Wars are catastrophic events bringing death, destruction, and long-lasting trauma to individuals and nations. While the death toll is the metric most often used to evaluate their impact, wars are known to cause both acute and chronic behavioral, physical, and mental health harm to people in afflicted societies that may be felt for generations. Despite extreme consequences, countless military conflicts continue to break out in different parts of the world. The ongoing Russian aggression in Ukraine is a full-scale war and the most significant military conflict in Europe since World War II. It made the headlines this year for killing thousands and displacing millions of Ukrainians within and outside of Ukraine in a very short period of time (Davidson 2022; Jaroszewicz, Grzymski, and Krępa 2022).
Although it is the current military conflict that has captured world attention, February 2022 marks the eighth year of Russia’s invasion of Ukraine. Spurred by Russia’s annexation of Crimea in Ukraine and the ensuing intervention and support for pro-Russian forces in the region of Donbas in Ukraine, the Donbas war engulfed Southeastern Ukraine in 2014, effectively putting the cities of Donetsk and Luhansk under Russian occupation. The Donbas War has killed over 10,000 and internally displaced at least 1.5 million people (Council on Foreign Relations 2022), many of whom have been displaced again due to the recent full-scale Russian invasion of Ukraine. In sum, any discussion about war trauma in Ukraine should incorporate the cumulative effects of the chronic military conflict endured by the nation for almost a decade.
Understanding the consequences of the Donbas War for the mental health, attitudes, and behaviors of those exposed to it was the goal our team pursued in 2017 when we began collecting conflict-related survey data in Ukraine. Two waves of data collection not only provided us with a wealth of information specific to ways in which Ukrainians cope with war, but also pushed to us to think beyond the current situation to the full impact of wars on those who experience them. In this article, we hope to highlight the often-invisible ways in which war trauma manifests in both the short- and long-terms. It is our firm belief that an in-depth understanding of the impacts of war is needed to shape future policies aiming to support nations ravaged by war.
War Trauma and Mental Health
Wars are as much individual and isolating experiences as they are collective experiences, placing people in extraordinarily traumatic environments and leaving long-lasting emotional scars. An estimate from the World Health Organization suggests that exposure to a military conflict will cause at least 10 percent of the exposed population to suffer from serious mental health conditions. Post-Traumatic Stress Disorder (PTSD) is a well-known example of psychological injury associated with war (Murthy and Lakshminarayana 2006) that may manifest years after war exposure (Hunt and Robbins 2001). Studies around the globe now find PTSD-associated symptoms in both combatants and civilians exposed to war (Besser, Neria, and Haynes 2009; Luxton, Skop, and Maguen 2010).
Our study (Johnson, Antonaccio, Botchkovar, and Hobfall 2022) in Ukraine compared the impact of war exposure on those internally displaced by war and those who did not have to relocate. The United Nations defines internally displaced persons (IDPs) as “[p]ersons or groups of persons who have been forced or obliged to flee or to leave their homes or places of habitual residence, in particular as a result of or in order to avoid the effects of armed conflict, situations of generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized State border.” Our findings revealed that, relative to non-displaced persons, those who have been displaced by the Donbas War are far more likely to report significant exposure to war trauma and exhibit PTSD symptoms. These results bolster earlier reports based on evidence from other non-western countries indicating greater vulnerability to war trauma among IDPs (Porter and Haslam 2005).
It is also known that most displaced Ukrainians never consult with psychologists (or seek mental health care) due to distrust of health care professionals and feelings of stigmatization (Roberts, Makhashvili, Javakhishvili, Karachevskyy, Kharchenko, Shpiker, and Richardson 2019). Economic constraints experienced by Ukraine affect the range of medical services provided to its citizens. Unsurprisingly, Ukrainians who do seek help report paying for consultation despite the provision of universally free medical care in the country (Roberts et al. 2019). This reaffirms that, even when actively sought, psychological help may not be readily available to those who need it. Unfortunately, scarce support available to those traumatized by war in low-to-middle income countries like Ukraine, as well as the cultural specificity of war-affected contexts, may ultimately translate into long-term PTSD consequences, including physical illness and behavioral issues such as violence and aggression (Rozanov et al. 2015).
Connecting War Exposure with Violence
Wars are inherently violent events. As wars gain momentum, violence escalates. Naturally, we expect violent behaviors to subside with the resolution of the conflict. However, as research evidence suggests, interpersonal violence may not deescalate quickly with the ending of war. While the exact nature of the association between war and violence has yet to be determined, several possibilities exist.
