Valeria Birman from Kyiv is studying for her second medical degree in psychiatry at the P.L. Shupyk National Medical Academy of Postgraduate Education. At the same time, she works as a resident physician at the Pavlov Psychiatric Hospital, where she helps AFU soldiers cope with post-traumatic stress disorder (PTSD). Based on her patients’ stories (all names have been changed), Valeria told The Insider how war affects the human psyche, what doctors can do about it and how psychiatrists themselves experience it.
“In every dream he crawls trying to get to cover under a bush”
Zeroing out as a protective response
Psychiatrists in need of a psychiatrist
“In every dream he crawls trying to get to cover under a bush”
They were ambushed on a road. Seryozha spent a long time looking for cover, he had to crawl past the bodies of his comrades-in-arms, past severed arms and legs. Now he cannot eat meat anymore. His hospital roommates are annoyed because he constantly plays music on his phone. But Sergei cannot fall asleep any other way. And in his sleep, over and over again, he crawls trying to get to cover under a bush or a tree by the side of the road.
He is one of our most difficult patients. He has no family, no loved one. You always need to find a lever to pull, but in Seryozha's case there is no lever. He wants to go to war. He thinks he's only wasting his time in hospital. While his comrades are fighting, he is here taking some pills.
He wants to go to war. He thinks he's just wasting his time in hospital
And sometimes Sergei loses heart and tells me: “I'd rather go to war, die there, and that's it”. And these phases of activity and passivity alternate. We already told his commander that if we cannot do anything in a month, we will have to leave him in hospital for a long time. Maybe forever.
The commander sent him to us. There are times when a soldier says to an officer: “I need to see a doctor right away, because there's something wrong with my head. Our commanders are quite young and understanding. They don’t say: “You made all this up, go to war”. They listen to the soldier and send him to us for examination.
Our very first task is to dig out all the dirt that is hidden from us. A person is uncomfortable, he may become violent, aggressive, or simply insane. Many people need to be sedated. They then come to their senses and say: “I remember the moment of the injection and I am very sorry.” We say: “You don't need to apologize. We just gave you a chance to rest and forget so that you wouldn't do anything bad”. In such circumstances, a single word or careless action can provoke aggression. For example, fighters are pathologically afraid of phones in our pockets. They're afraid we're going to record the conversation. They have a clear directive: to keep military secrets to themselves and not to tell civilians about the course of operations. So, I just give them my phone at the beginning of the conversation. They can browse through it, realize the recorder is off, and become more relaxed.
Then psychotherapy begins - the biggest layer of work. Our task is to constantly talk to the person, to show that you are a friend. After all, many people are afraid of the very word “psychiatrist”. And when a classic doctor in a white smock, as if from a picture, approaches them, they are unable to open up to him. And we build a relationship of equality. We treat each patient as a friend. Of course, it looks a little hypocritical, but it allows us to work.
First, we just talk, then we start a friendly lecture. We explain to the person what’s wrong with him and how it can be healed. For example, it is quite common for a soldier to dream about his dead comrades-in-arms who tell him: “You are alive, but we are not.” He blames himself. And we explain that it was his brain that invented it, that his brothers-in-arms did not call him. About 60% of our patients show positive dynamics.
Sasha's father was a policeman in the 1990s. He often took his son with him and showed him that when you hit a criminal on his fingers with a truncheon, he became more obedient. That is, he was taught as a child that physical violence was a normal method. The father used similar methods to on his son. Sasha is afraid of his father. When he comes to the hospital to visit him and walks down the corridor, Sasha literally has a tantrum. His pupils dilate, his shoulders are squared, his stands at attention, his fists clenched. Sasha, who has been traumatized by the war, fears his father as well.
PTSD has this nasty property of exacerbating old traumas. It is like an artificial intelligence that seeks out weaknesses in a person and presses on them. Even as a child, Sasha developed an imaginary friend. Another Sasha, but mean and able to stand up for himself. There are all sorts of people on the frontline. If you are too slow, they can tell you about this quite rudely, with all sorts of swear words. It’s quite offensive, and it wakes up the angry Sasha.
At one such moment my patient asked the commander to take his weapon away from him. He later recalled: “I felt worthless, and then the evil Sasha woke up and said: you have to be more brave, you just have to go and punch that commander in the face.”
Sasha isn't violent at all. He is infantile and does not know how to communicate with women. That's why it was hard to talk to him at first. On the other hand, he is also afraid of doctors. So, I had to take off my smock and visit him in ordinary clothes. As a result, Sasha and I became friends.
Our hospital complex is located in a forest, it’s quiet here. And, having lived here, Sasha calmed down a bit. With the chief doctor's permission, we can take the patients outside the hospital, if it's useful for them. Once we went with Sasha to the city to visit the museum. He liked it there but to get to the museum we had to travel to central Kyiv by minibus. It was noisy and full of people, and Sasha was squeezing my arm so tightly that it felt like he was going to break it. At some point, Sasha saw a ruined building, unfortunately, an ordinary occurrence in central Kyiv. His brain told him at once: we have seen it, it is not safe here. He made me duck and started leading me away from there.
