When we think about the damage wrought by war, we often think about the physical consequences such as injuries and destroyed infrastructure. However, the often-invisible mental scars left behind by war are no less important.

A woman who was kidnapped by Boko Haram and recruited as a bomber at an abandoned building at a camp for displaced people in Konduga, Nigeria. August 20, 2019. (Laura Boushnak/The New York Times)
A woman who was kidnapped by Boko Haram and recruited as a bomber at an abandoned building at a camp for displaced people in Konduga, Nigeria. August 20, 2019. (Laura Boushnak/The New York Times)

People affected by violent conflict may witness traumatic events, be displaced from their homes, separated from their families, exposed to physical and sexual violence, or forced to take up arms as a combatant. All of these experiences raise the risk of developing serious mental disorders such as post-traumatic stress disorder (PTSD), depression and anxiety. The World Health Organization, for example, estimates that more than one in five people exposed to conflict will develop a mental disorder, around half of which are severe.

Recent research has demonstrated that when left untreated, the mental scars of war increase the desire for revenge-seeking and erode people’s empathy. And while decades of evidence show that trauma or other mental challenges alone do not cause people to become violent, conflict-related stress and trauma can interact with other social dynamics — like marginalization, exclusion or political influences — to increase the risk of further violence and make peace harder to achieve.

The Psychological Toll of Conflict

Recent and ongoing conflicts in Afghanistan, Nigeria and Sudan are noteworthy examples regarding the importance of monitoring and addressing mental health in conflict-affected communities. In all of these contexts, conflict-related trauma has become intergenerational amid perpetual violence.

In Afghanistan, for example, over four decades of continual conflict have left many Afghans with a combination of mental health problems stemming from acute, chronic and complex trauma. Although there is no comprehensive data showing the full extent of mental health issues in Afghanistan, a nationally representative survey in 2021 found that two-thirds of the Afghan population had personally experienced at least one traumatic event, with nearly half of Afghans reporting high levels of psychological distress.

And since the Taliban takeover, systematic discrimination against women and girls has only added to their already dire mental health challenges. A series of U.N. consultations in July 2023 found that most women suffer from feelings of anxiety, isolation and depression. “[Before Taliban rule] I was a professional woman, dealing with people all the time, [but] now I feel like a prisoner in my own home,” one Afghan woman who previously worked at an NGO in Kabul told us. “I get an anxiety attack every time I go outside to buy groceries or see a doctor, feeling that I would get beaten or detained for breaking a rule that I am not aware of.”

In Nigeria, too, the conflict with Boko Haram and other militant groups has deeply affected the mental well-being of communities in the northeast part of the country, where abductions, home destruction and forced displacement by armed insurgents have become all too common.

The effects of these traumatic events tend to linger, with reports from the region consistently noting the prevalence of experiences like flashbacks, nightmares and insomnia — all of which can be associated with mental disorders like PTSD. “I came across an elderly woman that was unable to see or stand and was crying profusely, textbook signs of PTSD,” a clinical psychologist in northeast Nigeria told us. “After stabilizing, she narrated how Boko Haram had attacked her community and before her eyes, her husband and three kids were all [brutally killed]. As she walked away, she saw her family home set ablaze. She said this is the only image she can think of since.”

Similarly, in Sudan, the ongoing fighting between the Sudan Armed Forces and Rapid Support Force paramilitary has severely affected the mental health of people in the country. Millions have been uprooted and displaced from their homes, and there have been harrowing accounts of widespread sexual violence and other crimes against women.

One female doctor from Khartoum recounted just how quickly the mental toll of war set in for her: “It was a quiet morning until we heard gunshots. After that, I’ve suffered from nightmares, flashbacks, palpitations, low mood and apathy.” And while this doctor told us she tried to introduce mental health treatment to her health clinic for displaced people, the lack of resources and capacity made it impossible.

The Cycle of Trauma and Conflict

A lack of resources is not uncommon in active conflict settings, where treatment is rarely possible. Some programs, such as USAID’s Towards Enduring Peace in Sudan program, have incorporated trauma awareness components as far back 2018 — but such programs continue to be the exception rather than the rule in international peacebuilding.

Indeed, global estimates suggest that 80 percent of those affected by conflict-related mental disorders do not receive treatment. And without treatment or psychosocial support, conflict-related trauma can linger. As one Afghan woman said regarding her mother’s death in a rocket attack Kabul in 1992: “I find myself bitter and angry. Thirty years on, I still have trouble getting a good night’s sleep ... and sometimes wake up screaming. I want to face those who murdered my mother.”

These unhealed mental wounds, when combined with a lack of justice and accountability for perpetrators of violence, can contribute to a cycle whereby conflict creates trauma that then raises the risk of future conflict. Not only that, but it can make future attempts to address grievances and reconcile conflict parties more challenging, as feelings of collective hopelessness set in.

And in societies affected by intergenerational conflict — such as Afghanistan, Sudan and Nigeria — the cumulative hatred, righteous rage and desire to inflict punishment can be far more energizing than the difficult work of justice, reconciliation and forgiveness. In Sudan, for example, local militias in the Sudan’s civil war have been mobilized to fight based on unresolved grievances from past conflicts.

