TRAUMA: The vast but invisible toll of war

Misery for millions scarred for life by horrors they witness

Describing another war, former US Secretary of Defense Donald Rumsfeld famously distinguished between “known knowns,” “known unknowns” and “unknown unknowns.”

There are facts we know, he said. Then there are things that we know we do not know – known unknowns. Third, unknown unknowns – those things we don’t even know that we don’t know.

Applied to the Russian war in Ukraine, the single most significant “known unknown” is the trauma suffered by countless millions – both those who directly experience the conflict and others who witness it from near and far.

We know it exists. It is real. It’s massively consequential.

But we can never measure it with any degree of certainty.

What we can say for sure is that innumerable people are suffering from Post Traumatic Stress Disorder, and its close cousin, Vicarious Trauma. Many will live with it for the rest of their lives.

It’s without doubt a most significant “known unknown” of the current conflict and it’s a tragedy of enormous proportions.

The United Nations refugee agency reports that 18 million people in Ukraine are directly affected by the war. Unknown millions elsewhere are, too.

There is one way to quantify at least some of the suffering, imprecise as it is.

The tally of those directly exposed to the trauma is being monitored by the UN Refugee Agency which says the war is projected to internally displace up to 6.7 million people in Ukraine.

Being forced at gunpoint from one’s home is unquestionably a traumatic experience. It’s made exponentially worse by the fact that perhaps more than half those so affected are young children, who will spend the rest of their lives coping with it.

In addition, since the start of the war UNHCR reports that more than 5 million people from Ukraine have crossed international borders into neighboring countries including Poland and Moldova.

“According to estimates, the current crisis is projected to affect 18 million people, nearly half the total population of Ukraine,” the agency says.

By itself this is an enormous toll. Without accurate data, let’s assume that only half those directly affected suffer Post Traumatic Stress Disorder that can be clinically diagnosed. That’s a staggering nine million people.

Others may suffer stress, anxiety or depression but may never be diagnosed. That’s additional millions.

However, there is another even larger cohort also affected but likely to never be diagnosed with any clinical illness.

These are people like caregivers and humanitarian aid workers who witness to varying degrees the trauma suffered by others. The medical community has a term for what ails them.

It’s called “Vicarious Trauma,” and has recently been the subject of several authoritative academic studies like this one available from the National Institutes of Health, which documents Vicarious Trauma suffered by healthcare workers.

The Jefferson Center has an easy-to-understand explanation of Vicarious Trauma.

But you don’t have to be a medical professional to find a much more accessible explanation of the ailment.

There’s one available at the Jefferson Center, Missouri, a nonprofit community-focused mental health care and substance use services provider.

Its article What is vicarious trauma? explains it in plain language.

“Vicarious trauma is an ongoing process of change over time that results from witnessing or hearing about other people’s suffering and need.

“When you identify with the pain of people who have endured terrible things, you bring their grief, fear, anger, and despair into your own awareness and experience. Your commitment and sense of responsibility can lead to high expectations and eventually contribute to your feeling of being burdened, overwhelmed, and perhaps hopeless.

 “Vicarious trauma, like experiencing trauma directly, can deeply impact the way you see the world and your deepest sense of meaning and hope.”

While the medical research to date focuses on healthcare workers (like those treating COVID19 patients) and humanitarian aid providers, it can apply just as well to others who simply witness the traumas of war.

Suddenly, the universe of potential victims expands exponentially.

The Jefferson Center article provides a neat explanation of who experiences Vicarious Trauma.

“If you are regularly hearing about another person’s trauma, then you are at risk of developing vicarious trauma symptoms,” it says. “This can include medical providers, law enforcement, mental health staff, social workers, and those working in the courts. 

“How you experience vicarious trauma depends on many factors including personality, personal experience, life stressors, social support, and spiritual resources.”

This leads us to an inescapable conclusion: We are almost ALL at risk!

For over two months now our TVs and social media news feeds have been saturated with war coverage. It is been impossible to ignore. It has been constant. It has been overwhelming.

