By David Bonior. Contributors are Jim McDermott, Peter Daly, and Tanya Kepler.

On a recent trip to Poland and Ukraine to meet with Ukrainian refugees and their caregivers, it became immediately apparent that there is an overwhelming need for more mental health support.

Those of us old enough remember well the enormous pain and mental anguish of US combatants in Vietnam over half a century ago, and more recently in Afghanistan and Iraq. And now we see the same on our streets and in schools as the spate of gun violence in the US ravages the fabric of our society. In Poland and Ukraine, we heard and witnessed similar torment and depression.

In Congress, I worked with my colleague Jim McDermott, also a psychiatrist, on legislation to aid veterans with Post Traumatic Stress Disorder. After the Vietnam War I found there was a reluctance by combat veterans to seek help in VA hospitals. The Congress successfully created and funded counseling centers in store fronts and community centers around the country for returning veterans. The veterans were treated with dignity and respect. It was a welcoming place for them to open-up and unburden themselves while also sharing their experiences with others who had similar thoughts and feelings about their war service.

In Ukraine a similar phenomenon is happening through a program called Save Ukraine. War deprives children of critical developmental opportunities and violate their rights to grow in safe and nurturing environments and child friendly places.

The CEO of Save Ukraine is Mykola Kuleba, who from 2014-2021 was the Ombudsman for Children with President Zelensky and his predecessor President Poroshenko. Save Ukraine has been in the lead in rescuing Ukrainian children from Russia, and evacuating children from combat zones.

The heart of Save Ukraine is a network of Community Centers which provides a safe place for children and families for recovery, development, and empowerment. At these centers psychosocial support is provided for children that helps them to heal from war traumas. In addition to trauma therapy, the centers provide food, education, and other family services. Their goal is to create 500 Community Centers all over Ukraine. Fifteen centers were opened by early 2023 with another 50 opening by 2024. The centers have some of the same features as the Caritas centers throughout Poland that are playing an important support role for Ukrainian refugees from the war.

Children

In the meetings we had with caregivers in Poland and Ukraine there were often psychologists who were working with children who had been traumatized by the war. Coping with air raid sirens, bombings, missiles, and the specter of death at their doorstep, was often overwhelming. Talking their fears through with their parent(s), a social worker, psychologist, doctor, teacher, or a religious elder is helpful. But those opportunities are not available to all who need support, especially children. A significant percent of Ukrainians and displaced Ukrainians need mental health support. The World Health Organization says that ten million Ukrainians, a quarter of the country’s population have experienced some form of mental health illness.

Art Therapy Works

Art therapy works well in healing children of war. Art therapy is not about the art that is created by traumatized children, but rather it is about the self-healing qualities of the creative play process that the child becomes immersed in when the child creates.

Children don’t always understand, or have the words to describe, their inner experiences. In contrast, to adults talking through their issues, the art therapy process allows children to express their deep inner experiences without verbalizing those fears and anxieties.

All of today’s children of Ukraine are in some way children of the Russo-Ukrainian War. Some have lost their homes, lost a family member, lost friends, experienced terror from the weapons of war, and some have lost limbs. Each child is experiencing and processing this war uniquely.

Art therapy is a method that provides the creative play process to address their unique war trauma. The set-up is simple. A quiet and calm setting, art materials, and supervision and support by professional psychologists. Finger painting for the youngest ones. Painting, drawing, and sand or playdough sculpting works well with for older children. Drama, creative writing, and music and dance are other ways for children to express their emotions.

Their art tells the story of their life or parts of their life as they have experienced it. Their characters have qualities which pull together their survival instincts and inner resources to cope with and solve problems.

For example, if a child paints a picture of a super-hero defending others, this could represent the child’s inner desire to be strong and defend others. Having depicted this the child can experience their own sense of strength and mastery of their environment.

Tapping into their inner problem-solving strengths during creative play process of art therapy helps them defend themselves at an unconscious level, from the outer turmoil of war that these children of war have experienced. This can provide a calmer childhood including better sleep.

