Psychiatric Becomings in Times of War. A Short History

Dr Ukshini,

her back turned towards us in her white doctor’s coat, was busy preparing Turkish coffee over a small gas cooker. Laughing she remembered how American psychiatrists and psychologists had once turned up at her office asking for a training session in coffee making. It was their last visit to the psychiatric hospital in Prishtina before returning to the US after months of training the first cohort of health workers in community-based mental health support. Still chuckling, she carefully poured the flavourful foamy coffee into three cups before handing them to me and Albana, my research assistant.

Settling into our chairs across from one another, we started the interview.[1]

“I had many talents growing up,” Dr Ukshini began, responding to my question about when she had become interested in psychology.

Dr Ukshini explained how she had written poems, learnt several languages, had read a lot, and was fascinated by maths, chemistry, and physics. She devoured her father’s old psychology books – books one could not find in the local library at the time.

“I wanted to be an archaeologist, before that I thought of becoming a journalist like Oriana Fallaci while also thinking that I would make a good bio-chemist. Well, I really didn’t know what I wanted to do.”

She harboured a great interest in people. With enthusiasm in her voice, she told us, “I always wanted to know about what they were talking, how they behaved, what they did and how these things differed whether they were Macedonian, Albanian or Turkish.”          She decided that she wanted to understand people better. So, Dr Ukshini began to study psychology in Skopje.

Over four years, she steeped herself in psychological theory and took every opportunity to gain practical experience. With her diploma in hand, she returned to Kosovo where she began to work in the centre for social work. She started to get a feel for what it meant to be a psychologist, noticing that it was entirely different from what she had learnt in books over the years.

To educate herself further, Dr Ukshini signed up for training in Niš and Belgrade travelling back and forth until the beginning of the Kosovo War in 1998.

“I couldn’t travel anymore as it was getting dangerous,” she explained, sipping her coffee slowly. Then, with strength in her voice, she declared, “I always believed that science doesn’t have limits and no nationality. I continued the trainings despite the circumstances. I loved, I felt, and I practiced family system therapy.”

She did not think of diplomas and degrees, she just wanted to grow professionally and personally. Looking back, she wondered on reflection whether she had been mistaken.

“Now after 21 years of work, I encounter moments in which I don’t feel comfortable as there are people who only look at your degrees.” Shrugging her shoulders, she continued, “I always say that we all have our own development in life as well as in science.”

Dr Ukshini had experienced a steeply rising career trajectory despite the absence of the usual framed diplomas and degree certifications one might expect to see on the walls of a doctor’s office. She became part of the cadre of leading mental health professionals who transformed the mental health system in the post-war period.[2] She centrally contributed to training and certifying a new generation of mental health professionals – psychologists, nurses and social workers. She identified new talent and leaders – among them Dr Statovci who now had her office down the hall.

Dr Statovci

radiated energy, strength and youth. Tying her dyed blond hair back, she exclaimed how stressed she was. She had just started a new position in the psychiatric hospital and felt overwhelmed with work. While trying to wrap her head around the new post, she had also to deal with the many patients who kept arriving unannounced at her door presenting complex problems.

“I don’t have much time for the interview, but let’s see how far we get,” Dr Statovci informed Albana and me as she indicated two chairs for us to take our seats. Hastily, I dug out the recorder from my bag, placed it on the small brown coffee table between us and hit record.

Her dream had been to study criminology in Croatia. “I liked that idea a lot, but my mother didn’t allow it. She insisted I study medicine in Prishtina.”

Following her mother’s wish, Dr Statovci began studying medicine and ambitiously thought about possible specialisations and career paths early on.

Yet, her ambitions were curtailed with the increasing discrimination under the Serbian regime. Starting in 1992, Albanian students and professors were dismissed from the university in Prishtina and were forced to build up a parallel education system. Congregating in professors’ homes and garages, students continued their education and professional training.

A professor had once told me how scared she had been teaching students in her private laboratory. “At that time, my students came one by one, you know,” Professor Gashi-Luci had explained. “I didn’t want them to come in groups as I was afraid that my Serbian neighbors would become suspicious and call the authorities on me. I was worried that they would close my laboratory down. So, I gave each of them lectures here, one by one. I had to be extremely careful.”

Upon finishing their studies in such uncertain circumstances, students received their graduation certificates ceremoniously in their teachers’ homes. Yet, with unrecognised diplomas in hand, the graduates were stuck.

Dr Statovci remembered, “I finished university, but after that I couldn’t do anything here. I couldn’t work because of the system in which I was living. I wasn’t accepted as a doctor. I couldn’t apply for specialisation. I was just looking what the time would bring.”

The time brought more uncertainty, war and finally her family’s deportation.

“I was a refugee in Albania. First, I spent one week at the border between Macedonia and Kosovo. Then, I was deported to Albania.”

