When the full-scale Russian invasion of Ukraine began in February 2022, Nataliia Zhyliak’s world was upended in a matter of days. At the time, Zhyliak, a psychologist in the western Ukrainian city of Kamianets-Podilskyi, was working at an education and rehabilitation institute with a group of 50 orphans with special needs, most of whom were between 15 and 21 years old.

As air-raid warnings blared throughout the historic city, Zhyliak and her colleagues rushed the group to bomb shelters in the basement of the building, where they huddled in fear for hours. Working around the clock through the early days of the war, Zhyliak began to notice changes in the children. Some were showing more aggression and anger. Many cried uncontrollably, while others needed to be held.

Sitting alongside the orphans as they grappled with their new reality, Zhyliak says, she realized one of the most powerful things she could do was to simply ask them: “How do you feel?”

As the Russian war stretches into its third year, that question is increasingly central to the success of Ukraine’s defense strategy. Protecting the mental health of Ukrainian civilians and soldiers has become a political priority, one tied to Ukraine’s social, economic, and democratic stability. Creating access to such services is a daunting task during wartime, when infrastructure is crippled and underfunded and while tens of millions of Ukrainians have been displaced.

“Trauma has now become a population-wide challenge,” says Elizabeth Ames (MBA 1985/MPA 1997), whose nonprofit, Heal Ukraine Trauma, is working to provide mental health care services to Ukrainians. Since its launch just three months into the war, the organization has partnered with psychologists like Zhyliak to support children, soldiers, and others experiencing trauma. This is a critical and difficult task, Ames says, but one that is essential to the country’s long-term recovery.

“And the future of Ukraine is important to the world,” she says.

Natalia Hevchuk, a psychologist in Ukraine, noted that her young patients’ trauma was evident in their sketches, which often depicted air raids and destruction. “The children were drawing their nightmares,” she says. (Stanislav Ivanov/Global Images Ukraine via Getty Images)

In February 2022, Ames had been planning to relocate to Ukraine. She had sold her house in Massachusetts and packed up her furniture when she began to hear warnings that a Russian invasion was imminent. So she put her plans on hold, and instead began to focus on finding ways to assist Ukrainians. Ames has deep ties within the region: In 1992, she was named the director of the first Peace Corps program in Ukraine. Now she feared for the lives of her friends and colleagues and worried about the long-term impact that a ground war would have on their mental health.

Before the war began, there were already well-established concerns about Ukraine’s ability to assess and address the mental health of its citizens. The World Bank had estimated in 2017 that up to 30 percent of the country’s population would face a mental health disorder during their lifetime. In 2019, Ukraine had a higher average proportion of depressive disorders than did nearby European Union nations—5.2 percent versus 4.6 percent—and its suicide rate was twice as high as its EU neighbors, according to the World Health Organization, which attributes these disproportionate effects to historical trauma and Russia’s 2014 invasion of Ukraine.

Those figures and concerns have only grown: The World Health Organization and the Ukrainian Ministry of Health estimate 10 to 15 million of the country’s residents will need professional psychological support as a direct result of the conflict.

For Ames, the mental health care crisis in Ukraine has been a longstanding, and personal, concern. She first arrived in the former Soviet republic shortly after the dissolution of the Soviet Union in the early 1990s and found its citizens still suffering from the devastating effects of World War II and the Holodomor, the Stalin-led effort at collectivization that starved Ukrainians in the early 1930s. Now known as the Great Famine, it is believed to have led to the deaths of nearly 4 million Ukrainians.

“There were people who were carrying profound mental illness burdens from 50 years before,” Ames says. “Through the intensity of the experience, I developed extremely close connections with local Ukrainians, and also a great love of the country and understanding of the history.”

She also developed a severe case of PTSD during her time living in the region. Working in such a high-profile role required her to navigate the country at a time of chaos. Ames, who later served as a senior policy advisor for economic affairs and technology under two governors, says she had lived for 20 years with the “darkness” of the trauma she experienced working in Ukraine and Russia, dealing with depression and anxiety that profoundly affected her both personally and professionally. By 2017, she had exhausted existing psychiatric treatments for PTSD and found Michael Pollan’s How to Change Your Mind, about the new science of psychedelic drugs.

“I am not an ‘underground person’ by nature, but I knew I had nothing to lose,” she says. Ames connected with medical practitioners who were treating patients with therapeutic psychedelics. Through the treatments, she experienced profound relief and recovery from her severe PTSD. She soon began thinking that psychedelic-assisted therapy might help traumatized veterans in Ukraine, too.

In 2019, she and Oleh Orlov, a Ukrainian psychologist and expert on psychological crisis intervention, created the Ukrainian Psychedelic Research Association to advocate for the legalization of psychedelics to help veterans with PTSD.