We saw their drawings and paintings depicting war. When we walked into the Caritas refugee center in Warsaw, Poland, I was drawn to a painting on an office wall. It was reminiscent of the image of the student in Tiananmen Square in 1989 who stood his ground in front of a Chinese government tank. The painting was of a small girl dressed in white with her arm extended in front of her while standing in front of a looming black Russian tank with a large letter “Z” painted white on its side. The girl’s hand is raised as if to say “halt!” Or “You shall not pass!” Blue skies and gold-colored fields dominate the painting reflecting the Ukrainian national colors.

In a Catholic school classroom in the Carpathian city of Ivano-Frankivsk, we saw another child’s drawing of the Holodomor. It depicted graves with crosses of the dead and a disturbing drawing of a monster devouring people. The terror in the drawing was unmistakable as was the actual terror during the Holodomor in 1932-33 when the Russians under Stalin starved to death 4 million Ukrainians.

In Rzeszow, Poland at yet another Caritas Center we meet with four psychologists, two Polish and two who were refugees from Ukraine. One psychologist shared with us how she treated a child who suffered trauma from the war. “Draw what is bothering you,” she suggested to the child. Then when the drawing of bombs falling from the sky was completed, she talked with the child about it. The doctor reassured the child that her fears were in the past in another place. After discussing this idea, the psychologist told the child to cut up the picture into small pieces and throw the pieces into a trash container. “It is now gone from your life.”

Another child psychologist in Rzeszow was working with children and puppets. In puppet play, children use puppets to represent people, objects, thoughts, and behaviors through play. This play with puppets helps children with social and emotional skills as well as coping techniques. Puppet play creates an atmosphere of free expression that can captivate the child. The child tends to identify with the characters and projects their feelings and interpersonal conflicts into the play. In this way, children can communicate their distress without having to directly claim traumatic experiences and painful emotions as their own. The therapist can use the puppets to model, explain, and provide corrective emotional experiences in response to the child’s play.

Our translator in Poland was Olesia. She and her husband live in Gdansk but were originally from Luhansk in eastern Ukraine. They migrated to Poland in 2014 during the war in their region. Both studied acting and now have a puppet acting company. Olesia attested to the power of puppets to not only entertain children but also give them an opportunity to project their feelings through puppet play.

Child Prayer

In many communities in Ukraine there remains a reluctance to seek help from psychologists or psychiatrists. The more traditional way is through their religion. Father Peter Daly noted that some of the children pray to Jesus to keep mommy and daddy safe, and to keep themselves safe from war.

Father Daly added this to the church’s role with the mental health. “The situation has been made much worse by the destruction of an estimated 500 houses of worship, mostly in the Russian occupied areas of Ukraine. Places where people would formerly go for support are now gone. Russians seem to target especially those churches that are not Russian Orthodox.

Father Daly went on to add, “There is a healing in serving. In the retreat houses and the various aid stations, and centers we saw people who were deeply affected by the war finding a sense of normalcy and a way of coping by doing acts of service for each other, such as preparing meals, raising funds for the soldiers at the front, or like the women in Rzeszow who organized singing groups.” The two women who talked and sang traditional Ukrainian songs for us were Ira and Ola. They were among a group of mostly mothers of small children whose husbands remained in Ukraine to fight the Russian aggressors. The women found it healing to meet other women at the railroad station in Rzeszow and great them with tradition Ukrainian songs. The women at the church also affirmed the value of drawing classes for their children.

Teenagers

The Story of Constantine

The setting is a Catholic retreat house in the Carpathian Mountains. Thirty of us sat in an oval in the upper floor chapel of the alpine three-story building. We gathered to listen to the displaced Ukrainians who had sought refuge from different parts of Ukraine. There were several priests and seminarians present at our meeting. Each refugee in turn told their story.

Constantine at 16 is a tall and lanky young man with a serious demeanor that belies his young age. I watched him carefully as other refugees painfully unveiled their stories of dispossession, torture, and death. He listened intently respecting their stories and pain. After all they are now his family. I was taken by his maturity. Later he showed me on his I-phone the shelling that destroyed his house in Kherson and the fire that raged through it.

