Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

Editorial

Witness as Victim: Clinical Encounters with

Children Who Observed Violence

Galina Itskovich

The Interdisciplinary Council on Development and Learning, New York, USA

Address for correspondence:

Galina Itskovich, LCSW, Inc, 1525 Marine Parkway, Brooklyn, New York, USA, E-mail:

galaitsk@gmail.com

This work is licensed under a Creative Commons Attribution-

NonCommercial 4.0 International License (CC BY-NC 4.0).

©Copyright: Itskovich, 2022

Publisher: Sciendo (De Gruyter)

DOI: https://doi.org/10.56508/mhgcj.v5i2.144

Submitted for publication: 23

June 2022

Received: 18 July 2022

Accepted for publication: 02

August 2022

Keywords

war atrocities witness, childhood trauma, body image distortions, trauma informed treatments

In the spring months of 2022, Human Rights

Watch, the international humanitarian group,

released stunning details of the carnage in the

regions around Chernihiv and Kyiv that Russia left

behind. In a report released from May 2022,

Human Rights Watch stated that it was currently

investigating 22 potential summary executions,

nine other unlawful killings, six possible

kidnappings, seven cases of torture and 21

reported incidents of other forms of “unlawful

confinement in inhuman and degrading conditions”

carried out by Russian forces against civilians. But

even this report doesn’t take into account traumatic

impact on witnesses. Having witnessed the crime

once, the witness continues to see the world

through the prism of the observed violence.

The National Child Traumatic Stress Network

defines traumatic stress as the stress response to

a traumatic event of which one is a victim or

witness. Based on this definition, we can establish

that the witness is considered traumatized as well,

and the victim’s trauma is not less impactful on

his/her mental health and psychological well-being.

Watching the untoward, unimaginable acts when a

human life or health are endangered creates

psychological damage of extreme magnitude.

During the Iraq war, the results of the psychiatric

assessment of supporting military who were not

involved in active combat demonstrated that their

PTSD symptoms are roughly equal to / not less

prominent than those of their fighting fellows.

Watching other people’s suffering is toxic. When

the witness is a child, it complicates the

assessment, as child witnesses may be discounted

as “not understanding” or “not impacted”. Adults

tend to think that children “quickly forget” and even

report “better functionality” and “exemplary

behavior” under stress. Yet, empirical and

theoretical findings show that traumatic experience

takes years to process. This is especially pertinent

for young children as their sense of safety depends

on the perceived safety of their attachment figures

(NCTSN). Amplified emotional reactivity and a lack

of control of events leave young children

susceptible to stress symptomatology (Sossin &

Birklein,2006).

Little witnesses which, with the beginning of the

Russian expansion, started pouring into clinical

practices in Ukraine and around the world saw a

lot, most impactfully, deaths of parents, siblings,

neighbors and friends, rape and torture. A different

kind of witnessing is presented by indirect

exposure (via adult conversations or social media

involving violence toward people personally known

to the viewer). In some situations, children had to

make critical decisions about own survival (for

example, hiding under dead bodies) or about

obtaining help for the victims.

Sossin (2006) refers to tension flow between a

parent and a child and non-verbal aspects of stress

transmission. Children expressed internalizing the

emotional pain and experiencing physical aches as

they were witnessing parents in pain, recalled

thinking that “this was the end of me”, or, just the

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

opposite, felt numb and separated from/ floating

above their own body.

Once the direct exposure is over, images that

are consolidated into memories and overall

experience of trauma can turn into legacy that

shapes all future experiences. Triggers can appear

at different junctures, reflecting on every aspect of

the memory. Smells, sounds, touch, color, lights,

specific movement pattern or constricted range of

motion – any sensory stimulus can become a

triggering event. Physical reactions such as

increased heartbeat, sweating or bowel

movements can also serve as reminders. Places,

people, objects and situations reminding of the

aggressor (as well as the victim) can initiate the

associative process. For instance, a four-year-old

who survived two episodes of shelling

demonstrated a startled response when presented

with a ball that was colored in rainbow splashes, as

they reminded him of explosions; another

preschooler said that the pen looks like a barrel of

a tank. “According to embodied cognition, our

body, in all its aspects (sensory, motor, and body–

environment interaction), shapes and organizes

our mind, including high-level features (like

memory, concepts, and categories) and abstract

tasks (like reasoning and judgment)” (Morasso et.

al., 2015). Traumatic response can be initiated at

any point, whether by the memory or a bodily

sensation, and then escalate to a full-blown

flashback.

