Kennan Cable No.13: What Ukraine Can Learn from Other Countries’ Experiences with PTSD
Photo: Ukrainian soldiers walk outside a hospital in Artemivsk, February 18, 2015. REUTERS/Gleb Garanich
Despite continuing reports of sporadic shelling in eastern Ukraine and breaches of the Minsk agreement, there is hope that the heavy fighting may be drawing to a close. But the human toll of the war will continue to be felt in Ukraine for a long time to come, especially the psychological wounds that the war has inflicted on the country’s soldiers and the civilian population. Already in May 2015, when I was visiting Ukraine to investigate the issue, and when the first 30,000 (out of an estimated 240,000) combat troops had just been demobilized, many were sounding the alarm about the psychological impact of the war. Gun violence in Kyiv was said to be on the rise, and the military psychologists I spoke with noted trauma accounts among their clients. Since then, multiple articles have appeared in the press describing veterans’ struggles with the psychological trauma of war, especially the sequela known as post-traumatic stress disorder, or PTSD (see here and here for examples),.
Over the past decade, PTSD has become one of the central concerns of those in charge of military health care in the West. PTSD can manifest with anxiety, hypervigilance, nightmares, insomnia, anger, and violent outbursts. These symptoms are often compounded by feelings of shame, survivor’s guilt, and feelings of negative self-worth. It can also result in emotional withdrawal and isolation, particularly when the veteran feels that close others cannot relate to his or her feelings.
These problems are not confined to individual soldiers’ lives. They create a complex psychosocial phenomenon that affects the soldier, the soldier’s immediate family, and the community at large. PTSD can result in difficulties with reintegration, securing and keeping jobs, maintaining a normal family life, and taking care of one’s health. Alcohol and drug abuse are common, as are family and workplace conflicts. Among the most disturbing consequences of untreated PTSD are increased rates of homelessness and suicide.
Some of these issues are already making their presence known in Ukraine. In a recent discussion at the U.S. Institute of Peace, Natalia Karbowska, chair of the Ukrainian Women’s Fund and adviser at the Global Fund for Women, pointed to an uptick in violence against women in the families of demobilized soldiers, a phenomenon first registered in western Ukraine’s Volyn region, which was among the earliest to send volunteer fighters to the east. Speaking on the same panel, Ambassador Melanne Verveer, executive director of the Georgetown Institute for Women, Peace and Security, emphasized that without reintegration programs for demobilized soldiers, Ukraine is likely to see a significant increase in domestic violence.
The problem of psychological rehabilitation for Ukraine’s soldiers should not be relegated to the back burner.
Some troubling statistics on suicide and noncombat-related deaths among Ukraine’s troops are also becoming available. Out of the 2,027 military personnel deaths reported by the government in 2014–2015, 597, or nearly 30 percent, could be attributed to non-battle circumstances. Of these, 171 deaths were suicides and 137 were caused by accidents. (Experts tend to attribute the higher rate of accidents to psychological trauma and associated risky behaviors.) High levels of alcohol abuse at the front have also been reported, and Karbowska reported that women’s rights organizations have gathered anecdotal evidence of sexual violence against the female civilian population in proximate areas.
How serious a concern should the effects of war-related trauma be at this time for Ukraine’s policymakers and the international community working to help the country? The experience of the afgantsy—the soldiers who fought in the Soviet Union’s 1979–1989 campaign in Afghanistan—provides a perspective. Thousands of Ukrainians participated in the Afghanistan campaign, which saw 620,000 Soviet soldiers engaged. Ukraine suffered the second largest losses, after Russia, so the following overall numbers can help us get a perspective.
By 1989, 3,700 veterans of the Afghanistan campaign had been imprisoned. Three quarters of all families of afgantsy had experienced divorce or significant domestic abuse and disturbances. Similarly, 75 percent of the veterans had been fired or had changed jobs frequently because of conflicts in the workplace. Ninety percent of students who had fought in Afghanistan were doing poorly academically, and 60 percent suffered from alcoholism and drug addiction.Testing done in the early 1990s in Russia showed that 35–40 percent of those who had fought in the campaign were in dire need of psychological counseling.
