APPLICATION OF AN ECOLOGICAL FRAMEWORK TO CLINICAL PRACTICE WITH ADOLESCENTS: TRANSGENERATIONAL TRANSMISSION OF WAR-RELATED TRAUMA IN BOSNIA AND HERZEGOVINA

In the period between April 6, 1992 and December 14, 1995, an estimated 102,622 people were found to have died due to war-related causes in armed conflicts in Bosnia and Herzegovina. Of those killed in the war in Bosnia and Herzegovina it is estimated that 54% were civilians. The war profoundly affected the civilian population, which was subjected to mass killings, the systemic use of rape and sexual violence, and the physical and psychological torture inside concentration camps. This case study paper has four aims. First, it highlights the complexity and severity of the traumatic psychological effects of the war in Bosnia and Herzegovina on its citizens, including the effects of the war on the generation born during or shortly after the war. Second, the paper proposes a heuristic in the form of a broader theoretical approach; an ecological analysis of human development (Bronfenbrenner, 1989). This approach aims to provide a framework for research and the development of intervention strategies for the adolescent children of adult war survivors who have been affected by war-related trauma. Third, the paper presents a case vignette of an adolescent to demonstrate the application of the ecological framework to clinical practice with adolescents. Finally, we explore how the current cultural, political, and societal realities in Bosnia and Herzegovina affect the population in general and the children of war survivors in particular. The transition from a state of war to peace is a long and continuous process with residual effects of violent conflicts permeating the broader society and its * Corresponding author: Assoc. Prof. Dr. Mirsad Serdarević, Applied Clinical Psychology, The Chicago School of Professional Psychology, Southern California Campuses, E-mail: mirsad.serdarevic@gmail.com. Epiphany Journal of transdisciplinary studies Application of an Ecological Framework... M. Serdarević and S. Tahirović 10 Epiphany: Journal of Transdisciplinary Studies inhabitants, even after the war’s official end over 23 years ago. The authors argue that roles of psychologists and other mental health providers should expand beyond traditional focus on intrapsychic problems. Rather, effective treatment strategies should also include recognition of and attenuation of the larger systemic stressors that patients experience on daily basis. This could be accomplished through collaboration among psychologists and patients, patients’ families, teachers, and community members, all of whom directly or indirectly affect patients’ treatment outcomes.


INTRODUCTION
The war in Bosnia and Herzegovina profoundly affected the civilian population, which was subjected to mass killings, systemic use of rape and sexual violence, and physical and psychological torture inside concentration camps. In an effectiveness study of U.S.-based Bosnian refugees who experienced multiple forms of trauma, it was shown that the sources of trauma included civil war, combat exposure, loss of loved ones, bombings, with nearly two-thirds of respondents also reporting torture (Schulz, Resick, Huber, & Griffith, 2006). Further, a strong association was demonstrated between psychiatric disorders (depression and posttraumatic stress disorder [PTSD]) and disability among Bosnian refugees, both upon initial assessment (Mollica, et al., 1999) and upon follow-up (Mollica et al., 2001).
The war in Bosnia and Herzegovina was characterized by the use of extreme violence against civilians (Mrvic-Petrovic, 2001). The psychological effects of trauma are expected to be more severe if the exposure to trauma and traumatic events were prolonged (e.g., Herman, 1997), consistently endured, and included several different sources of trauma including death, proximity to death, rape and sexual violence and proximity to rape and sexual violence, and concentration camp imprisonment, along with familial proximity to those imprisoned in concentration camps.
In the period between April 6, 1992 and December 14, 1995, an estimated 102,622 people were found to have died due to war-related causes in armed conflicts in Bosnia and Herzegovina (Tabeau & Bijak, 2005). Of those killed in the war, it is estimated that 54% were civilians (Tabeau & Bijak, 2005). Further, the war was marked by the systematic use of sexual violence and rape (Skjelsbaek, 2006). In addition to the above documentation, attempts to estimate the number of these crimes have also been made (e.g., CID, 2002;Meznaric, 1994). According to Meznaric (1994, p. 92) there is general agreement on the following points: • there were at least several thousand victims of mass rape; • many rape victims were young girls between the ages of seven and fourteen; • rape was often committed in the presence of the victim's parents or children; • the rape victim was raped by several assailants (Meznaric, 1994, p. 92).
Skjelsbaek (2006) notes that extant "research literature on these crimes emphasizes that sexual violence was carried out in order to humiliate, or destroy, the identity of the victim, and that this was the way in which the violence constituted a weapon of war" (e.g., Allen, 1996;Gutman,1993;Nikolic-Ristanovic, 2000;Stiglmayer, 1994, as cited in Skjelsbaek, 2006. It is important to emphasize that the transition from a state of war to a state of peace is a continuous process, and even though the war in Bosnia and Herzegovina officially ended on December 14, 1995, the residual effects of violent conflicts are expected to permeate the broader society long after the war's official end. Demeny (2011) argues that the aftermath of a violent conflict such as that in Bosnia and Herzegovina not only affects individuals, families, households, and their proximal or distal sociocultural environment during the war, but also, for a period after the war-impacts a society's political context, power relations, and the civilian population's socioeconomic situation. For example, Oberschall (2000) proposes the concept of a cognitive frame to explain that ethnic relations in postwar Bosnia and Herzegovina, while mostly operating under a cooperative frame, are also influenced by and based on memories from the Balkan wars, which the elites use to spread ethnic hatred, insecurity, and fear, all of which activates a crisis frame. It could be argued that, on a broader societal level, such an anxiety-inducing atmosphere could have negative effects on a population in general and on survivors of war-related trauma in particular. This is an important factor to consider when evaluating parent-child dyads of parents with war-related PTSD and their children, as the parent-child dyad may be one in a constellation of causes of distress in children and adolescents in postwar Bosnia and Herzegovina.
This case study has four aims. First, it highlights the complexity and severity of the traumatic psychological effects of the war in Bosnia and Herzegovina on its citizens, including the effects of the war on the generation born during or shortly after the war. Second, the paper proposes a heuristic in the form of a broader theoretical approach; an ecological analysis of human development (Bronfenbrenner, 1989). This approach aims to provide a framework for research and the development of intervention strategies for the adolescent children of adult war survivors who have been affected by war-related trauma. Third, the paper presents a case vignette of an adolescent to demonstrate the application of the ecological framework to clinical practice with adolescents. Finally, we explore how the current cultural, political, and societal realities in Bosnia and Herzegovina affect the population in general and the children of war survivors in particular. The transition from a state of war to peace is a long and continuous process with the residual effect of violent conflicts permeating the broader society and its inhabitants, even after the war's official end over 23 years ago.