His grandmother died because the Russians would not allow the family to go out and get her medication. When Constantine visited her grave near a Russian checkpoint, soldiers approached Constantine and threatened to take him into the Russian army. On another occasion he escaped death when a mine exploded 20 meters from him. At night through his bedroom window, he heard the terror of torture as the Russians murdered civilians suspected of siding with Ukraine. He told us about the screaming from torture and people begging the Russians to spare their lives. It still haunts him. When the Russians approached Constantine or interrogated him, he could feel the fear inside him. He said the opposite was true when he was near or around a Ukrainian soldier. He felt pride and safe.

As I listened to Constantine and others tell their stories I could feel the community that they created for each other, how their fate drew them together bonded by the terrible scars of war and their determination to survive.

The story of Sofia, Oleg, Masha, and Dasha

During most of the testimonials at the retreat house, Sofia sat with her teenage daughters, Masha and Dasha, off to the side in the back of the chapel. Our colleague, Tanya Keppler, approached them separately to hear their story. The family lived on the 9th floor of an apartment building in the heart of Melitopol in Southern Ukraine. Melitopol was occupied by the Russians on the first day of the 2022 invasion. The girls helped their mother and father, Oleg, gather what food and medicine was available at home and in the stores that remained open. During that first day the electricity and water were turned off. The family spent two weeks without lights, water, or gas. Tanks and soldiers roamed the streets. A curfew was established. Except for the air explosions the city was eerily quiet. People were frightened, remaining for the most part inside their houses or apartments. Sofia said there were no sirens warning that the war had started. Her words were simple but stark.

“Being occupied is when you have no rights! Your life and property do not belong to you! When you cannot protect children and loved ones. I felt terrible. Terrible fear that made my body tremble incessantly.”

“As for our daughters, we made mistakes, a lot, because we were not taught how to behave during the war. What to say? What should I do? We didn’t calm them down. We didn’t talk. We were in shock! We were all silent. And only cried.”

“During the war our girls were very frightened. My daughter Masha was so scared she lost consciousness. We ran out of food. We could not get money from the ATM machines. We didn’t even eat bread for a week. Now because of this experience I cannot eat fresh food. I wait for two days until it starts to deteriorate. My psychologist says this syndrome is because of my hunger experience.”

“My girls were scared. They closed themselves in.”

“When bombing started in and around the city we decided to move to my husband’s parent’s village where there will be food. We also were afraid of the ‘bomb storming.’ We lived on the 9th floor. When the shelling began the building was all wobbly. And to die under the rubble, there was a big chance.”

On the road in their family car the family was caught in a terrifying crossfire. They tried to escape from the village but had to turn back—too dangerous. On their second attempt to leave from near Zaporizhzhia to Ivano-Frankivsk into the safer Western Ukraine, they travelled 700 miles. Initially they had to get through 22 Russian checkpoints. At every stop, guns were pointed at them in their car. At these roadblocks there were between 5 -20 soldiers. “The Russians cared about two things,” said Sofia. “There are no guns in your car and what could they steal from you. They also checked phones to look at what was posted online.”

It is stunning to realize that this harrowing trip was completed by so many fleeing Ukrainian families.

Sofia is a photographer by profession. With the permission of Father Igor who runs the retreat house, she took photos of refugees as they arrived and when they left. She documented with her camera how refugees at the retreat house had changed over time—almost all getting better and improving in every respect.

Prayer is also an important part of life of Sofia and her family. At 9 pm each day in the retreat house they gather in the chapel for a community prayer service. During the first weeks of the Russian invasion in Melitopol when it was safe, Sofia and Masha left their building to go to a square near their apartment to meet others to pray. For 32 years Sofia and Oleg belonged to Grace Church in Melitopol. The church has been there for over 200 years. Sofia’s grandmother was active in the church. It was the center of their community. Now the Russians have closed it.

But somehow the family is hopeful. This fall Masha will be going to college. Sofia wants to open a photography shop in Ivano-Frankivsk. Her husband Oleg wants to get back to building craft furniture. They are trying to rebuild their lives. But the specter and horror of war hangs over them as it does for all Ukrainian people. Sofia says, “Now on radio and television are only Ukrainian artist—turns out we have a lot of them. The artists were given freedom. They sing and record new songs. And this is a contribution to our country both financially and morally. That is why we say that Ukrainian is the language of birds. There is such bird—a nightingale! That is how he sings, that’s how he sounds, gentle, like our language. Yes, the world is strange now. There is war, people are dying, and the world does not stop.”