Registering as a refugee, she was recruited to work as general practitioner for Doctors of the World and Doctors Without Borders. One day, a Spanish psychiatrist approached her asking whether she could take on more work. He was running out of translators. The first had started crying whenever he heard the refugees talk about their experiences; the second started to give unsolicited advice; and the third – Dr Statovci could not remember what was amiss with him – “maybe he forgot to translate” she chuckled. I didn’t know how to say no. Plus work was the way I handled my stressful situation.” Dr Statovci paused looking out of the window where patients and health workers were milling about between appointments.

After a while, she continued, “I was a refugee working in the camp, not knowing what will happen to my family – I had no idea what was going on with my extended family and my home. So, I worked – I just wanted to work.”

The Spanish psychiatrist thought that she was a natural as he observed her interaction with the patients. He kept giving her more responsibility and let her run support groups for women experiencing emotional distress.

“We spoke about their feelings, their behavior, and how these things influenced their family life.” Dr Statovci said and continued to explain that, “we taught them relaxation techniques. The aim was to give them a place to debrief and to learn how to handle their situation.”

As the war drew to a close and Dr Statovci was about to return home, the psychiatrist advised her to specialise in psychiatry.

“You know, I didn’t say anything,” she said tears glistening in her eyes. “I was just thinking, ‘is he crazy?!’ I will return to Prishtina, I don’t know if I will find my home or what happened to the people I love, and he is thinking about specialisation! It was ridiculous for me at the time.”

She returned to a looted home with all her medicine books stolen – books she had felt connected to. Taking little time to mourn her loss, she began working in community mental health, gained her specialisation in psychiatry and made it to head of inpatient services at the University Clinical Centre where she works to date.

Dr Zaimi,

sitting behind his wide wooden desk in his private clinic recollected how he had been introduced to PTSD[3] during the war.

“PTSD only occurred after the war,” he told us contemplatively. He first witnessed its symptoms working as a doctor and researcher in refugee camps in Albania. Foreign aid organisations had come to administer diagnostic questionnaires, to capture PTSD in-situ, as refugees were disgorged from war-torn Kosovo into the camps, carrying with them their horrific stories.

Dr Zaimi, together with his family, had been part of the refugee track. When NATO started its bombing campaign against Serbia in March 1999, the killings and destruction intensified in Kosovo. Armed to the hilt, his Serbian neighbours and paramilitary were patrolling the streets while he was in hiding, huddling with his wife and four children in the basement. His daughter started losing her breath – panic spread while he felt totally helpless, without light, without equipment, and without expert support.

On April 3rd, they finally escaped the dark basement joining others on their flight to Albania travelling the short distance over three days and three nights.

Upon registration at the camp, he was hired by international aid workers who were desperately looking for mental health professionals. With a psychiatry degree acquired in Zagreb, Dr Zaimi was thought to be the right person to treat traumatised refugees and to join research efforts intended to help understand mental disorder in the midst of the raging war.

Rummaging through one of his filing cabinets, Dr Zaimi pulled out a pile of yellowing questionnaires. The emerging data, he explained, suggested that around 15 to 20 percent of the population had PTSD – a relatively low number in his opinion.

“The reason might be,” he suggested, “that the Albanian population survived lots of traumas even before the war. They were prepared for the war. We knew what we were to expect from the Serbs. That is why the percentage is lower than expected.”

People knew what to expect based on their own experience of discrimination and persecution. They had also absorbed the news stories about human rights violations committed during the previous Yugoslav Wars at the beginning of the 1990s. Refugees from Bosnia, Croatia and Serbia had streamed into Kosovo earlier. Mostly hidden away in camps, they had little contact with the Albanian population. Yet, Dr Ukshini had told me how she was once summoned by her Serbian superior to accompany him to one of the camps.

“’There is a Serbian woman from Bosnia with whom we can’t communicate, you go and try,’” she was told.

The woman had locked herself in a horse carriage covered by tarps and cloth. Dr Ukshini had approached the carriage and started talking. “I couldn’t see her. I don’t know how much time went by and for how much time I spoke. Finally, she appeared looking so very tired. Looking lost, her first words were, ‘there is so much cement and it is so cold.’”

Dr Ukshini discovered that the woman had fled, “from a place surrounded by mountains and green,” only to witness her father and brother being killed on the way to refuge.

“Looking at her,” Dr Ukshini had told us, “I started to think about what is going to await us people. We were waiting for the war. I hoped that it would not happen to us, but at the same time I knew that it was going to come.”

And come it did. The refugees whom Dr Zaimi had encountered in the camps in Albania were just as traumatised as the woman in the carriage. Assessing their suffering with foreign scales, the long-term implications of war on psychic suffering began to dawn on him.

