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The current round of fighting between Russia and Ukraine may end on the battlefields of Eastern Ukraine and Crimea, but Ukraine will continue to live with a threat on its border. The psychological effects of Russia’s invasion on Ukraine’s population will likely continue to do damage for years to come. This psychological damage is not just a symptom of the conflict but also a threat of strategic significance. The net effect of this trauma possesses the potential to erode Ukraine’s stability and threaten its long-term strategic defence. The countries that support Ukraine are in a position to help. NATO, and its partners, boast a number of techniques to help Ukraine with this strategic threat. Likewise, historical precedents exist which provide a model from which NATO and its partners can draw to support this type of intervention.
Ukraine is fighting for its life today and while it is important that its friends and partners help in that struggle, those outside the conflict zone enjoy the capacity to think about tomorrow. The NATO countries, and its allies and partners, must take steps to make sure that Ukraine does not buy victory in the current conflict at the expense of its future. Currently, Ukraine likely does not have the strategic capacity to worry overly much about the long-term effects the war will have on its future and stability. While, Ukraine’s friends and strategic partners can mitigate part of the threat when the conflict with Russia concludes through aid and reconstruction, some challenges cannot wait.
NATO, the NGO community, and NATO’s other global partners must take the steps to help mitigate the long-term impact of acute psychological trauma among Ukraine’s population, especially its children. While this may not seem an immediate problem, or even one to which the defence community should pay attention, the failure to act on it now will have significant impacts in the future. When contemplating the reconstruction of a country and reconstituting its forces, thinking often turns to damaged buildings and lost equipment. The human capital and the long-term resilience of a country can be much harder to repair and, for Ukraine, the time to begin is now.
The Psychological Impact of War on a State and its Society
The long-term threat that Post Traumatic Stress Disorder (PTSD), and particularly Complex PTSD, poses to the collective population of Ukraine should not be underestimated. For an individual, the spectrum of effects from PTSD may range from mild to severe; the aggregate impact of a significant PTSD caseload across Ukraine’s collective population can prove devastating and undermine the country’s long-term stability. The symptoms of PTSD include feelings of detachment or estrangement from others, and diminished interest or participation in significant activities. These are more commonly known as avoidance and behavioural withdrawal. The net effect of these symptoms can cause irreparable harm to both social stability mechanisms and to the very social systems of care which a person experiencing trauma requires creating net harm to civil society.
The collective, and long-term, PTSD problem can be magnified when the trauma occurs to a generation of children. The survivors of childhood trauma are prone to developing insecure attachments with adults. These insecure attachments prevent the child from developing meaningful and lasting relationships with other people, often continuing into adulthood. Children may suffer from complex traumas including from the loss of parents. When left untreated this may translate into persisting symptoms such as anxiety, hypersensitivity, social isolation and aggression issues, and exhibited severe emotional disturbances. These may present even when the children reach adulthood.
The collective, and long-term, PTSD problem can be magnified when the trauma occurs to a generation of children. The survivors of childhood trauma are prone to developing insecure attachments with adults.
The effects of PTSD on society go beyond the initial generation who suffered the trauma. When children experience significant trauma they are more prone to develop weak attachment relationships with their own children. Therefore, not only does the significant trauma retard their ability to trust others and their community but some pass this trait to their children.
The process of multi-generational, or historical, trauma has lasting adverse effects. At the community level, the manifestations are often lower levels of trust and communication, the loss of traditions, and higher rates of substance abuse and medical issues. The traumatic events inflicted onto a group generate elevated levels of collective distress and mourning inside of the group’s contemporary community. This may contribute to higher than average rates of child abuse, interpersonal violence, and substance abuse. In short, when one generation experiences wide scale trauma and it goes unmitigated, the event becomes a long-term cause of trauma for subsequent generations, which in turn, can have a major impact on societal stability. This means that Ukraine may emerge victorious from the war against Russia, but the widespread psychological trauma in Ukraine’s population may, if left unmitigated, prove devastating to the long-term stability and health of the Ukrainian state, and its population.
A Path Forward
Although many Ukrainians, both soldier and civilian, have likely suffered the effects of trauma during the Russian invasion, children, atrocity survivors, and the local defence volunteers are discrete populations of particular concern. Each of these populations will require somewhat different approaches in treatment. For example, children are likely to suffer from complex traumas including the loss of parents, safety, and networks of support and stability. There are also different complicating factors to accessing each population and being able to provide the care they need. These challenges create the requirement for a planned effort and a coordinated approach.
Ukrainian soldiers and defence volunteers exposed to extended periods of combat are at significant risk of PTSD and Complex PTSD. Studies of veterans with PTSD have shown that the majority (76%) have Complex PTSD; that is, they experience affective dysregulation, negative self-concept, and disturbances in relationships. Whilst there are a range of recognised treatments for PTSD, which are often effective on civilian populations, Complex PTSD frequently persists. Further, Complex PTSD is a severe disorder and as a result, standard treatments tend to result in improved function but do not address core symptoms. Contemporary reviews of randomised, controlled trials of cognitive processing therapy (CPT) and prolonged exposure therapy (PET) for military and veteran populations with PTSD found that both outperformed waitlist and treatment as usual. Forty-nine to seventy percent of both treatments achieved a meaningful symptom reduction. However, 60% to 72% of veterans continued to meet the criteria for PTSD after treatment. Non-response rates were high in follow-up studies. Researchers concluded that existing treatments need improvement and additional research is required to identify new interventions to address Complex PTSD.
