Society will have to adapt: psychologists on rehabilitation of people who lost their limbs in the war

War always results in trauma for the society that falls victim to it. Entire nations experience common grief in cases of attacks by other states, terrorist attacks, or natural disasters. Psychologists refer to such symptoms as collective trauma, which is shared by every participant in tragic events.

In such circumstances, society is forced to adapt to completely new living conditions when entire cities of the country remain destroyed, millions of citizens lose their homes as a result of occupation or missile attacks, and thousands suffer injuries that later lead to amputations and life with disabilities.

According to The Wall Street Journal (with reference to the assessment of the world’s largest manufacturer of prostheses – the German company Ottobock), as of August 1, 2023, over the nearly 1.5 years of Russia’s full-scale invasion of Ukraine, about 50,000 people have lost their limbs. In such cases, the rehabilitation process is not limited to prosthetics and physiotherapy. Patients also need psychological help to get used to their new way of life.

In Ukraine, initiatives already encourage people to seek psychological help and provide opportunities to receive it. In 2022, at the initiative of First Lady Olena Zelenska, the National Program for Mental Health and Psychosocial Support and the All-Ukrainian Mental Health Program “Are You OK?” were launched. Many Ukrainian NGOs and charitable foundations advocate for changes by providing free psychological counseling to people traumatized by war.

In particular, in 2024, the state budget of Ukraine allocates UAH 4.5 billion (about $114.3 million) to provide citizens with auxiliary means of rehabilitation. This made it possible to make prosthetics in Ukraine free of charge for those affected by war. Numerous initiatives and rehabilitation centers help those who have lost their limbs. For example, the Unbroken Rehabilitation Center, the Superhumans Center, and the Without Limits Center are among them.

It is essential for society to adapt to the new conditions and learn how to communicate with people heavily affected by the war. 

In this article, we have collected the recommendations of Yehor Iordek, a practicing psychologist who specializes in providing psychological assistance to military and civilian Ukrainians who have suffered amputations and serious injuries as a result of the war, and Volodymyr Lykhach, a practicing psychologist at SuperHumans Center, who specializes in rehabilitation process and its stages, psychological assistance in restoring the functionality of people affected by war, and their integration into society after experiencing trauma. 

The complexity of rehabilitation

At the beginning of the war, the main causes of amputations were injuries sustained during artillery and rocket attacks. Many are now injured in battle, from mines laid along the front line or left by the Russian military in the cities and towns they temporarily occupied.

According to Antonina Kumka, president of the Protez Hub initiative, there are about 80 prosthetics providers in Ukraine. One of them is the Superhumans Center, an all-Ukrainian center for prosthetics, reconstructive surgery, rehabilitation, and psychological support for people affected by war, founded by Andrii Stavnitser.

Most prosthetic centers work with both injured military and civilians. 

In the case of amputations, prosthetics are only the first stage of rehabilitation. Restoration of physical functionality must also be accompanied by psychological support. According to Volodymyr Lykhach, rehabilitation can be considered complete when the following three conditions are met:

• a person must earn money or engage in some paid activity;
• а person must also have a social and family life;
• a person must integrate back into a society that does not reject them.

For example, the last point in real life can look like the tailoring of the amputee’s place of residence to meet his or her needs: widening the corridor and installing ramps and handrails. Under such conditions, a person will be able to achieve at least partial independence and meet their basic needs on their own.

Often, in such cases, it is necessary to involve the local community to re-equip the victim’s apartment or private house.

Volodymyr also highlights possible aggravating factors. “One of my patients is from Soledar (a city in the Donetsk region of Ukraine, after the start of the full-scale invasion, there were fierce battles; currently, there are no remaining buildings in the city – ed.). She lost her home and had no anchors from her life before the injury. This is a difficult case because the physical problem can be solved, but there is still a psychosocial one – where and how to live.”

Adapting to the new conditions on a national scale

It will be possible to assess the full extent of the trauma caused by the war only after the victory. However, it is already clear that the country will have to adapt to many everyday things: ramps, redesigned restrooms in restaurants and shopping centers, and much more.

The Ukrainian medical system has already begun to adapt to the new challenges. For example, primary care physicians can undergo training that would allow them to diagnose certain mental disorders.

“Steps are being taken in terms of hospitals and rehabilitation. Mental health centers are being set up in each cluster hospital. This is already under development, and it is important. In addition, many charitable foundations provide psychological assistance. Many more people now realize this is essential“, said Volodymyr Lykhach.

Beyond the basics, society will also have to take responsibility for healthy communication with victims and their integration back into the community after the trauma they have experienced.

According to psychologists, communication and any interaction with trauma survivors should include three components:

• a trauma-informed approach, in which people need to understand how trauma affects behavior, what stress is, and what its characteristics are;
• a barrier-free and inclusive approach, which includes equal access to all services, as well as the absence of spatial restrictions;
• the social contract approach. It is about the acceptance of a person with an amputation by society. 