Following the war, he began to work in hospitals and eventually became the director for the Community Mental Health Centre in Gjakova.

“We dealt a lot with traumatised people, and we started to work with new methods like group work and working with families and working in the community outside the clinics.” The work felt meaningful and important.

At some point, however, the patient population changed. More and more people with psychosis sought help at the centres pushing the trauma work to the margins.

“I objected to this – the prevalence rate of psychosis was relatively low in comparison to all these people suffering from the traumas of war,” Dr Zaimi explained, “and it didn’t feel right to abandon them.” Consequently, he resigned and decided to work full time in his private practice.

Dr Lila

took over as director from Dr Zaimi. He was an imposing man and well known in the region. Mothers in the villages would threaten their unruly children saying, “if you don’t behave, I will send you to Mahmud Lila. He knows how to deal with the crazy ones!”

Dr Lila set a fast pace for the interview, and we were very much in his hands. Albana and I tried to keep up, scribbling frantically as he took us on historical excursions, laid out professional networks, explained his clinical practice, and gave gruesome details about the war.

Sitting behind a wide desk in his office at the Community Mental Health Centre, he folded his arms across his chest waiting for me to press the record button and to ask the first question. He had studied medicine in Novi Sad and pursued his specialisation of neuropsychiatry in Belgrade with follow up trainings in “all the important centres of Yugoslavia” – Niš, Zagreb, Skopje.  He used to be the head of an organisation of neurologists of the former Yugoslavia and led similar organisations in Kosovo while struggling to maintain influence during the cruel Serbian regime.

“We as Albanians were always suppressed by Yugoslavia,” he stated. “We were always under suppression. They didn’t allow us to progress in our careers even though it is said that Albanians are some of the most intelligent people.”

Dr Lila paused for effect before adding that, besides being intelligent, Albanian families were also characterised by their strength. He reasoned, “This is why we are morally strong and have fewer traumatic cases.”

From here he proceeded without pause into a historical detour, taking us back in time to the 1700s. It was then that Kosovo sought autonomy from Ottoman rule while Kosovo Serbs filed petitions to the Congress of Berlin demanding that Kosovo be united with Serbia in 1878. [4]  As the influence of the Ottoman empire waned, Dr Lila explained, the Serbian army marched into Kosovo in 1912, assuming power over the region by force and killing over 20,000 Albanians while displacing others. Kosovo changed hands again when the Austro-Hungarian forces occupied Serbia during the First World War and yet again, when Serbia pushed the central power out forming the Kingdom of Serbs, Croats and Slovenians.

From here Dr Lila jumped to the period immediately after the Second World War, when the Communist government of Yugoslavia took over control, defining the region as the Autonomous Region of Kosovo and Metohija, and placing Kosovo within the People’s Republic of Serbia. In Dr Lila’s view, this was a grave mistake as it resulted in rising tensions between the Albanian population and the Yugoslav government.

“In 1974, Kosovo became a constitutive federal element of Serbia”, he raced on explaining that his country gained its own administration, assembly and judiciary as well as membership in the presidency and the Yugoslav parliament.

While I began to wonder where this historical tour would lead in a conversation that was supposed to be about mental health, Dr Lila found his way back to the Kosovo War in 1998 – one more fight in a row of others for his country’s autonomy and eventually independence.

In an ominous tone he said, “when the war started, atrocities occurred – killings, massacres, inhumane things, abuses of women, massacres of children and parents, burning, destruction, deportation of the Kosovar population. It affected our people.” He paused briefly and then continued, “imagine, a mother witnessing the killing of her children. Imagine a woman abused and later killed by Serbian soldiers. Imagine women who were forcibly impregnated through rape.”

Quietly he continued, “there was one girl who defended herself not letting the soldiers rape her; since they couldn’t rape her, they killed her. She was 16 or 17 years old. Just imagine.”

While these scenes of horror were unfolding in my mind’s eye, Dr Lila went on to explain that the suffering continued in all its might after the war had ended as the search for missing people began and mass graves were uncovered across the region.

“One day, they found twenty and the next day thirty bodily remains. This causes trauma and psychological problems.”

The distress was further exacerbated due to the poor economic situation coupled with high unemployment rates.

“With everything up in the air, drugs started to come in, prostitution started.”

Family bonds began to weaken as the elders had little to offer the young generation.

With sadness, Dr Lila remarked, “the young generation is destroyed – our family life used to be so rich here.”

His vocation was to alleviate some of the pain and hardship unfolding in his community.

“The mental health centre,” he explained, “offered various therapies including medication, while trying not to lose sight of the wider social environment which affected people’s wellbeing.”