Teen Diaries of the War Brought to Life on Stage

In Diaries from Ukraine, Scott Illingworth of New York University and Oleksandra (Alex) Oliinyk from the Ukrainian Actors Lab have combined to produce on stage the diaries of Ukrainian teenagers during the war of the last 17 months. I was privileged to introduce this production at the NYU campus in Washington DC soon after I returned in March from our two-week listening tour of Poland and Ukraine.

In the introduction the director and producer, Scott Illingworth had this to say.

“On February 25, 2022, one day into the war in Ukraine I began collaborating with my colleague Alex from Kyiv. She teaches children between the ages of 11-18. As she fled the country herself and tried to keep track of her students’ safety, we began recording interviews with them and had each student record audio diaries.

In the months since, these diaries have become a remarkable chronicle of experiences of a group of young people plunged into war and crisis. Some became refugees across Europe. Others stayed in Ukraine or have returned. Still others could not escape and live under Russian occupation, recording their experiences behind enemy lines.

The recordings offer an intimate view of how they cope with the trauma of war and displacement—from deep commitments of building a new life of humanitarianism to a simple wish to be reunited with pets or favorite toys.

The play is constructed of excerpts from these 80 hours of gripping audio punctuated with Ukrainian poetry (delivered by a native speaker), ensuring the language of their homeland is elevated and preserved even as they work to communicate to an English-speaking audience.

The actors listen to the recordings on stage each night and perform using a real-time in-ear verbatim technique. This method preserves the rhythms and poetry of their spoken English, adds a tangible sense of urgency as they receive and relay transmissions with immediacy, and still allows the performers to build a cohesive theatrical whole in the room with the audience.

An ensemble of six actors plays the fifteen young Ukrainians. As we watch, they step in and out of these memories. Sometimes directly addressing the audience, other times speaking to one another as confidants or scene partners or watching or reporting their own experience as the rest of the company enacts a key moment of image or gesture. Sometimes the group repeats a physical refrain from a previous story creating resonance or dissonance between the wide range of experiences. Over the course of the play the ensemble plays with distance to reinforce the chaos or isolation or danger. The result is a theatrical experience that goes past reporting to illuminate what is not or cannot be said and build a visual vocabulary of how memory loops, how we look away from what we dare not recall, or how the words we use sometimes barely contain what they try to describe.”

For me and the audience, this enactment of over 80 hours of diary entries and recordings was stunning in its authenticity, anguish and even humor.

Voices of Children Charitable Foundation

Every month about 600 children turn to the Voices of Children Foundation for psychological help. In the first year of the full- scale invasion, the foundation aided about 7,000 children. On June 1, 2023, they opened the “War with Children’s Voices” exhibition which is part of the Do You Hear Them campaign designed to call all of us to listen carefully when children talk about war. The foundation has been helping children affected by the Russo—Ukrainian War since 2015. They provide long-term, comprehensive psychological and psychosocial support for children experiencing war trauma, working towards to preventing PTSD. They provide around the clock counseling to children and families, emergency psychological assistance, and they assist in the evacuation process.

The foundations programs have worked extensively in villages and towns along the frontline in the Donetsk and Luhansk regions. Below are some of the features of the programs.

The foundation has established rehabilitation for children with autism and spectrum disorders, cerebral palsy, and other disabilities.

Their mobile psychological teams go to rural and remote areas as well as the de-occupied territories. They are finding that in some cases only when areas are liberated from occupation, that children’s memories and emotions begin to emerge.

Leisure Time. Children need both rest and leisure time to heal from their war trauma. The foundation facilitates activities such as summer camps, excursions, and sports activities. All of this helps children with growth and development, both academically and in making new friends.

Online support. Young Ukrainians and their parents can be helped by telephone, Telegram, and a Viber bot. Using technology in this way they can reach children from all over Ukraine.