The Ecological Model
Studying the experiences of adult war survivors and their children requires a heuristic in the form of a broader theoretical approach. In this review study, we thus selected the ecological analysis of human development (Bronfenbrenner, 1989) (see Figure 1) to inform our arguments. Bronfenbrenner's (1989) ecological model states that individuals are embedded within multiple levels of ecology, with each ecological level exerting influence on the individual's development, while the individual may be empowered to exert his or her own influence on various levels of ecology, a concept better understood as bidirectionality. The following levels of ecology make up Bronfenbrenner's framework: the individual, the microsystem, the mesosystem, the exosystem, the macrosystem, and the chronosystem. Bidirectionality refers to the environment-individual dynamics that involve the individual's abilities to exert influence on the environment, while the environment also exerts influence on developing an individual. The ecological model has been argued as an optimal systems approach that allows conceptualization and responses to trauma at the individual, family, community and societal levels (e.g., Awad, Kia-Keating, and Amer, 2019;Hoffman and Kruczek, 2011). To authors' knowledge, no such approach has been used in Bosnia and Herzegovina in provision of mental health services.
The microsystem consists of individuals (e.g., parents, teachers) and communities (e.g., school) with whom the individual comes into direct contact. Much of an adolescent's daily experiences occur within the microsystem.
The mesosystem represents the quality of relationships in an individual adolescent's microsystems, but does not include the adolescent. For example, the relationship between an adolescent's parents would be considered on the mesosystemic level of an adolescent's ecology.
The exosystem consists of one or more interconnected settings in which the individual is not directly involved, but which have an effect on an individual (e.g., state policies that determine funding for mental health services, school enhancement, or prevention programs). For example, an adolescent may not have access to mental health services at school as a result of public health policy.
The macrosystem represents society's social blueprint and consists of cultural norms, values, and social structures. For example, macrosystemic factors may include Bosnians' beliefs about the political system and its ability to bring about positive change, or distrust of opposing political views tied to wartime politics.
Finally, the chronosystem represents the development of relationships among individuals and their environments over time (e.g., historical eras; political relations) (Serdarevic & Chronister, 2005).
Note: Chronosystem, which represents change over time, is not represented in the figure.