This holistic approach had grown out of collaborative efforts between Kosovar mental health professionals, the World Health Organisation and experts from the University of Illinois at Chicago. Together, they had drawn up a plan for mental health services following a community-based approach that was eventually implemented into the Kosovar health system in 2006.[5]

It was a productive time of system-building and awareness-raising with everyone working in mental health involved. Just a few days earlier, Dr Qoqai, the then director of the Community Mental Health Centre in Prizren had told me how his team had trained local staff in trauma therapy while working in the community to “sensibilise the population.” They distributed pamphlets, created radio programmes, gave public lectures in villages, and ran TV campaigns to educate people about trauma, symptoms of distress, illness management and treatment. People started to show up at the mental health centre self-referred despite the stigma surrounding mental illness.

“They came telling us about their experiences. ‘I am about to lose my mind, I cannot sleep, I constantly think about the war.’ They complained that they don’t feel well. ‘I have stomach pain.’ They experienced heart racing, their blood pressure oscillated, and what is most interesting, they isolated themselves.” It was during this time, Dr Qoqai reflected that psychology and psychiatry found a place in the Kosovar society.

While this may be so, Dr Lilia complained that work related to mental health was underfinanced. Spreading a document on the table, he read out that per 100,000 inhabitants, there were only two psychiatrists, 0.3 psychologists, 8.8 psychiatric nurses and 0.6 social workers. A mere two percent of an already underfunded healthcare system was devoted to mental health and Dr Lila predicted that it would be lower in the years to come despite promises by the Ministry of Health.

Dr Agani

was waiting for me in the smoky bar of the Grand Hotel Prishtina, a 13-story concrete block in the heart of the capital city. It was here that Josip Broz Tito had occupied a suite on his political visits and Serbian paramilitary mingled with foreign journalists during the years of conflict and war. In the immediate post-war years, the hotel rooms were booked by foreign military commanders, aid workers, politicians, and business investors until better, more luxurious hotels opened their doors in the city.[6]

I took my place on a bar stool next to Dr Agani. After ordering our macchiatos, we entered immediately into conversation. We had little time to waste. Dr Agani was a busy man – he was the country’s health minister, professor at the University of Prishtina, and a psychiatrist with his private practice to run. Frustrated that he could not push mental health higher up the government’s agenda, he also struggled with growing waiting lists in his private practice.

Mental health was an issue not to be overlooked, he explained. Sixty percent of his patients were women presenting with depression, anxiety and pains. The pains, he outlined, varied from person to person. There was burning in the chest, heat moving up in the body, tension and pressure, cramps, neck pain, headaches…

“And then there is fear.”

“Fear of what?” I asked.

“There are the memories of war and flight. Memories of loss.”

“How do you talk to your patients about these?”

“When I ask my patients about the war, I ask them about traumatic experiences like torture, witnessing torture etcetera or something else that they have experienced during the war and still remember.”

Reflecting briefly, he continued, “Interestingly, they never mention that their house was burnt. Never at all. And when I mention, ‘have they burnt your house?’ they say, ‘oh yes, everything was destroyed, but that was nothing in comparison.’ So, the burning of their house, the destruction of their economy was nothing in comparison to what they had gone through. You know, people relativise material things in these moments. It shows to me the resilience of Kosovar people. They are strong.”

“How do people cope, what makes them strong?” I probed.

“They are starting over by tackling the layers of suffering. Layer upon layer upon layer. The war, separation from family, inability to receive a good education, unemployment and poverty. 120,000 houses were burnt during the war. These are 12,000 families who had to start from zero. Half of the population.”

Dr Agani considered that most of them would benefit from therapeutic intervention to help them cope with their traumatic memories and ongoing hardship. However, many felt too ashamed to actually visit “a doctor for the crazies” and most could not afford a private practitioner such as Dr Agani in the first place. Nevertheless, he was satisfied with what he was able to achieve despite his lack of time and resources.

“Patients are getting better. Relapses are rare. I can only speak for myself, but I think that this is good work.”

Before I could ask another question, Dr Agani took a surprised look at his watch. Time had flown by. He had to rush to get his transit visa for a trip to Egypt. Politics was calling, mental health had to wait.

Author: Hanna Kienzler

[1] All interviews presented here were conducted between 2007 and 2008. Participants agreed to have their real names used considering that anonymity would be difficult to guarantee due to the small number of mental health professionals in Kosovo at the time.

[2] Kienzler, H. (2019). Mental health system reform in contexts of humanitarian emergencies: toward a theory of “practice-based evidence”. Culture, Medicine, & Psychiatry, 43(4), 636-662.

[3] Post-Traumatic Stress Disorder

[4] Kienzler, H. (2009). Kosovo’s masters and their influence on the local population throughout history. Anthropos, 499-517.

[5] Kienzler, H. (2012). The social life of psychiatric practice: Trauma in postwar Kosova. Medical Anthropology, 31(3), 266-282.


Share This Post