“‘You fought, and we accept and appreciate you.’ This is how this social contract is formed. A person with an amputation is becoming a new norm in Ukrainian society because of the war,” says Volodymyr Lykhach.

However, this does not mean that every citizen should undergo special training to build adequate communication with those affected by war because, at a basic level, it does not differ from ordinary communication: 

• you should respect the other person’s boundaries;
• not ask uncomfortable questions about the other person’s trauma or past experience if they do not want to share it themselves;
• do not touch the other person without their permission;
• do not impose yourself with help if you are not asked for it directly.

“You must also be careful and understand that you should stay away if you can’t handle the emotional stress of being around them. You should also not reach out with your hands. If the person is in a wheelchair, then approaching from the side or behind and putting your hand on the shoulder is a horrible thing. Do not touch or impose yourself; do not create additional emotional pressure. This can only make things worse,” explains Yehor Iordek.

Рsychologists also have simple tips on how to restrain emotional impulses when communicating with soldiers who have lost limbs. 

People usually have two common reactions to severely wounded soldiers or people with amputations: avoidance reaction оr vice versa, when people start crying and feeling sorry for the soldier. 

“And these are two extremes in which the victim has nothing to do with it. These are rather emotional reactions of another person,” said Volodymyr Lykhach.

In such situations, psychologists advise a fairly simple solution: stop, mentally count to 5, and understand whether you are ready for communication in which you do not become a trigger for the victim.

Heroization is another obstacle to the full integration of the military into society. 

As a result, the military will experience much more pressure from society, where they will constantly have to live up to the image of a “hero,” while each of us is just a person with our own worries, habits, and views on life, psychologists explain.

Volodymyr Lykhach emphasized that there is often something else behind every heroic act, or its price was too high. Not all military personnel are ready to talk about this publicly or in everyday conversations.

“One of my patients had several awards, one of which was to be presented at an award ceremony with the President of Ukraine, Volodymyr Zelenskyy. But he didn’t want to talk about it and refused to wear the medals because he associated each of them with his fellow soldiers. Everyone applauds and thanks him, but he is sad.”

“There is a narrative that ‘heroes don’t die’. But they do, and that’s the sadness of it,” the psychologist summarizes.

It will take time and care

When a person’s familiar world is destroyed, and they have to live in new, uncharted conditions, it takes a long time to adapt fully. However, the loved ones of a person with an injury or amputation can play a significant role in speeding up rehabilitation, and society can help make it more comfortable. 

The first steps for relatives and close friends of a defender are to see and accept the person’s new body and to recognize that this is normal and does not make the person inferior. Yehor Iordek emphasizes that it is vital to show the veteran that he has nothing to hide or be ashamed of, regardless of the injury: amputation, scarred face, burns, etc. You need to start with gratitude that your loved one is alive and back home.

“We see more and more boys and girls wearing prostheses. Unfortunately, their number will increase in the future. And losing one’s previous appearance is still a loss that takes a long time to overcome. They did not get used to it in a month. They keep looking for a second slipper, trying to lean on the amputated limb. It’s a long process of adaptation, of dealing with loss, and you need to communicate with them as with people experiencing a loss“, said Yehor Iordek.

The family and close friends of a person with an injury or amputation also need some psychological training to understand the peculiarities of communication and not to harm them with their actions.

When soldiers return from the battlefield with psychological or physical injuries, society is responsible for their further integration. Part of an unspoken social contract is to be ready to accept and containerize all the emotions and thoughts they bring back. This is aggression, a sense of injustice, impulsivity, addictions, a completely new worldview, an exacerbated sense of inferiority or, on the contrary, of being chosen.

Also essential for the public is to understand the mechanics of post-traumatic stress disorder and challenging experiences in general.

“I always give the example of a long journey. Your eyes hurt when you drive for a long time, but you must continue anyway. After 10 hours, you leave the car and sit in a chair at home, and what do you see in front of you? The road. You’re already home, but it feels like you’re still traveling. There’s a vibration in your body somewhere, a buzz in your head. Now imagine that a person has been at war for 2 or 4 years. When he comes home, what will he see in front of his eyes? The war.

What do we do when we meet guests from a long way away? We meet their basic needs: a shower, a fresh, clean bed, peace and quiet, food, and water. These are basic everyday needs. These are the things that the military have been limited to all the time they were in the war zones”, said Iordek.

The psychologists explain that despite the frequent and predictable symptoms of amputation, one should not assume that everyone needs the same approach. Each case is unique and, therefore, requires a unique interaction. 

As the number of people living with limb amputations in Ukraine grows due to Russia’s military aggression, it is essential for society to adapt to the new conditions, work on providing a barrier-free environment, and learn how to communicate with people heavily affected by the war.