Extant Literature on the Transgenerational Transition of War-Related Trauma
The transgenerational transition of war-related trauma has been explored in the past with regard to Vietnam veterans and their children. For example, in the study conducted by Rosenheck and Fontana (1998), children of Vietnam veterans with PTSD have shown to be at a higher risk for behavioral, academic, and interpersonal problems. According to the study, compared to children of non-combat Vietnam era veterans who do not have PTSD, the children of veterans with PTSD are perceived to be more depressed, anxious, aggressive, hyperactive, and delinquent by their parents. Further, the children of veterans with PTSD are perceived to have difficulty establishing and maintaining friendships. According to the authors, family discord and dysfunction can make it challenging for adolescents to establish positive attachments to parents, making it difficult for children to create healthy relationships outside the family. Finally, additional research indicates that children may have particular behavioral disturbances if their veteran parent participated in abusive violence (i.e., atrocities) during their combat service (Rosenheck & Fontana, 1998).
Veterans with PTSD have been shown to have similar effects on adolescent children as they do on younger children (Dansby & Marinelli, 1999). Compared to adolescents whose fathers were not veterans, adolescents whose fathers served in combat roles in Vietnam showed more negative attitudes toward their fathers, poorer attitudes toward school, lower scores on creativity, and higher levels of depression and anxiety (Dansby & Marinelli, 1999).
These findings serve as a key reminder that it is important to not only target our interventions on individual adolescent children, but, ideally, on the entire family. Further, given the complex societal effects on adolescents whose parents suffer from PTSD, it is important to propose, informed by the ecological model, an overarching prevention, advocacy, and psychological treatment approach to the treatment of PTSD for both parents with PTSD and children/adolescents of parents with PTSD. Suggestions for such an overarching intervention approach are summarized in Table 1. Rather than focusing intervention on one level of ecology, the model encourages engagement with educators and policy makers to assure better treatment opportunities and reduce factors that may contribute to the retraumatization of individuals and their children (e.g., TV news format and the emphasis on coverage of aggressive politicians with covertly violent messages).
According to the fifth edition of the Diagnostic and Statistical Manual of Mental health Disorders (DSM-5), for children aged seven years old and older, PTSD diagnostic criteria include four clusters of symptoms that emerge following exposure to various traumatic events. Our focus is on a child's learning about the traumatic event(s) occurred to a parent(s) or caregiving figure, child exposure to a parent's PTSD symptomatology (e.g., irritability, anger, impulsive behaviors, increased arousal), and societal contributions to a child's belief that the world is not safe (as a consequence of both the home environment and societal messages).

Case vignette
To better illustrate how the ecological model helps inform our clinical practice we present a case vignette, which demonstrates both individual interventions and the additional strategies listed in Table 2. Note that all case materials are disguised to protect patient privacy and confidentiality. The information is provided for illustrative purposes only and is not intended to direct how treatment should be provided in a particular case. After her return to Tuzla, Aida formed a relationship with a man who became addicted to some "serious drugs." During this relationship, the atmosphere at home was rather chaotic, which included frequent arguments to which Samir was exposed. Over the 10-month relationship, Samir also experienced verbal and physical abuse by his mother's boyfriend. Although Aida is currently in a more supportive and peaceful relationship, the presence of a "stranger" at home makes Samir anxious. Also, Samir reports feeling "uneasy" when he watches TV news with his mother as she seems very upset whenever the news covers stories related to the war in the 1990s.

Samir is a 13-year-old boy who is currently in the seventh grade. Born in
In addition to the aforementioned situations, Samir dealt with emotional and physical abuse by his peers in childcare and kindergarten while in Germany. As a result, he refused to go to school and he suffered from psychosomatic symptoms (e.g., vomiting and headaches). His mother eventually moved Samir to another school.
For Case conceptualization of Samir, based on the proposed ecological model, please refer to Table 2.

Discussion
The case study presented in this article highlighted the complexity and severity of the traumatic psychological effects of the war in Bosnia and Herzegovina on its citizens, including such effects on the generation born during or shortly after the war. By using a heuristic, in the form of an ecological analysis of human development (Bronfenbrenner, 1989), the present study proposed a framework for clinical research as well as intervention strategies for the adolescent children of war survivors who suffer from war-related trauma. The case conceptualization of the adolescent in this study aimed to demonstrate the application of this ecological framework in clinical practice.
The cultural, political, and societal realities in Bosnia and Herzegovina have greatly affected the population in general, and the children of war survivors in particular. Indeed, the transition from a state of war to peace is a long and continuous process in which the residual effects of the violent conflicts permeate society as a whole. In this case, the perpetrators of war crimes and their victims spoke the same language, they often lived close to one another before the conflict, and they even knew one another. For them, transitioning from a state of war to peace is even more complex. Moreover, the current political climate of Bosnia and Herzegovina has not significantly changed (e.g., Less, 2016;Kartsonaki, 2016;Tamkin, 2018) compared to the pre-war and wartime periods, thus making it more difficult for survivors suffering from war-related PTSD to recover and function in society. For example, Kartsonaki (2016) describes Bosnia and Herzegovina as being in "a dire political, social and economic deadlock" (Kartsonaki, 2016, p. 497). Further, Kartsonaki argues that continuous Republika Srpska's secessionist claims and referendum rhetoric continue to threaten the country's security. While the referendum is unlikely in the foreseeable future the mere existence of this rhetoric engenders a sense of insecurity (Kartsonaki). In the context of war-related trauma and PTSD, such rhetoric, especially when repeated almost consistently on the local news, could have an effect on people in general and on those who survived the war in Bosnia and Herzegovina in particular as such rhetoric communicates a realistic threat of future conflicts.

Conclusion
In sum, the roles of psychologists and mental health providers should be expanded beyond the traditional focus on intrapsychic problems. Psychologists should also recognize interaction between their psychiatric symptoms and the larger systemic stressors that patients experience on a daily basis. As such, psychologists must also serve as advocates who urge local and state governments to provide more resources for psychosocial support. Finally, psychologists must focus on the larger context in which they collaborate with the patients' parents, teachers, and community members, all of whom directly affect the health and well-being of the patients themselves.