The above suggests that the problem of psychological rehabilitation for Ukraine’s soldiers should not be relegated to the back burner. Here international experience with combat-related PTSD should provide some useful guidance for Ukraine as the country addresses this problem. There is as well a role for the international community to play in providing assistance.
PTSD in International Context
Levels of war-related PTSD vary widely across different countries’ armed forces. They range from 1–2 percent in Israel to 10 percent in Canada and the UK to 15–25 percent in the United States. These figures further vary for different veteran subpopulations with veterans of earlier wars tending to exhibit higher rates. In the U.S., some 35 percent of American Vietnam War veterans who saw battle before the U.S. military began to seriously address the issue suffer from PTSD. The original rate of PTSD among veterans of Israel’s 1973 Yom Kippur War—the first time Israel encountered this issue on a large scale—was 20 percent, declining to 6.8 percent 32 years later.
There are other differences as well. U.S. troops suffer from a staggering 22 military suicides per day, or nearly one soldier committing suicide every hour of every day. More active-duty troops in the United States have committed suicide since 2001 than were killed in the American campaign in Afghanistan (though some argue that this number tracks fairly closely the general suicide rates in the United States, and should be viewed in that context). In contrast, suicide rates are fairly low in the Israel Defense Forces (IDF), ranging from 28 total cases in 2010, to 21 in 2011, to 7 in 2013 and 15 in 2014. Troop suicide is so rare that when three Israeli troops committed suicide after Operation Protective Edge in the summer of 2014, it became a subject of public discussion.
The high level of homelessness, especially among American veterans, is another example of the social costs of PTSD. The U.S. Department of Housing and Urban Development estimates that 49,933 U.S. veterans lack shelter on any given night. The National Coalition for Homeless Veterans, a nonprofit dedicated to serving former American servicemen, notes that while this may have to do with the “shortage of affordable housing, livable income and access to health care,” an additional contributing factor is that “a large number of displaced and at-risk veterans live with lingering effects of posttraumatic stress disorder (PTSD) and substance abuse, which are compounded by a lack of family and social support networks.” Some 12 percent of the adult homeless population in the United States are veterans.
Military cultures have traditionally been hostile to the notion of psychological help.
The difference in PTSD rates across different militaries suggests that some strategies work better than others. A few factors appear to play a particularly prominent role in whether or not PTSD manifests in troops and the extent of it.
Availability of Professional Help and Troop Education and Training
Israeli experience suggests that the most successful psychological interventions begin long before combat. Pre-combat education and training are a central element of this approach, as are timely interventions during combat. So critical is the time factor that the IDF now teaches soldiers to recognize the symptoms of acute psychological shock in their comrades and to counter them on the battlefield, before the shock hardens into long-term trauma.
Treatment for psychological shock has become a routine part of first aid both in the IDF and among the civilian population. Even in the absence of physical wounds, soldiers are treated for shock when necessary. (The same is true for civilian victims of terrorist attacks.) At the same time, in the IDF, professional psychological help is available at all times: before, during, and after engagement. Besides the value of having professional help close at hand at all times, this helps the soldiers develop a relationship of trust with the psychologist, which in turn makes it easier for them to ask for help when needed.
Normalizing Psychological Trauma and Encouraging Help-Seeking Behavior
Military cultures have traditionally been hostile to the notion of psychological help. Whereas physical wounds have been viewed as marks of honor, psychological wounds have been dismissed or, worse, viewed as a sign of weakness. Laboring with such a narrow definition of mental strength, soldiers have been conditioned to avoid seeking help, in the belief that they should be able to handle emotional stress by themselves.
In recent years, this perspective on mental health in the military has begun to change. The U.S. Department of Defense, for example, has invested $2.7 million in its Real Warriors public health awareness campaign, whose goal is to encourage help-seeking behavior in soldiers. One of the most powerful aspects of the campaign entailed enlisting commanding officers to share publicly the stories of their own struggles with PTSD. Policies have been introduced to ensure that those receiving mental health care are not automatically disqualified from promotion or the ability to obtain a high-level security clearance.
