A little girl plays with her doll after arriving in Zaporizhia with her family to seek safety in Zaporizhia. Amid the intensified war crisis in Southeast Ukraine, millions of Ukrainian families have now been evacuated from the war zones and Russia controlled territories to Ukraine controlled territories, Zaporizhia. According to the United Nations, more than 11 million people are believed to have fled their homes in Ukraine since the conflict began, with 7.7 million people displaced inside their homeland. (Photo by Alex Chan Tsz Yuk / SOPA Images/Sipa USA)(Sipa via AP Images)

Vladimir Putin’s war on Ukraine has upended international norms and killed untold innocents. The more cruel and enduring damage may be to the psychological well-being of Ukraine’s noncombatants. The purposeful trauma visited on Ukraine’s civilians—especially its children—will likely echo for generations, long after the destruction of the nation’s physical infrastructure is addressed.

It has built slowly as horror, grief, sorrow, depression, survivor’s guilt, and anger have swelled since the February invasion. During the war’s first weeks, messages left at the National Psychological Association of Ukraine (NPAU) were pleas for basic human needs such as where to find food, water, and shelter, and how to contact lost loved ones. As the war intensified, with Russian forces bearing down on Ukraine’s civilians, phone messages and emails have swelled with complaints of anxiety, panic, sleep problems, hopelessness, and chest pains. Ukraine’s psychologists—many suffering war trauma themselves—scramble to help victims of Russian rape, torture, and other atrocities amid the “new normal” of this war: neighborhoods in rubble, family members lost, incomes lost, safety lost, and fading hopes that anything will get better.

Beyond Ukraine, the war trauma of civilians has been intensively studied. Decades of research and lived experience show that the symptoms caused by heightened vigilance and other normal reactions to violence may or may not resolve over time. Repeated exposure can cause chronic depression, cardiovascular ailments, and post-traumatic stress. The outcomes for traumatized children can include impairment of cognitive development, moral reasoning, impulse control, and emotion regulation, according to Michael Niconchuk, an applied neuroscience researcher and practitioner at Beyond Conflict, an international nonprofit based in Boston. For adolescents, there’s an increased likelihood of obesity, depression, and substance abuse, among other woes. And, in a foretaste of more conflict to come, there is a greater propensity to engage in extremist violence.

“Our psychologists are focused on protocols to help prevent panic and high-level anxiety, with special attention to children—how to talk to them about war, how to support parents who are deployed [in the fighting], how to prepare a child for forced relocation, and even what games to play with children in bomb shelters,” says Valeriia Palii, a psychologist and the president of NPAU.

In a telephone interview from Kyiv, Palii acknowledged that many of her colleagues are traumatized. “They’ve gone through horrible experiences, some forced to move to safer places in western Ukraine or are refugees in European countries, some hidden in cities being shelled and bombed.” One colleague, she said, is providing psychological counseling in a Kharkiv underground metro. NPAU is fielding more than 100 cries for help a week; these are assigned to member psychologists and foreign volunteers. The practitioners set up meetings, when possible, over Skype or Zoom. Increasingly, victims of rape and torture are making the calls. “There is,” she said, “collective trauma for all of us.”

As a journalist covering wars for more than 35 years, I’m familiar with the mental health burdens on soldiers and Marines, especially those who engage in direct killing. Deep as those psychological injuries are, the mental pain of civilians caught in the war in Ukraine seems to cut more deeply. Unlike the tight-knit community of fellow fighters whose training prepares them for combat, civilians have much less support as they face death and destruction.

International law entitles civilians trapped in war zones to expect some protection from slaughter. But Putin’s invaders have made a mockery of global norms about protecting noncombatants. Killing civilians as a path to military victory is a tactic seen only rarely, but the physical and psychological damage is severe and enduring. One need only recall the Nazi sieges of Stalingrad and Leningrad, America’s atomic bombing of Hiroshima and Nagasaki, and Putin’s wars in Grozny and Aleppo. Moscow seems to believe that Ukraine can be brought to its knees not by killing its army but by slaughtering and traumatizing its citizens.

Knowing that Putin’s military is deliberately targeting them imposes an additional crushing burden on Ukraine’s civilians, a deep moral injury. “Disasters caused by humans have a deeper psychological impact than ones caused by nature,” Sandra Mattar, a clinical psychologist at the Immigrant and Refugee Health Center at Boston Medical Center, told me. “There is something in them that has been shattered, notions of humanity and who human beings are. It is hard to put back together.”

Thus, the mental health challenges for Ukraine are enormous. Of the country’s 44 million people, more than 5 million have fled the nation as refugees; over 7 million, including 2.5 million children, have abandoned their homes to find shelter somewhere else in Ukraine. The country was already the poorest in Europe, behind nations such as Belarus and Moldova. Now, almost two-thirds of those who remain in Ukraine report that their monthly income has dropped to $170 or below. More than 5,000 civilians have been killed or seriously wounded.