Sasha saw a ruined building in central Kyiv, made me duck and started leading me away
In the first days when Sasha joined us, he wanted to become a special forces officer. Because Special Forces are cool. And now he dreams of being a programmer. He goes to the library, reads history books.
He doesn't want to go to war anymore. Now the commander has sent a request to return Sasha to the front. Alas, he will either die there or come back after the war as a completely ruined man. All the treatment will go to waste.
Zeroing out as a protective response
Kostya began to forget his fellow soldiers. Soldiers complained that he looked not at them, but through them. Mechanically he remembers what to do, but he does not recognize people. His brain keeps trying to bring him back to a time when everything was still normal and calm - when the war had already started but Kostya had not yet gotten to the front line. One day he said to the commander: “Dude, who are you anyway?” He got angry at first, and then he contacted us.
Sometimes in our conversations, too, Kostya suddenly looks around the room and asks: “First, who are you, and, second, where am I?” At some point the pills did their work. And we explained to Kostya that he was in a psychiatric clinic; before that we were telling him he was in a sanatorium, to keep him from losing his nerve. He understands what month it is. His brain has rested a little and returned to normal. The important thing now is to make sure that Kostya doesn't zero out again.
By the way, all his relatives are in Russia. He and his wife came to Ukraine in the noughties. First, he landed a good job, then he opened his own business. When the invasion started, Kostya gave up his car to help the AFU, and went to the front. I asked him if he was in touch with his relatives in Russia. He says that at first, he tried to open their eyes to what was happening, but it was useless.
Now many people in Ukraine hate Russians. But the most interesting thing is that none of my patients have this hatred. They understand that what the enemy is doing is bad. But they don't have time to hate, they have to protect their homes. A combatant understands that there is an enemy who is also fighting, that he must be outsmarted and defeated.
They don't have time to hate, they have a home to protect
Another patient of mine, Petya, who experienced the cruelty firsthand, does not have this hatred towards all Russians. This guy is a veteran of the ATO, he fell under occupation at the beginning of the war. The enemies were specifically looking for former military men or those associated with the military and tortured them. Petya ended up in a torture chamber. He was terribly beaten there, all his ribs were broken. But he managed to get out of the captivity and immediately went to the enlistment office. There he said he would not go away until he was sent to the war. Already at the front, Petya had a week's leave from the front line. He looks after himself, so he went to see a doctor and confessed, among other things, he noticed some changes in his psyche. For instance, he snapped at his wife recently. The doctor contacted us, and we examined Petya and saw an absolutely clear case of PTSD. We called his commander and told him he wouldn't come back right away, and we had to treat him. We had him for a month. He complained that he had nothing to do and wanted to go back to war. Petya has no direct indication not to go there. And he's still an effective combat unit. And he also has quite a peaceful motivation: after the victory he wants to revive the business he had before the war.
He was a military man who fought in Afghanistan, then in Chechnya on the side of Ichkeria. And even in peacetime he was spending time online on military forums with people like him. He is always on the alert, he literally lives for the war. He joined us because there was an altercation in the dugout, the soldiers jostled with each other as little brothers do sometimes. He dropped the ball on them and decided that this was an enemy incursion and he started laying about him. With us, he got lazy, took his pills every other day. We're not the kind of an establishment that forces treatment on its patients. He kept saying it was unnecessary to treat him and he had to return to the front. So, he was sent back to the front. There he could at least do some good. But after the war he would probably end up in our psychiatric clinic, because in reality he posed a danger to society.
After the war, he'll probably end up in our psychiatric clinic because he poses a danger to society
About half of the fighters want to return to the front. They are experienced military men and believe they are needed there. Most of those who serve in the army now are people who already have wives, children. And everybody wants to see their daughter go to school. But at the same time, you want your daughter to call you a hero. Hence the dissonance. We advise many of those who want to go back not to do it. Their psyche won't hold out, and then we'll have sick members of society. It's very important to explain everything honestly. That’s why we say: if you want to go back, if you are not ready to give up your military career, you have to volunteer. And then their eyes light up, just like little boys'! One of our patients, Slavik, is now supplying his unit with necessary things. Socks, thermal underwear. He communicates with them, they remember him, they greet him joyfully. He's happy. We know that, because we are required to keep an eye on our patients for two years after discharge. Only then will he go off on his own. We have to explain to a PTSD patient that when our treatment is over, he will be dealing with his problems on his own. Of course, the role of the family is very important here.
When our treatment is over, the patient will have to deal with his problems on his own
Wives, sisters, mothers often come to us. They ask us how to communicate with fighters so that their unpleasant memories do not return. We advise them to remember how they first met, the first dates, their interest in each other. The wives of our fighters visit them at the hospital as well. Because of the shelling, there are power outages in the city, there is often no light in some of the back rooms. You should see those romantic couples sitting together in our canteen by candlelight.