In a similar vein, the UK Ministry of Defense has invested £7.4 million to support the mental health of its personnel, including a 24-hour Combat Stress helpline, another called Big White Wall, and a public awareness campaign dedicated to destigmatizing PTSD called Don’t Bottle It Up.
Perhaps one of the most important dimensions of these campaigns has been to reframe the language in which PTSD is discussed. Rather than referring to psychological problems, for example, the Real Warriors site speaks of “invisible wounds,” linking physical wounds with psychological ones and diminishing the stigma of PTSD. It also refers to psychological help as a form of resilience training, which can help a soldier view accessing help as part of his training to become a better warrior.
Building the Social Environment for Reintegration
On a practical level, a returning soldier’s top priority is securing employment, housing, and benefits so as to feel a useful member of society. This reintegration is critical for recovery, allowing the veteran who may be struggling with psychological issues to reestablish a sense of dignity and self-respect in civilian context. It is especially important if the soldier has also been physically injured and is facing disability. But the society to which the soldier returns plays an important role as well.
In a recent article titled “How PTSD Became a Problem Far beyond the Battlefield,” Sebastian Junger wrote: “Recovery from war is heavily influenced by the society one returns to, and there are societies that make that process relatively easy.”
It turns out that such factors as social cohesion and a shared sense of purpose, which can help bridge a divide between the returning soldier and the society, have a significant impact on how well a soldier reintegrates into society. Societies in which a majority of the adult population serves offer a better environment for reintegration, as universal conscription helps reduce the veteran’s feelings of isolation and the perceived lack of understanding on the part of the civilian population.
The Israeli system, in which 60 percent of the adult population are conscripted (essentially all but the ultra-Orthodox Jews and Arab citizens), is a case in point. The society as a whole shares a fundamental sense of unity and purpose. In addition, any separation between the army and the society is minimal. In contrast to U.S. service members, who constitute just 1 percent of the population and endure months-long deployments to distant locations, Israeli soldiers in noncombat situations can go home every weekend. For the soldier, this minimizes the sense of living in a separate reality and diminishes the problem of readjustment.
Ukraine’s Experience Today
Psychologists have played an active role in today’s Ukraine from the early days of the Euromaidan. Elena Podolyan, founder of the Forpost volunteer services network in Dnipropetrovsk, which provides psychological and legal help to veterans, was one of them. During our meeting in Dnipropetrovsk in May 2015, she told me that as a trained psychologist on the Maidan, she immediately realized that the stress of the protest was exerting a tremendous toll on the participants. “Someone experiencing a stress reaction might be considered an agent provocateur,” she said. “Someone looks at you askance, and you could explode.” She and her colleagues frequently intervened to defuse tense situations. “We were never without work,” she said. “We were always needed.” They became known as Maidan’s “psychological hundred.”
One of the organizations that grew out of that experience was the volunteer-based Ukrainian Association of Specialists in Coping with the Consequences of Psycho-Traumatic Events (“Українська Асоціація фахівців з подолання наслідків психотравмуючих подій"), headed by Volodymyr Pogoriliy. According to Natalia Shaposhnik, military psychologist, member of the Board of Directors, and former coordinator for the Association’s military personnel services, the group rapidly expanded to 19 regions of Ukraine. By August 2014 it included 500 psychologists assisting troops both inside and outside the war zone. Much of the psychologists’ work involved conducting awareness training with newly mobilized soldiers and their commanding officers. They worked to “normalize,” or explain, stress reactions and taught stress-coping techniques.
Today, volunteers from the group continue to work with demobilizing soldiers. Many team up with lawyers to help soldiers get the status required for them to receive veterans benefits. They also double as informal employment agencies.
In September 2014, with advice from volunteer groups, the government created its own psychological service and a state agency for veterans affairs and participants in the Anti-Terrorist Operation (ATO), Ukraine’s name for its war with Russia. These agencies are working to devise a unified government policy on the subject. Nevertheless, the lion’s share of providing psychological support for both active-duty soldiers and veterans continues to be shouldered by volunteer psychologists. However, Ukraine’s ability to serve its demobilized soldiers is hampered by an economic crisis and a shortage of funds. The country is attempting to reform its political system while in a state of war. Beyond those major impediments, several other historical and cultural factors also have a direct impact on the nation’s ability to offer mental health support to returning veterans.