Identifying triggers and resulting behaviors can

become an important instrument for understanding

children’s emotions and functioning in the long

term. When we look at the families who fled the

horrifying scene of atrocity together, they may

present with shared triggers and, consequently,

shared maladaptive behaviors. For instance, a

mother of a child who survived shelling reported

that she had to fight her own urge to hide while

trying to convince her son to look at the July 4th

fireworks.

No matter the modality, such reactions need to

be brought up in clinical encounters. It’s important

not to be afraid to open up the box with terrifying or

shameful event, even as a metaphor in the course

of the play session. It is the reprocessing of trauma

that allows to advance towards the acceptance of

the past trauma and reintegration of the individual

who survived it. Victor Frankl noted about his

Auschwitz experience, “The only thing that we

could control was the attitude towards what was

happening” (). Such “attitude adjustment”,

therefore, is the important aspect of the therapeutic

work. Another crucial aspect is building trusting

relationship with the child witness. The child can

be angry at the significant adult(s) or generalize

this anger to all and any adults for failing to protect

him/her. The child can later depreciate the role of

adults, as part of identifying with the aggressor.

Psychosocial effects of witnessing violence can

be divided into three categories:

 Externalizing (aggression/ identification

with the aggressor, tantrums);

 Internalizing (withdrawal, anxiousness,

depression); and

 Feigning social incompetence

(antisocial, avoidant behavior or

amotivation).

Pervasive sense of gloom and hopelessness,

anxiety, overall depression, grief, anger, fear,

distorted sense of the reality and lowered self-

esteem – this is just a partial list of reactions to

witnessing the atrocity. One more, easily

predictable, effect is the loss of control that can be

manifested in different contexts, right after the

exposure and as a delayed onset. Because of the

activation of the mechanisms of the autonomic

nervous system, displacement takes place quite

frequently. Interaction can start with the minor

disagreement on a playground and escalate to the

full-blown flashback and the symbolic reenactment

of the episode where the child felt helpless in the

face of the mortal danger. Child witnesses can also

behave in the aggressive manner with other kids. If

not addressed, this defense mechanism of

identification with the aggressor can lead to later

distortions and overall normalize violence in their

lives.

Another widespread aftereffect is the survivor’s

guilt of significant intensity. We’re not to forget that

preschoolers look at the world from the egocentric,

and therefore omnipotent, point of view. Not unlike

the feeling of own helplessness, he or she can

irrationally blame themselves, “I was bad, and

mother was tortured,” or, “I didn’t listen to the

grandmother and now she’s dead.” They later

replay the heroic or aggressive scenes, alternately

blaming and redeeming themselves. This play

scenarios, if co-created and interpreted by a

trauma-informed therapist, are pivotal for the

process of psychological recovery and healing.

One more aspect of surviving the atrocity as a

witness is learned helplessness. The child who has

witnessed violence or atrocity can display

regression of ADLs, loss of developmental

milestones and flat affect, overall loss of emotional

functionality, numbness, freezing or outbursts of

aggression at the time of decision making.

Witnessing sexual violence: treatment

approaches

Mass reports of rapes and other types of sexual

assault from the regions around Kyiv rarely

mention children who weren’t physically harmed

but became incidental or, in many described cases,

intentional witness to crime. In one report from the

paramedic, children in Bucha were forced to watch

their parents’ rape, torture and death. In addition to

the obvious psychological damage, watching rape

or sexual assault leads to the distorted body

Mental Health: Global Challenges Journal

https://mhgcj.org ISSN 2612-2138

schema. Since yearly in human development, we

all have the internal image of what we look like. The

process of developing the inner representation of

one’s own body ends as late as 8 years of age.

Therefore, if we are to discuss preschooler or

younger witnesses, they are subject to cognitive

distortions in the way they perceive their own

bodies. This may have top-down, as well as

bottom-up consequences.

For instance, the distorted body image can

reshape their motor planning skills and control over

their own body in space, feeding and elimination

behaviors, specifically, constipation.