According to the Jefferson Center, there are several common symptoms associated with vicarious trauma:

• PHYSICAL: Feeling on edge, difficulty sleeping, feeling tired, getting sick

• EMOTIONAL: Feeling sad or anxious, angry, irritable, lonely or unsupported, unsafe

• COGNITIVE: Difficulty concentrating or making decisions, memory problems, disturbing imagery, nightmares, “zoning out”

• BEHAVIORAL: Social withdrawal, drinking or smoking more, changes in eating patterns, overprotectiveness

• RELATIONAL: Expecting the worst of others, becoming judgmental, relationship problems, loss of friends

• SPIRITUAL: Cynicism, discouragement, loss of faith, an attitude of “why bother”

If you examine your own emotions over the last two months, you may recognize several from this list of common reactions. I do! We are clearly not alone.

The Headington Institute is a non-profit providing services to humanitarian workers suffering from Vicarious Trauma.

One of the groups research has identified as being most at risk of suffering from vicarious trauma is humanitarian workers providing relief to victims of natural and man-made disasters – with armed conflict being a primary situation requiring their participation.

A non-profit NGO devoted to caring for this group is the Headington Institute which has spent decades providing support for humanitarian caregivers around the world.

“The Headington Institute is a nonprofit team of psychologists that partners with responder organizations worldwide before, during, and after deployment in order to ensure the wellbeing of their staff,” it says on its web site.

In an article Understanding and Addressing Vicarious Trauma it provides more insight into the causes of Vicarious Trauma and what can be done about it.

“Humanitarian workers often assist people who have been victimized. They work in and with communities that have been devastated by natural forces or conflict.

“They themselves are sometimes the targets of violence. As a result of all these things, humanitarian workers are likely to experience lasting psychological and spiritual changes in the way that they see themselves and the world,” the article explains.

While some find it easy to cope with the stress and anxiety arising from their work, others do not do so well.

“[S]ome of the changes that can come from witnessing and experiencing suffering can be more problematic, leaving potentially permanent scars. (emphasis added)

“Humanitarian workers also talk of how their work can sometimes leave them feeling numb, disconnected, isolated, overwhelmed, and depressed.”

This can manifest in clinical symptoms which are now diagnosed as Vicarious Trauma.

Many humanitarian workers turn to faith for comfort. “[They] talk of how their deepest spiritual beliefs have been challenged by their work. While some feel their faith (however they define it) has been strengthened by the work, some feel they lose their faith or spiritual grounding as a result of things they see as a humanitarian worker.”

The Headington Institute offers a variety of services to help aid workers in need of support.

“Many struggle from burnout, addiction, and stress impairment or PTSD as a result of what they have seen and heard. And the work is growing more dangerous,” the group says. 

Its mission is to provide counseling to those who need it most – focusing on aid workers from around the globe.

Psychological effects documented

A March 5 article in The Psychology Notes addresses directly the psychological effects of the Ukraine war and the list includes: risk of developing mental disorders; development of phobias; trauma damaging brain functioning; and anxiety because of economic loss.

“These kinds of wars not only affect one or two countries but the whole world,” the article notes.

“Not only Ukraine but the whole world is facing an anxious situation. Citizens of Ukraine have fear about their lives. We can’t even imagine their situation. [The] after-war effect is dangerous because many people will have to face mental disorders.”

From the research and our own experience it is obvious that trauma is affecting not only those directly involved in the horrendous events in Ukraine, but many of us, too.

Some will suffer only minor reactions; the degree of suffering depends on a variety of variables and individual responses.

The worst will suffer from Post Traumatic Stress Disorder, a clinical illness that is treatable. Many more will experience Vicarious Trauma which may not be as serious but certainly can be debilitating.

How many will suffer is one of the great “known unknowns” of the war in Ukraine. We know it exists but we will never be able to quantify how many people are affected and how seriously they suffer.

It is another of the many tragedies stemming from a war that was totally preventable but extensively damaging to millions of people around the world.