If we observe a patient’s positive dynamics, we can let him/her go home, where, as they say, the walls heal. The wives tell us they have a completely different family life now. People regain interest in each other. I will not bring up sexuality, although it is also positively affected by treatment.
I can give one piece of advice to soldiers' wives and girlfriends: don't ask them about anything. It's hard for a military man to tell, but it's hard for a civilian to listen. He comes home to have a rest, to be satiated with emotions and impressions. Just live the life you tried to live before. If you are a married couple, at some point it is better to give the children to grandmother and go to a cafe. Then have a playdate with the baby. Just make it a goal to learn to relax.
It is very important that a person has something to live for. We examined Dima, who returned to his town after the Russian retreat and saw that his house was gone. All his relatives had fortunately managed to leave, but of the house only a section of the fence was left. Dima carved wood as a child. And when he saw the wreckage of his handicrafts in the ruins, he just burst into tears. He knew the war was going on and many houses had been destroyed, he just could not stand it. But it motivated him. Now Dima wants to finish everything as soon as possible and rebuild his house. He says he loves the place so much. The man knows how to treat himself.
Actually, no one sent Dima to us. He came to visit a comrade whom I was also treating. The comrade and I went outside to meet him. A big car drove by, making a noise, and the military man grew tense. I realized: here's another patient of ours. I contacted his commander and told him that we were taking the soldier for examination. Fortunately, we did not find any pathology. In general, such a reaction to noise as Dima's is common. The key manifestation of PTSD is anxiety, various kinds of anxieties. Explosions a soldier has heard on the battlefield may cause him to grow tense, or even drop to the ground, upon hearing ordinary city noises. There are many military servicemen on leave in Kyiv right now, and they are easily recognizable by such a reaction.
Ordinary city noises may cause a soldier to grow tense, or even drop to the ground
However, it can also happen to civilians. There is probably no one in Ukraine today who does not know what explosions and bombings are like. That's why in all the time I've worked in the clinic I've never encountered the reaction we know from veterans of the previous wars. I've never seen contempt for civilians “who weren't there”. After all, our whole country is at war.
From the very beginning, the entire Ukrainian state came alive like a giant anthill and started collecting aid for the military. There are boxes for the AFU in stores. People buy sausages, canned food, chocolate. Everyone is trying to help the army with something. The military understands this and responds with gratitude. Yes, sometimes the guys get upset: while they fight at the front, civilians go to cafes. I usually tell them: yes, of course, and let's also go to a cafe. And we do go, and I explain that people need to rest somehow, that everyone has a moral and informational overload, and that we need to get positive emotions from somewhere.
Psychiatrists in need of a psychiatrist
My close friend was in an occupied territory near Bucha and Irpen, he had a house there. There was no water in the house, nothing to cook on, nothing to drink. He went to fetch water, but the Russian military wouldn't let him through. Now he lives in Kyiv, he goes to work, but he keeps a large supply of water in water cans at home because he's afraid he won't be able to get water. This is how his PTSD manifests itself.
Many doctors also feel crippled, and it's going to be very hard for them after the war. People have to work in an environment that they would never have dreamed of in peacetime. For example, my friend who is an anesthesiologist and resuscitator, says that the current situation is simply horrible. You're swimming in a pool of blood and pus and slime. You need every supply you can get, and you need it right away.
A lot of doctors feel crippled too, and it's going to be very hard for them after the war
My first medical specialty was forensic medicine. And at the beginning of the war I was still working as a forensic expert. It would seem that when you see violent deaths all the time, it toughens you up, makes you stronger. We have our own cynical humor. For example, when you have to assemble a person's body from parts, it's called “playing Tetris.” But even such an experience does not protect us from what we see now. I saw grown-ups, experienced forensic experts cry when they had to dissect bodies of children after Bucha and Irpen.
The de-occupied area reminds me of Murmansk in 1945 - I was very interested in the history of World War II and read about Murmansk, which Hitler wanted to destroy completely. You walk down the street, and you see a little hand sticking out of the ruins. You go inside and you find a baby there and the mother, covering the baby with her body. Both dead.
We were kind of ready for it. On second thoughts, we weren’t, I'm wrong, we weren't ready for it. No one believed there could be such an atrocity in the twenty-first century! You see a pregnant woman on your table who was about to give birth. Or an old man who was shot in the street. And you think: well, he was just on his way to get bread or water. But why was he killed?
We were not prepared for it. Such atrocity in the twenty-first century! You see a pregnant woman on your table who was about to give birth. Or an old man who was shot in the street
After that I also sought help from a psychiatrist, a colleague of mine. I did not need medication, but we worked through it all together. All of us are broken now, because our ordinary existence has been disrupted by the war, irrevocably disrupted.
That's why it's very good that I went to study to become a psychiatrist. It's going to be a much-needed profession. We can cure people and help build a healthy society after the war.