But when the Russians invaded, Ames knew she needed to redirect that effort into a countrywide approach to treating trauma. And she knew whom to approach for help: two former sectionmates, Elaine Klein and Colin Greenstreet (both MBA 1985).

Klein, who is the board president at Heal Ukraine Trauma, had remained a close friend of Ames for four decades. She and cofounder Greenstreet, who were both longtime health care executives, immediately recognized the challenge. “When Elizabeth shared her experience and her ideas, I basically said, ‘How can I help?’” Klein says. “To me there was such a compelling need.” Many other HBS sectionmates supported the startup with seed funding to launch Heal Ukraine Trauma.

Among the first tasks the nonprofit undertook was assessing that need. Working with health care providers in Ukraine, the organization prepared a report on the state of mental health care there today: Outpatient mental health treatment in the country is limited and severely underfunded. Patients bear an outsize burden of the costs. The variety of practitioners makes it difficult for civilians to know where to turn. And the cluster of nonprofits and NGOs offering services that have sprung up since the 2014 invasion are not able to coordinate in an effective way.

What’s more, cultural stigma often prevents Ukrainians from seeking care. Many communities view mental health disorders as a symbol of weakness, and older generations distrust the psychiatric system with cause. Prior to 1991, the Soviets used it as a suppressive tool, diagnosing dissidents with mental illness and incarcerating them in the country’s psychiatric hospitals. A 2021 study of Ukrainian adults showed that 75 percent of respondents “agreed that psychiatric hospitals seem more like prisons than places where the mentally ill can be cared for.”

Heal Ukraine Trauma’s assessment put these challenges in stark terms: “The invasion has stripped civilians of their sense of identity. Their world was turned upside down overnight, allowing for little preparation and increasing cases of depression, anxiety, and PTSD,” it stated. “These issues are rooted in all-encompassing trauma that hits sequentially, including a fear of death, loss of freedom, grief, separation of families, social dislocation, social disruption, forced migration, and more.”

The World Health Organization and the Ukrainian Ministry of Health estimate 10 to 15 million of the country’s residents will need professional psychological support as a direct result of the conflict. (Artur Widak/NurPhoto via AP)

As the invasion stretched on for months, Natalia Hevchuk, a psychologist and colleague of Zhyliak’s in Kamianets-Podilskyi, knew that her young patients were experiencing trauma. She could tell from their sketches, which often depicted explosions, air raids, and ravaged homes. “The children were drawing their nightmares,” she says.

One of Heal Ukraine Trauma’s first endeavors was helping these children cope. It established a partnership with Volunteers, an NGO that has spent 25 years working to provide child-protection assistance in Ukraine. Despite the organization’s long-standing presence in the region, its limited capacity in offering psychological support became even more constrained during wartime, says Yana Sinelnichenko, a project coordinator with the group.

“When the war started, our lives changed. And I think, in the full sense of this word, it was divided into before and after,” she says. The organization knew it would be critical to address children’s mental health care needs, she says, and it has contracted with practitioners like Zhyliak and Hevchuk, who were treating children who were scared and not feeling safe in their homes. Many of them couldn’t understand why their lives had changed.

A grant from Heal Ukraine Trauma funded Teaching Recovery Techniques, an evidence-based program designed to help children cope with traumatic stress from war and reduce the risk of long-term mental health effects. During the summer of 2023, volunteers administered more than 50 small, in-person support groups for 648 children and adolescents in six regions in the country that were most heavily impacted by the war or have seen the highest volume of internally displaced people.

The children met for 90 minutes two or three times a week for five sessions and learned visualization and drawing techniques designed to calm them. Over time, Hevchuk began to see results. “A child would draw his house shelled by rockets, and then draw a cover to protect the house,” she said. Another child drew images of jets flying over the city, but instead of dropping bombs, they dropped flyers saying Ukraine had won the war.

“Through these techniques, children could share their feelings and emotions that probably they haven’t shared before with anybody,” says Zhyliak. The results of the program showed that the children were better able to avoid intrusive thoughts related to traumatic events. (Zhyliak says she uses the techniques herself when she’s feeling stressed.) The organization is now fundraising with the hopes of serving more students, including those with special needs, in 2024.

For Ames, the impact of this work was driven home during a visit to Ukraine last summer, when Volunteers received an email from the mother of a nine-year-old boy who had been through the program. “She said that her son was quite affected and withdrawn from the impact of the nightly and daily barrages,” Ames recalls. But one night, after the air-raid sirens had gone off and they’d all gone into the bomb shelter, the woman wrote, her son broke the silence and asked for help. “He was surrounded by adults, and he said, ‘I’m afraid. Would you mind breathing with me, so we can all lose the fear together?’ And that’s what they did.”