The Stigma of Providing or Receiving Psychological Treatment
To a considerable degree, the psychology profession in Ukraine continues to struggle under the heritage of Soviet-era abuses, when psychology was associated with “strait jackets and medicines that turn a person into a vegetable.” In addition, as Dr. Valentina Bondarovskaya, who heads Ukraine’s Rozrada (Comfort) center, told me, Soviet psychologists focused on research rather than on clinical work. These two circumstances, the legacy of the Soviet medical system, have contributed to shortages of both generalist and military counselors and psychiatrists in Ukraine today. And as with other professions in Ukraine, corruption has contributed to discrediting the field, with diplomas bought and sold on the market.
The unfortunate consequence, as Dr. Tina Beradze, a psychiatrist in Kyiv, observed in our conversation, is that it is impossible to separate the stigma of working in the profession from the stigma of receiving treatment. Volunteer psychologists working with troops told me that soldiers often refuse to ask for help because they don’t want to be viewed as crazy.
Ukraine is experiencing a particular shortage of military psychologists—in part, because its universities have not offered this as a separate specialization track. Generalist psychologists serving troops as volunteers have tried to fill in gaps in their training as opportunity allows. Trainers from other countries, including Canada, the United States, Croatia, and Israel, have come to Ukraine to offer free training. However, this effort has on the whole been fragmented and inadequate to the need. One result is that gaps in quality of care exist.
All of this means that many opportunities to offer timely and skilled psychological help have already been lost. Troops who fought the heaviest battles of the war, for whom psychological training and assistance would have been invaluable, will be bearing the consequences, as will the society to which they are now returning.
Moreover, there is some expectation that psychological help will continue to be offered for free by volunteers. There are no budget allocations to begin changing the picture. And while the upsurge in war-related volunteerism has become a powerful symbol of the new Ukraine and indicative of the strength of its civil society, volunteer burnout is already a reality. Even though many volunteer counselors see the psychological support of the troops as their highest mission, there is a danger that the dropout rate will increase.
Yelena Podolyan told me that in a war situation, psychologists are the second largest group after soldiers to fall victim to psychological stress.
Social Factors Limiting Assistance
It is difficult to know how welcoming Ukraine’s social fabric will be to the returning veterans. The country has demonstrated tremendous patriotism and solidarity with its troops. The level of volunteer participation in the war effort has been extraordinary, and the war is viewed as just by an overwhelming proportion of the population in government-controlled areas of Ukraine. Other countries’ experiences suggest that these factors bode well for a smoother reintegration for returning veterans, as they may help create the kinds of conditions that reduce the separation between fighters and civilian population.
However, demobilizing soldiers are encountering multiple problems. Chief among them are bureaucratic hurdles to securing benefits. It has been notoriously difficult for demobilized volunteer soldiers to acquire the necessary documents to receive benefits, pointing to a widening gap between professional military personnel, on the one hand, and volunteer combatants and conscripts on the other. Servicemen in the latter two categories face an uphill battle getting the status of an ATO combatant. Without this status, Ukrainian law views them as reservists, who are not eligible for military pensions and benefits. The government representatives I spoke with believe that the process is straightforward, but volunteer psychologists working directly with soldiers view the process as convoluted for everyone and nearly impossible to wade through for anyone suffering from psychological distress.
Several volunteer psychologists and veterans themselves have reported that this may result in Ukraine’s volunteer soldiers developing a perception that the state used them to plug holes and is now discarding them. Some have floated allegations of incompetence and even outright betrayal against commanding officers in charge of some of the most traumatic battles of the war, such as Ilovaisk. This is the sort of fraught environment that can fuel anger and violence in an already distressed veteran population.
To counter problematic social situations, some veterans have formed organizations geared toward supporting their own. In Kyiv, Taras Kostanchuk, a former assault group commander with the Donbas volunteer battalion, formed a veterans organization called Spravedlivost (Fairness). Its practical objective is to help his comrades-in-arms get benefits, and support each other as they do so: the Donbas battalion suffered the greatest losses at Ilovaisk. The former Donbas fighters have renovated a building and use it to live together. They are gainfully employed, with most providing protection services.