Psychodynamically speaking, defecation is

symbolic of a loss of a body part. Therefore, many

children witnesses may regress, “unlearn” toilet

training or hold the feces. One of the useful

techniques in addressing voluntary withholding

feces is to let the child sit on the potty in front of a

mirror or otherwise involve mirror images, letting

him/her observe their own body and identify feces

as substance that is totally different in color and

consistency from the rest of the body.

Techniques to restore the inner representation

of the body include games that involve identifying

body parts, restoring or developing better body

awareness via labeling motions and naming body

parts, mirror games, spatial awareness, weight

bearing activities. Pillow fight, for example, can be

a productive technique to increase proprioceptive

input and overall body awareness, provided that

the child allows and tolerates touch. Obtaining

permission for touch allows the child to reclaim full

control over his/her own body. If the child is looking

for the proprioceptive input but is adamant about

not being touched, there are other means of forging

physical contact such as building a tent, using a

weighted blanket, setting up a play area near the

wall or in the corner, therefore creating opportunity

for sensing the parameters of his/her own body

without feeling triggered.

To reiterate, safety continues to be the

overarching goal. Physical safety in the therapeutic

setting and at home, creating safe space and

negotiating comfortable distance between the child

and others will accelerate processes of

psychological adaptation and healing. From the

physical safety of good locks and reliable windows

to creating trusting environment where

verbalizations or memories are elicited only with

the child’s consent at a comfortable pace, -

everything needs to be aimed at the creation of a

safe space in every meaning of this word.

It makes sense to discuss the issue of control in

greater detail. One of the pivotal conditions to

regain control would be a symbolic repair of the

child’s world. Dis-membering of dolls and puppets

and re-membering, in a sense of reassembly and

building new connections, fixing what’s broken and

severed in the course of the symbolic play are

aimed at recreating the whole from the parts,

symbolic repair a.k.a. rebirth, restoring subjective

sense of control and omnicentrism. These goals

can be reached by the means of puppet, figurines,

and doll play, and using toys like Mr. Potato Head

that allows to pull apart and then reassemble a

human-like figure. Any theme chosen by the child

will provide ample opportunities to act out this ritual

of reassembly and symbolic rebirth. Keeping in

mind the abovementioned possibility of aggressive

behavior, it is important to remember not to shy

away from aggressive play or disturbing scenarios

generated by the playing child. It’s crucial to stay

with the theme offered and not to disrupt the game

or “make everything alright” if the therapist

him/herself is uncomfortable with the aggression.

However, it is as crucial to repair everything that’s

been pulled apart or broken by the end of each

session. Repair as many toys as possible,

simultaneously involving the child into the symbolic

restoration. Therefore, the therapeutic task of

reassembling the safe world will be achieved.

Another important task is to create new rituals

and routines, specifically, rituals and routines

associated with the victim of violence, whether

alive or deceased. As an example, a child who left

his building at the time of the air raid and never

came back nor ever saw his grandmother who’d

stayed behind, gradually engaged in the memory

game. We tried to identify what his grandmother

looked like, what clothes she wore, what dishes

cooked etc. We started to draw grandmother’s

portraits, restoring from memory different moments

of the prewar life. Forgetting makes one feel guilty;

rebuilding (and even reinventing) memories, on the

other hand, is empowering.

As we work on these tasks, we do not rewrite

the past but rather rebuild disrupted neural

connections, reprocessing memories and

modulating pain and post-traumatic reactions. Any

trauma informed therapy, from EMDR to tapping

techniques, can be useful now as long as the

trusting therapeutic relationship continues to

unfold. Additionally, the fact of mere presence of

the permanent, non-threatening, safe respectful

adult carries the healing properties.

The Ukraine Recovery Conference that took

place in Lugano in July of 2022 introduced the term

"children in early stages of vulnerability." While the

proposed definition is, while understating, also too

broad, it undeniably includes children who

witnessed horrendous violence during the war

unleashed by Russia. This paper merely scratches

the surface when it comes to the tasks of clinical

formulation and treatment of child witnesses, but

it’s important as ever to emphasize the

multidisciplinary, multisystem approach. It will help

the processes of comprehending specific

therapeutic challenges and of successful

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restoration of the sense of agency, trust, and safety

for the young victims.

Conflict of interest

The author declares that she has no conflict of

interest.

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