As a Volunteers team member read the email out aloud, Ames and the other adults in the room struggled to keep their composure. “We weren’t just thinking of a child. We were feeling the experience ourselves,” Ames said, as she and the others were still seeking cover in shelters on a regular basis from attacks. “The power of a nine-year-old saying, ‘Can we all breathe together?’ was overwhelming.”

Heal Ukraine Trauma cofounders (from top) Elizabeth Ames (MBA 1985/MPA 1997), Colin Greenstreet (MBA 1985), Elaine Klein (MBA 1985), and Elise Wilson. (Courtesy Heal Ukraine Trauma)

Heal Ukraine Trauma cofounders (from top) Elizabeth Ames (MBA 1985/MPA 1997), Colin Greenstreet (MBA 1985), Elaine Klein (MBA 1985), and Elise Wilson. (Courtesy Heal Ukraine Trauma)

In May 2023, approximately one hundred stakeholders from Ukrainian military, medical, and political circles gathered at Forest Glade, Kyiv’s leading military rehabilitation hospital, an ivy-covered building on the outskirts of the city; thousands more joined virtually. Inside, more than two hundred Ukrainian soldiers suffering from depression, anxiety, and other mental health disorders wandered through its halls. Some bore obvious scars of war, walking with crutches or canes due to amputations. Others suffered invisible wounds: headaches, brain injuries, or chronic pain. But nearly all were struggling with mental health challenges that lingered long after they’d left the front lines.

The convening was Ukraine’s first-ever medical conference to discuss psychedelic-assisted therapy’s potential for veterans suffering from PTSD. It was cosponsored by Heal Ukraine Trauma and hosted by the Ukrainian Psychedelic Research Association and Forest Glade.

While the use of psychedelics has not been legalized in the United States, many clinicians who have begun clinical trials of psychedelics hope that the FDA might approve them in 2024. In Ukraine, ketamine—a dissociative anesthetic—is legal, and through the Ukrainian Psychedelic Research Association, Ames and Orlov are working to expand its availability and help legalize other psychedelics for use in serious conditions such as treatment of resistant depression and severe PTSD.

Both Ames and Orlov said they didn’t know what the attendees would make of the conference. “This was the first time when the term psychedelic was pronounced in an official institution,” Orlov says. “We didn’t have a clue about how people would react.”

They were floored by the positive response. In October, the Ukrainian Parliament held a roundtable committee meeting to explore various perspectives on using psychedelics to overcome mental health crises. Ames and Orlov’s organizations are currently developing a group-therapy model utilizing ketamine in a clinical setting that they hope to launch in 2024.

“It led to an incredible breakthrough in interest and incredible progress with the government legalization effort,” Ames says. “I actually think that psychedelics will be legalized [in Ukraine] both for research purposes and compassionate use.”

The current Ukrainian emphasis on mental health care during wartime is unprecedented, Ames and Klein acknowledge, but it’s also a critical part of the country’s geopolitical future. And it’s now being touted from the highest levels of government.

Last December, Ukrainian first lady Olena Zelenska launched the “How Are You?” campaign to destigmatize mental health care. “Against the background of daily alarming news, missile attacks, human grief and trouble, it doesn’t seem appropriate to ask yourself ‘How are you?’ ” she said in a statement. “But, in fact, psychological well-being and understanding of what is happening in our inner world is more timely than ever.”

She’s now working alongside the country’s prime minister and the World Health Organization to create the National Program of Mental Health and Psychosocial Support. The effort openly recognizes the effect mental health will have on the country’s ability to recover economically from war.

“When the shooting is over and the smoke clears, Ukraine needs to be able to recover and rebuild as fast as possible,” says John Tedstrom, a Heal Ukraine Trauma board member and longstanding global health and security leader. Tedstrom believes that Russia’s interest in dominating and oppressing Ukraine isn’t simply going to go away. But with proper mental health care services in Ukraine, “Russia can be dissuaded from pursuing that line,” he says, particularly if Ukraine is able to rebuild successfully and become more economically and socially integrated with Europe. “To accomplish that, we will need every Ukrainian to be contributing to that effort. That’s really important.”

Heal Ukraine Trauma’s cofounders believe that their organization has the benefit of being in the right place at the right time, with the right team of people behind them. They plan to spend the next several years supporting Ukraine through this critical juncture and hope to eventually apply their lessons in the next decade to other countries impacted by war.

“The mental health future of Ukrainians is critical to rebuilding after the war,” says Ames. “We look at it as a human capital issue and a humanitarian issue that will be transformational to the country’s future.”

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