Professional psychological help is supposed to be available. Eventually Kostanchuk hopes to help his comrades secure their own housing—one of the promised yet hard-to-get veteran benefits. In the meantime, the ex-fighters are able to offer one another peer support. And there is a bigger purpose that unites the group: Kostanchuk’s ambition is to see that the top commanding officers, who are viewed by many as having abdicated their responsibilities at Ilovaisk, face justice. All of this appears to be as close an approximation as one could wish to an ideal social environment conducive to veterans’ healing.
As the U.S. National Coalition for Homeless Veterans notes, “The most effective programs for homeless and at-risk veterans are community-based, nonprofit, ‘veterans helping veterans’ groups. Programs that seem to work best feature transitional housing with the camaraderie of living in structured, substance-free environments with fellow veterans who are succeeding at bettering themselves.”
Forpost, the volunteer services network in Dnipropetrovsk, is working to create something similar. The group was fortunate to secure support from a local donor to open a veterans’ home. The home, to be run by the veterans themselves, is to be used for social gatherings and as a safe haven by veterans who may need to escape their daily reality: there are beds on the second floor, and one can stay there for a few nights. Yelena Podolyan is negotiating contracts with local organizations to secure employment for the veterans. She is also working with volunteer lawyers and social workers to help demobilized soldiers acquire the documentation they need to be eligible for benefits, to help them get job skills training and find ways to support their families. These safe havens may be particularly helpful, in light of the widespread lack of understanding of the problem among the general population.
What to Do
The PTSD problem facing Ukraine is not going to be limited to the troops. An estimated 5.5 million Ukrainian civilians have experienced the trauma of war, including the 2 million living on either side of the cease-fire line in the east (four million total) and the 1.5 million internally displaced persons in Ukraine. Most of these are women, children, and the elderly.34 Many of them have undergone significant trauma, such as bodily injury, death of loved ones, violence, destruction of the family home, and prolonged periods without adequate food, water, or any assurance of personal safety. On top of that, thousands of civilians were part of the violent events on the Maidan and later traveled to the war zone as volunteers, delivering supplies, supporting prisoner exchanges, even recovering bodies. The cumulative traumatic experience of the nation is likely to have an impact on its ability to recover not just psychologically but also economically.
If a silver lining can be found in all this, it is that Ukraine need not reinvent the wheel. It can learn from past mistakes by turning to international best practices developed out of other nations’ experiences. But to do so, it needs to abandon the piecemeal, disjointed efforts that have characterized its approach so far and adopt strategic, long-term thinking. And for that, it needs the support of the international community.
Helping a nation’s soldiers heal their wounds is a highly complex task that spans government policy, professional training, ethics, and social values.
The following recommendations are aimed both at Ukraine and at the international community:
• First and foremost, the state and civil society should recognize that psychological trauma is one of the major psychosocial issues Ukraine will likely be facing in the near term and going forward, affecting not only demobilizing soldiers but also the civilian population. Public health, family structures, national productivity, and population mortality are among the state level concerns that will be adversely affected.
• Both the Ukrainian government and the international community should think strategically when approaching this issue. Rather than piecemeal approaches crafted to address immediate needs, a cohesive strategy is needed to achieve long-lasting results.
• State-level agencies responsible for trauma education and treatment should look to the international community for guidance. Despite certain factors unique to Ukraine’s situation, the problems it faces, and the mistakes it is making, in handling war-related PTSD and other forms of psychological trauma are common and well understood in other countries.
• A group of international advisers should be engaged to work with Ukraine’s government and civil society to help develop an integrated, multidimensional approach to combat-related trauma using evidence-based, state-of-the-art techniques. The Israeli experience in particular appears relevant for Ukraine.