Unresolved trauma can also create a barrier to the successful reintegration of ex-combatants when the host community and people returning do not receive adequate mental health and psychosocial support. Indeed, community members may experience “re-traumatization” when they are forced to once again live with those who have previously perpetrated violence against them.

These unresolved and recurring traumas can thus create barriers to the successful reintegration of ex-combatants as they make it more difficult for communities to accept and reconcile with ex-combatants and contribute to stigmatization that makes it harder for ex-combatants to return as healthy and positively contributing members of the community.

Mainstreaming Mental Health into Peacebuilding

Resolving this cyclical violence will require new responses to violent conflict that mainstream mental health in the field of peacebuilding. Some options for how policymakers and peacebuilders can proactively address mental health in order to create more sustainable peace include:

1. Expanding mental health and psychosocial support (MHPSS) alongside peacebuilding.

In societies dealing with collective trauma, addressing violence requires thinking beyond traditional conflict resolution practices based on negotiations between rational parties. As one peacebuilder in northeast Nigeria described to us: “Peacebuilding practices pull on this sort of stability of logic. And that isn’t possible at times in conflict zones. We may be pushing a negotiated agreement where really there is no collective will because of the trauma standing in the way.” Or as South Africa’s Institute for Justice and Reconciliation (IJR) puts it, there can be “no peace without peace of mind.”

For this reason, MHPSS should be expanded in conflict-affected communities alongside peacebuilding, as both activities are necessary to address the causes of conflict. This expansion in MHPSS requires mainstreaming mental health into the overall health care system of conflict-affected countries.

To achieve this in low-resource settings, MHPSS can be expanded in regular health care facilities (as exemplified by the World Health Organization’s mhGAP program) and through task-sharing approaches, in which lay individuals and religious leaders are trained to provide some services, with a referral system for cases in need of more specialized care.

This mainstreaming should also draw on the local practices of trauma healing and peacebuilding that have emerged among those most impacted by conflict and violence.

In Nigeria, for example, we spoke to a priest who had brought together other religious leaders in a network to provide faith-sensitive mental health care to victims of Boko Haram violence. We also spoke to a women-led Nigerian NGO, the Neem Foundation, that is pioneering new approaches to bringing mobile mental health and peacebuilding clinics together, with a focus on women’s empowerment.

These local approaches are often stymied by limited capacity and funding, however. For this reason, the international community should consider tapping into and helping expand local resilience-building and trauma-healing practices through partnerships with civil society, peacebuilding, mental health and religious organizations.

There should be particular attention paid to providing mental health support to displaced populations and ex-combatants, and the host communities where they return to, as these populations are at increased risk of mental health challenges — especially when they return to an area where conflict is ongoing or has recently occurred.

USIP’s RISE Action Guide, which seeks to help those disengaging from violent extremism reintegrate and reconcile with local communities, includes recommendations about the critical role of trauma recovery in promoting community resilience.

2. Co-create and coordinate interventions.

Mainstreaming mental health into peacebuilding requires better coordination between peacebuilders and mental health specialists, as well as other actors like civil society and religious organizations, whose work continues to be siloed. IJR’s global survey of 75 peacebuilders and mental health specialists in 2017, for example, found that while nearly all practitioners agreed that peacebuilding would benefit from mainstreaming mental health, less than half had worked on projects that incorporated aspects of the other field.

Better coordination can be achieved through the process of co-creation, whereby practitioners come together to better understand their respective work and how it can be brought together. For example, USIP’s work with displaced trauma survivors has found that engaging with the faith sector is particularly important in addressing conflict-induced mental disorders, as religion can be a vital source of coping and an entry point for providing culturally resonant treatment. Indeed, co-creation workshops attended by mental health, peacebuilding and civil society stakeholders have shown promise empirically in promoting mutual understanding between practitioners and facilitating more holistic interventions.

An integrated approach to peacebuilding and mental health is required to address the physical security and mental well-being of those affected by conflict. Such an approach requires bringing together Indigenous practices of trauma healing alongside professional mental health treatment and community-level peace, justice, and reconciliation work, part of an approach known as psychosocial peacebuilding.

Indeed, one promising study in northeast Nigeria examining intervention by the NEEM Foundation validated that their approach to combining mental health counseling with peace and social cohesion education reduced both mental illness and vulnerability to violent extremism. “Psychosocial peacebuilding will help break the cycle of violence that begins with trauma,” a psychiatric nurse in northeast Nigeria told us. “It helps people in seeing their enemy as not really an enemy, but also a brother who has also experienced trauma ... [They] release the negative energy that is throbbing in their body — it is the first step towards peace.”

Manal Taha is a program officer for Sudan at USIP.

Benjamin Oestericher is a former research assistant on disability-inclusive peacebuilding at USIP.

PHOTO: A woman who was kidnapped by Boko Haram and recruited as a bomber at an abandoned building at a camp for displaced people in Konduga, Nigeria. August 20, 2019. (Laura Boushnak/The New York Times)

The views expressed in this publication are those of the author(s).