Common immediate responses to violence for the survivors are sleeplessness, startle responses, and self-medication with drugs or alcohol. Children can become hyperactive and sometimes experience learning disorders because they can’t concentrate, the psychologist Laura Murray, a senior scientist at the Johns Hopkins University School of Public Health, explained in an interview. She is an expert in global mental health who has worked in many war zones and in Ukraine since 2015, training mental health specialists in trauma care.

In wartime, “your brain is trying to file a traumatic event away in your sense of what the world is like, and there’s no place to file it, no way to make sense of it,” she said. “In Ukraine, people are seeing these horrific things for the first time, and because they can’t make sense of it, they can’t concentrate, they’re jittery, and they can’t sleep, which leads to a host of other problems. There’s a lot of sexual violence that can lead to suicide, substance abuse, and lack of trust or sense of safety in the world. Some people never go out again. People can become very clingy, especially young kids if they have had a lot of loss, and that can last their entire life if they can’t think it through or talk about it.”

Richard Mollica, director of the Harvard Project in Refugee Trauma and a professor of psychiatry at Harvard, has found in his extensive research of refugees that the long-term consequences of repeated exposure to trauma can lead to outbreaks of PTSD and depression later in life. Chronic extreme stress, he said in an interview, “seeds early death.” Twenty years from now, Mollica noted, the survivors of repeated war trauma “will be dying early on in their 50s of high blood pressure, diabetes, heart disease, stroke.”

I asked him what could be done.

“Stop the killing,” he replied.

Missiles, bombs, and artillery rounds raining down on Ukraine’s civilians leave little time or space for the evidence-based therapies that have been developed for war victims. Instead, psychologists in Ukraine are focused on cognitive coping, the equivalent of psychological first aid. Murray of Johns Hopkins explained that it’s problem-solving, working with the normal response to danger, and heightened vigilance. “The people we’re talking to are still in danger—we don’t want them relaxing,” she said. But when people are terrified and hopeless, “cortisol is screaming through your body, your brain loses the capacity to problem-solve and think logically. We can help.”

A young mother in Kharkiv, for instance, may have fled the family apartment with her five-year-old daughter and found brief refuge in an underground shelter. She knows she can’t stay—it’s too dangerous—but is frozen in panic about what to do. A psychologist trained in cognitive coping can lead her through potential next steps: What’s a safe city where you know people? What five or six steps do you need to take to get there? The idea is to shift the patient’s mind-set from hopelessness to action and give them agency. “You can’t control your environment,” Murray said. “But you can control how you think about it. You can’t change that you’re in a shelter and sirens are going off, but you can think in a way that doesn’t make you panic more.”

Psychologists who work with war-traumatized civilians say it’s essential not to over-pathologize. They recognize that many victims of war persevere, and a few become stronger. “Having survived adversity and many struggles, refugees tend to be resilient and resourceful and, if they encounter reasonably facilitative conditions, the majority of them can and do manage on their own with minimal or no assistance,” writes Renos Papadopoulos, founder and director of the Centre for Trauma, Asylum and Refugees at the University of Essex in Colchester, England.

“We are all in extreme mode, which opens inner resources,” NPAU’s Palii said. “In some ways, stress activates us, and many of our colleagues experiencing trauma help themselves when they volunteer to help others, and they consider it a contribution to our victory. We want to live free in our country. And we will win.”

Still, she acknowledged that without help, widespread trauma and moral injury can lead to nightmares, self-isolation, unpredictable and uncontrollable emotional swings, chronic headaches, and loss of trust, hope, and affection, among other afflictions.

After the war, Palii has written, “we expect a growing number of individuals with shock reactions, post-traumatic stress disorder, depression, acute stress, and other psychiatric disorders. A large number of victims will also have brain injuries, so our activity will be focused on neurocognitive recovery and rehabilitation.”

The crisis in Ukraine has drawn volunteer mental health counselors from around the world, but more help is needed. The country’s psychologists, used to peacetime issues, need training in trauma care, crisis counseling, and instruction in the grim specifics of working with victims and witnesses of atrocities. Palii has set up a way to donate and help the mental health workers in Ukraine treat civilians: https://en.npa-ua.org/donate.

“We are doing everything we can to ensure that our society survives and recovers,” she told me. When I pressed her about her own situation, she paused. “I am not sure about my future, not sure about the future of my husband or my parents. It’s been really difficult. I try to do yoga; I try to read books even in these dark and dangerous days. I enjoy conversations with friends and relatives. All of these things help me in this difficult period—but I am sure that we will win.”

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Follow David on Twitter @wood writer. David Wood is a Pulitzer Prize-winning journalist who has covered war for four decades. His most recent book, What Have We Done: The Moral Injury of Our Longest Wars, published by Little, Brown, won the 2018 Dayton Literary Peace Prize.