it is, could make an important contribution to healing and treatment for both sides, for our “invisible war-time children” and for the society in which they are growing up to have children of their own.

5 Conclusions

Our story of Adnan has illustrated that in addition to all the well-known pathogenic circumstances in which people live in post-war Bosnia and Herzegovina are the “invisible children” born after war-time rape. For these children and their parents, support is very much needed and professionals have an obligation to respond to their needs. Appropriate responses require an interactive multidisciplinary team approach focused on recognizing that socio-emotional health depends on identifying the effects of transgenerational transmission of trauma and seeking help for it in a safe environment.

This is what our online counseling center “A World without a label” aims provide. We believe it has great potential to contribute to solving the post-war mental health problems of young people (also children and adults) and to create the motivational patterns that support changing risky behaviors and persisting in implementing those changes. As counselors, we offer the opportunity for our young people to address their problems with a professional team but without the fear of being labeled or judged in any way. The service in addition is able to offer a duration of treatment that is limited not by the limitations of available resources but only by the intensity and duration of the difficulty presented by the young person and their own needs and vulnerability. Our hope is that as we gain experience of the program, it will lead to development of a number of similar online mental health counseling centers in Bosnia and Herzegovina and elsewhere.