A possible intervention for veterans is the use of virtual reality to facilitate exposure-based trauma therapy. Despite the fact that the cost of headsets has fallen significantly making this a practical solution, designing a particular program would require more research. The first study of the use of virtual reality to treat veteran PTSD was in 1991. Virtual reality (VR) immerses a participant in a computer-generated virtual environment that changes in a natural way with head and body motion. VR exposure was proposed as an alternative to imaginal exposure treatment for combat veterans with PTSD. A Vietnam combat veteran with PTSD was exposed to two virtual environments: a Huey helicopter flying over Vietnam and a clearing surrounded by jungle. The veteran experienced a 34% decrease on clinician-rated PTSD and a 45% decrease on self-rated PTSD. Treatment gains were maintained at six month follow-ups.
As the conflicts in the Balkans during the 1990s illustrate, civilians in war zones are at significant risk of PTSD, especially when also victims of atrocities. A range of treatments are effective for treating civilians traumatised by war. The treatments include trauma-focused cognitive behaviour therapy (CBT), cognitive processing therapy (CPT), and prolonged exposure therapy (PET). PTSD is commonly co-morbid with depression, particularly among refugees who have lost their homes, businesses, or family members. This can be treated by Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants. These include fluoxetine (Prozac), approved by the FDA in 1987, together with sertraline (Zoloft) and paroxetine (Paxil).
Children, who have lost family members in the conflict, or been forced from their homes to live in unfamiliar towns or countries, are also at risk of Complex PTSD. For refugees in general, narrative exposure therapy (NET) has been shown to be an effective initial intervention. Typically, small groups of people receive four to ten sessions of NET. With the guidance of the therapist, the child or adult creates a chronological narrative of his or her life. Children are coached to concentrate primarily on their traumatic experiences, but also incorporating positive events. The purpose of this approach is to provide context for the cognitive, affective and sensory memories of the traumatic experience. By expressing the narrative, the person fills in details of fragmentary memories and develops a coherent autobiographical story. In this way, their memory of trauma is refined and understood.
Psychological first aid (PFA) is the first intervention for civilians and children fleeing a war zone. Zahava Solomon and Rami Benbenishty’s study of forward psychiatry, conducted during the Lebanon War of 1982, laid the foundations for the psychological first aid for those suffering from acute stress reaction. In essence, PFA consists of the provision of a safe environment, food, sleep, medical care, and situational stabilisation to calm those who are emotionally overwhelmed or disoriented. PFA offers a framework for supporting people in ways that respect their dignity, culture, and abilities. Training in PFA includes being able to identify children and adults that are in distress and how to provide practical support to help them feel safe, connected, and able to take steps to help themselves.
Bringing any of these treatment methods to the scale that the conflict in Ukraine requires is an enormous task and a task that cannot wait. The challenge is one of resources and coordination. While some efforts are underway to address this looming crisis, they are scattershot and localised. Further, the nature of the dispersion of refugees and internally displaced persons (IDPs) further complicates matters. As Ukrainian refugees have spread across Europe and globe, they have become dependent on the services of their respective host nation. There is no centralised means to provide support to mitigate the effects of trauma. Closer to the conflict zone there are a number of actors each trying to help across a spectrum of challenges but little collective coordination.
Within Ukraine itself, the Ukrainian government is trying to achieve what it can but the scope and scale of the need is far beyond its current capabilities. As President Zelensky recently stated, the reality of Ukraine’s “neighbourhood” is such that the ongoing war with Russia is unlikely to be its final war. Ukraine’s ability to maintain a resilient population will be a key determinant of its ability to resist Russia in the long-term. Treating psychological trauma in Ukraine is a crucial aspect of building and maintaining national resilience, and it is one in which NATO has an important role to play.
NATO and partner militaries may not have sufficient psychological support capabilities to render the assistance the crisis requires but this does not mean that they do not have a part to play. The 2004 tsunami that rocked Southeast Asia provides an important example for how to address analogous problems in Ukraine. During the disaster, the US military established Combined Support Forces 536 (CSF-536) to coordinate and resource the humanitarian response. Non-governmental organisations (NGOs) and intergovernmental organisations (IGOs) provided the resources in which they specialised because CSF-536 coordinated the logistics and provided a planning element to harmonise prioritisation. Rather than a number of individual relief efforts CSF-536 allowed for the focused allocation of relief. In addition, the US military provided the type of logistics capacity in which it specialises which allowed NGOs and IGOs to focus on their specialties and help them get their resources to where the need was greatest.
In the case of Ukraine, NATO and its partners should follow a model based on CSF-536. PFA requires the existence of a safe environment. NATO militaries and their partners should establish such locations in the countries bordering Ukraine. These sites will allow Ukrainian civilians an opportunity to rest, obtain psychological assessments, and participate in PFA before they move on to their host countries. These facilities could help with initial care and help the refugees to receive targeted services in their final host countries. NATO militaries may lack sufficient capabilities to provide treatment in such facilities, but many specialised organisations do possess the required expertise in psychological trauma to help, but lack the logistics backbone to coordinate a response at the required scale.
NATO should look towards historical organisations, such as CSF-536, as a model for coordinating an international response to the Ukrainian crisis. Further, Ukraine’s partners should develop nascent capabilities that can move into Ukraine as soon as possible (or immediately upon a ceasefire) to provide care to Ukrainian soldiers, volunteers, and civilians.
NATO and its partners will undoubtedly develop plans to rebuild the physical infrastructure and physical resiliency of Ukraine. Doing so while neglecting the resiliency of the population of Ukraine will render the physical reconstruction less effective. While rebuilding Ukraine may be able to await the cessation of hostilities, provide help to those at risk from psychological trauma cannot. To prevail against Russia in the long term, Ukraine needs the type of stability and resiliency that only a population free from the widespread and unmitigated effects of trauma can achieve. This means that for NATO, and Ukraine’s other partners, providing PFA and treatment for psychological trauma is not only a matter of humanitarian aid — it is a strategic necessity.