Branch locations. As of Dec 2022, there were 9 locations in Kyiv, Lviv, Truskavets, Chernivtsi, Ivano-Frankivsk, Berehove, Kryvyi Rih, and Kharkiv. At the branches they provide support for parents and children using sophisticated methods designed for children of war. They offer art and sand therapy, recreation activities, and group and individual counseling sessions. In these safe places both parents and children can talk about their worries. It is a place where families of war can be with other families of war in a way the helps rebuild their sense of greater community.

Training of Psychologists. They train psychologists by using methods designed specifically for treating childhood trauma and the stresses of war. The foundation also trains school psychologists and crisis counselors.

Combatants I

It’s Sunday March 19th and our group gathers at the Church of St. Peter and St. Paul in Lviv’s city center. The Church is packed this morning. It is also known as the Garrison Church of the Armed Forces. The chant during mass is beautiful and haunting in the midst of war. The Church is Ukrainian-Greek Catholic. It was founded between 1610-1630. Today this Jesuit church is in the heart of the city near Rynok Square and Svoboda Avenue. During the Soviet era, when religion was forced to go underground, the church was used as a book depository housing about 3 million volumes.

After 65 years of Soviet neglect, with Ukrainian independence, the church was reopened and serves as the church of the Ukrainian armed forces. The church is home for not only the military but also is dedicated for students, orphans, and prisoners. On this Sunday, the feast of St. Joseph, it feels like all those groups are inside to celebrate mass and to honor and pray for those who are giving their lives for Ukraine in the war with Russia.

Inside the church many of the paintings and icons are wrapped so they will survive a missile or drone attack. Along one side aisle the war is tragically portrayed in photos of hundreds of Ukrainian soldiers who have lost their lives in battle. What grabbed my attention is the age of the deceased men, many looking to be in their 40s and 50s. Fathers and uncles were the first to fight in this war. This gallery of heroes is a reminder of the price of Freedom and Justice.

Hanging above the photos are paper doves. Your eyes are immediately drawn to this dichotomy of war and peace. It’s confusing, yet it sets up the connection between a lasting peace with freedom and the ultimate sacrifice that is required to attain it. That message was underscored by a battalion of young soldiers who had just finished their basic training and were brought into the Church to see the photos of the fallen. Their commander led this young group to the aisle that above them was covered with the paper doves. In front of them at eye level were the photos. When the youthful cadets entered the Church as the mass was ending, everyone quieted. It was silent, as these soldiers paid their respects to the fallen. All eyes were riveted on the fresh troops. Most of the parishioners were undoubtably thinking as I was: Now it is the sons and daughters who fight. Many of them also will die. Their photos too will join the other heroes who were killed in combat.

Source: Lviv Regional State Administration

Combatants II. The Brutality of Trench Warfare

On this very day, March 19, 2023, while we were commemorating the valiant war dead at the Garrison Church of the Armed Forces, millions of others were leafing through their Sunday New York Times Magazine. On the remarkable cover are photos of nine Ukrainian soldiers who are photographed in profile, all against a black background. These tortured souls are patients at the psychiatric hospital in Kyiv. The hospital treats patients with severe mental illnesses, mostly schizophrenia. The staggering photographs of these warriors were taken by Antoine d’Agata with the text by Ellen Barry. I highly recommend this NYT Magazine piece.

Russia’s war in Ukraine stands out among modern wars for its extreme violence. “We are looking at a war that is basically a repetition of WWI.” Says Robert van Voren who heads the Federation Global Initiative on Psychiatry which provides mental health support in Ukraine.

In the US Civil War, the increasing power of weapons, like cannons, smaller arms and eventually the Gatling gun led the Northern and Southern armies to build extensive trenches. With the trenches came misery.

The trenches were long narrow ditches dug into the ground where the combatants lived for months at a time. They were cramped and personal space for the soldier was all but gone. Sanitary conditions were deplorable especially when dug out toilets overflowed, often leading to dysentery, which killed an estimated 45,000 Union soldiers and 50,000 confederate soldiers. The disease was called “quickstep” by the fighters. The trenches were often muddy and leaked and reeked of human waste.

The wet and cold environment often led to “trench foot,” which in turn could lead to debridement or amputation which was not uncommon for combatants from World War I trenches.