• Programs should be developed to mitigate popular misperceptions of psychological trauma. The U.S. Real Warriors campaign may serve as a model for troops, but a much broader public education campaign is needed for the general populace, with focused education for specific groups. Family members and colleagues can be taught simple techniques to help defuse explosive situations. They can also receive counseling in how to speak with demobilized soldiers about their experiences, how to respond to violent outbursts, and how to identify signs of suicidal thoughts and behaviors.
• Separate educational efforts aimed at different social groups are needed. Such groups might include the partners and mothers of returning servicemen, children, potential employers, or any citizens who might have direct exposure to this issue.
• The afgantsy experience can be fruitfully harnessed. Thousands of afgantsy have been fighting on the side of Ukraine in the current conflict. Left to fend for themselves after the Soviet campaign in Afghanistan, many have accumulated invaluable experience that should benefit tremendously the most recent generation of veterans.
• Psychological help should be ensured for the troops still stationed at the front. Despite the cease-fire, a steady stream of death reports has been trickling in from the front lines. Idle troops staring down an enemy are known to engage in risky behaviors that lead to loss of life. International donors have been leery of funding psychological help for active-duty troops, viewing it as support for war. But Ukraine is in a war it did not start, and, absent adequate treatment and prevention programs of its own, it must rely on international aid to support the mental health of its troops, combat veterans, and civil society.
• Volunteer psychologists, currently shouldering the brunt of PTSD treatment, should be moved into paid positions so that they can continue their work. Some of these recommendations may be difficult to realize, but they are necessary. In the longer term, Ukraine will need to rebuild its psychological profession, with special emphasis on professional military psychologists. Other countries’ methods and state-of-the-art approaches can provide a platform to start from. Ultimately, however, only Ukraine’s preparation of its own cadre of specialists will serve to address the problem in the long run. This will take time and resources, but it is critically important to do.
The Soldier and the Nation
In the preface to Nancy Sherman’s book, Afterwar, Lieutenant General, U.S. Army (Ret) James M. Dubik writes, “In a very real way, war is the abnormal turned normal.” The preface raises directly the questions “that often don’t arise until years after a war: ‘What kind of person am I to have done this?’ ‘How do I square my sense of self with what I had to do?’ ‘How can I lead a good life, given what I did—even if what I did was justified?’” As Dubik points out, “Reconciling war’s paradoxes, without dismissing the humanity of those whose lives were taken or whose livelihood destroyed, involves dealing with moral injury.”
Helping a nation’s soldiers heal their wounds is a highly complex task that spans government policy, professional training, ethics, and social values. What makes it even more complex is that war can at the same time bring out the best in individuals. The sense of honor and responsibility, the clarity of purpose, and the emotional bonding with fellow troops that many experience in war are hard to replicate in civilian life, and their loss can be difficult for civilians to comprehend. The way a society handles this complexity reflects its broader values and the vision it has of itself. How Ukraine addresses the issue of psychological help for its soldiers will reflect what kind of a society it wants to be.
The opinions expressed in this article are those solely of the author.
In addition to the sources given in the notes, the article is based on the author’s personal interviews with the following persons:
• Dr. Tina Beradze, psychiatrist, Kyiv, Ukraine
• Dr. Valentina Bondarovskaya, psychologist, Director of the Rozrada Center, Kyiv, Ukraine
• Ella Lamakh, Fellow, Woodrow Wilson International Center for Scholars
• Alla Martynyuk, volunteer working with troops, singer and artist, Kyiv, Ukraine
• Yelena Podolyan, psychologist, founder and head of the Forpost veterans organization, Dnipropetrovsk, Ukraine
• Natalia Shaposhnik, member of the Board of Directors, Ukrainian Association of Specialists in Coping with the Consequences of Psycho-Traumatic Events (“Українська Асоціація фахівців з подолання наслідків психотравмуючих подій")
• Several other volunteers and professionals who asked to remain anonymous
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About the Author
The Kennan Institute is the premier U.S. center for advanced research on Russia and Eurasia and the oldest and largest regional program at the Woodrow Wilson International Center for Scholars. The Kennan Institute is committed to improving American expertise and knowledge of Russia, Ukraine, and the region. Through its residential fellowship programs, public lectures, workshops, and publications, the Institute strives to attract, publicize, and integrate new research into the policy community. Read more