One scenario is that the psychological harm caused by military conflicts promotes aggressive and violent behaviors. Some research points to a potentially important role PTSD plays in translating war trauma into some forms of aggressive behavior (Roth, Ekblad, and Prochazka 2009). However, other studies fail to confirm these findings, pointing to alternative routes to be explored (Gartner and Kennedy 2018). For instance, one of our studies suggests that daily strains may serve as a connecting link between war trauma and violent behavior (Timmer, Antonaccio, Botchkovar, Johnson, and Hughes 2022).
Another intriguing possibility involves cultural shifts that occur during war and make violence permissible (Gartner and Kennedy 2018). Wars not only trivialize but also reward violence and expose individuals to violent “role models.” There is also evidence (Boxer, Huesmann, Dubow, Landau, Gvirsman, Shikaki, and Ginges 2013) that collective exposure to violence effectively changes socialization patterns, thus promoting violence by future generations. We believe this route to be more likely where exposure to violence is prolonged and widespread. Our study of Ukrainian urban dwellers, whose war exposure was neither geographically widespread nor chronic, found indirect war trauma to be conducive to changes in moral beliefs, making interpersonal and political violence more acceptable (Timmer, Johnson, Antonaccio, and Botchkovar 2022). Interestingly, the (possibly temporary) cultural shift we recorded was not at all uniform and appeared closely aligned with the psychological state of respondents and their daily lives. We found that depressive moods and everyday stresses linked war trauma with changes in moral beliefs. In sum, cultural changes associated with war exposure may be important for explaining spikes in violence during and after war.
War Trauma: Direct vs. Indirect Influence
So far, we have discussed war exposure without defining it. This is because, for most researchers, war trauma stems from direct exposure to war, including personally witnessing or being subject to bombings, abductions, losses of loved ones and similar experiences. While these events are undeniably traumatizing, war trauma from indirect exposure may be equally catastrophic. Indeed, stories about violent deaths and destruction heard from close relatives and friends or media reports sharing details about enemy attacks may easily be emotionally exhausting, particularly so for those who feel personally involved. While relevant research remains scarce, studies find indirect war trauma to be a potent predictor of mental health problems and violence (Jayuphan, Sangthong, Hayeevani, Assanangkornchai, and McNeil 2020). In our study focusing on the Donbas war, Ukrainians reported both direct and indirect war trauma (Timmer et al. 2022). Unlike the direct exposure that affected a relatively small pool of individuals, some degree of indirect war exposure was virtually omnipresent. Although the risk of violence was more prominent among those directly affected by the war, higher levels of indirect war exposure also translated into more violent behavior. The significance of these findings cannot be overestimated. The tendency to focus narrowly on direct exposure to military conflict not only limits understanding of war trauma, but also directs efforts to help victims of war away from those who may not fully recognize and/or acknowledge their trauma.
Helping Victims of War
To summarize, accumulated research evidence from Ukraine and elsewhere in the world suggests that war exposure is a multipronged trauma that may have significant short- and long-term effects on the mental health of those who experience it. Furthermore, for a variety of reasons, war may elevate the risk of violence among those reporting both direct and indirect exposure. These effects may last a few months, years, or even decades. Similar to other countries affected by war, Ukraine has few resources to address these issues now or in the immediate future.
These findings reaffirm the urgent need for organized campaigns focused on victims of war in any country that has recently experienced a military conflict or hosts war refugees. The scattered fabric of support available to the survivors of the Syrian war suggests that such efforts need to be coordinated and supported by international organizations such as the WHO instead of relegating these responsibilities to individual countries or the afflicted nations themselves. Collaborations between major international organizations and networks including but not limited to HealthRight International, Ukrainian Foundation for Public Health, United Nations, and UNICEF could help provide more nuanced and comprehensive support for Ukrainians and others affected by war.
The goal of these campaigns should be the provision of resources to those directly or indirectly exposed to war as well as raising awareness about the multifaceted nature of war trauma and its symptoms. Victims of war can be unaware of their own PTSD and other mental health disorders, need for care, or even the availability of it. Furthermore, even when presented with an opportunity to receive counseling, those who have not directly experienced war may not perceive themselves to be psychologically affected and thus will not seek help unless otherwise advised. Therefore, efforts to help victims of war must consider people’s perceptions and attitudes as well as the context of individual countries to provide better care.
The Russo-Ukrainian war is neither the first nor the last serious conflict to be encountered by the global community. The timeliness of comprehensive and culturally sensitive psychological aid provided to those affected by war may push back the time when humanity is forced to witness another military crisis. The time to act is now.
Any opinions expressed in the articles in this publication are those of the authors and not the American Sociological Association.