In WWI the brutality and horror of fighting in those trenches is shown in the academy award winning film of 2023, All Quiet on the Western Front, adapted from the international best-selling novel by Erich Maria Remarque. The film takes place in and around craters and death-scape trenches which separate the German and British forces in an area called “no man’s land.” Aggregated, this hell-scape might serve as a venue for Dante’s eighth ring of hell and deserves to be reserved for the likes of Putin.

The front in the Ukrainian War stretches 600 miles and much of that is now trenched and fortified leading military experts to see a potential stalemate in the battle.

Trench warfare is particularly conducive to shellshock because of long periods of inactivity in conditions of constant fear, with no opportunity for action. The artillery shelling that soldiers in the trenches must endure frays their nervous system. The number of artillery shells fired by the Russians and Ukrainians has reached staggering numbers to the point that both sides are experiencing ammunition shortages.

In a trench at any moment an artillery shell can land on top of combatants or bury them in the mud and dirt. Soldiers in trenches sit in a constant state of suspense and anxiety. The light flashings and the noise from the explosion enhance the fear and anxiety. It’s a living hell.

“No man’s land,” cratered and scared sits between the lines. Soldiers are sent from their trenches into no man’s land to draw fire which reveals the enemy’s position and makes them vulnerable to attack from the air from drones, aircraft, and artillery fire. Soldiers are also sent into the zone to mine or de-mine strategic areas of the no man’s land. This assignment can break a combatant, literally driving them to madness.

In the early 1950s the director John Huston made a film entitled Let There Be Light. The film is so realistic about the trauma suffered by World War II soldiers that the U.S. Department of Defense embargoed the film, fearing it would turn off Americans from supporting the armed forces. It was eventually released decades later and provided a contrast with mental illness in WWI veterans who were described then in medical text as “moral invalids.”

With each new war we have expanded our understanding of war’s effect on the combatant’s mental state. The war in Vietnam finally made it clear how much mental health support was missing. For Ukraine to truly recover they too will need much more support in the field of mental health.

One of the wonders that we found in Ukraine was the voluntary work of US medical doctors. We met with Dr. Steve Orten of Dallas, Texas and his team. It was his third time in Ukraine. This time he brought ten other doctors with him to work on war injuries of Ukrainian soldiers. Plastic surgeons and orthopedic surgeons were doing face reconstructions. These doctors also operated on children with cleft lip and palate, also changing their lives.

Combatants III

In a pine forest just outside of Kyiv sits The Veterans Mental Health and Rehabilitation Centre with 200 patients. A report by France 24.com in mid-June 2023 investigated the mental health crisis among soldiers and civilians. The numbers of soldiers with serious mental health illnesses since 2014 are very concerning. The increase since Russia’s 2022 invasion of Ukraine is staggering and alarming. The World Health Organization, an arm of the United Nations, suggests that one quarter of the Ukrainian population is suffering from mental health illnesses that run the gamut from schizophrenia, Post Traumatic Stress Disorder (PTSD) to anxiety, panic attacks, depression, and insomnia.

The World Health Organization is training all its medical staff in Ukraine to treat mental health issues. They are working to ensure that these issues are addressed immediately, instead of waiting for the war to end.

Eugene Bozhenko, a psychologist at the Veterans Mental Health and Rehabilitation Centre summed up the mental health crisis in Ukraine. “PTSD affects five to six percent of the population in average peaceful societies. In Ukraine we expect that figure to hit 25% of the population within a few years. We’ve got to face reality. This war is making us stronger every day, but it is constantly testing our mental resilience.”

*In March of 2023 former Michigan congressman David Bonior and former Washington State congressman Jim McDermott, also a psychiatrist, travelled to Poland and Ukraine with Father Peter Daly, a retired Catholic priest who is also an immigration lawyer. Accompanying them was Tanya Keppler, an IT specialist. This group of four spent two weeks talking with Ukrainian refugees and Polish and Ukrainian caregivers of refugees. In Lviv, they stayed at the Ukrainian Catholic University and met with student classes. This is one of several pieces they have written and lectured on since their return from Europe.