Raiman al-Hamdani; Yemen Policy Center, ARK Group, The European Council for Foreign Relations
After six years of war, Yemen experienced a diplomatic breakthrough on October 16, 2020; when the main parties to the conflict concluded a prisoner of war exchange under the auspices of the United Nations and the International Red Cross. Despite this positive development, militarily and politically, the situation remains basically unchanged since the conflict began in 2015. And despite promises to the contrary, none of the parties involved have taken significant steps toward actualizing peace. 80 percent of the country remains dependent on humanitarian aid, with more Yemeni children dying from hunger than from conflict-related causes. The situation today is characterized by widespread famine conditions, rampant preventable diseases, water shortages, acute lack of healthcare facilities, economic collapse, and now, COVID-19. Despite the UN Secretary-General’s call for a global ceasefire amid the outbreak, the conflict’s belligerents have so far failed to respond to this invitation.
While Yemen is in many ways embroiled in a frozen conflict—an enduring state of war in which little progress is made on either side—this characterization obscures the ongoing psychological trauma experienced by its victims. In Yemen—whenever this war ends—the collective memory of violence will endure well into the post-conflict future. For Yemeni society to truly heal from the brutality there must be a collective mechanism for processing trauma that acknowledges, rather than attempts to bury, the reality of the violence as a lived experience. The absence of this kind of process post-conflict foreshadows a grim cycle of soft peace and hard war. For those living in the shadow of a former war – especially children who are too young to have ever experienced peacetime – conflict is the norm. For a society to escape the memory of the violence that surrounded them, they must become normalized to peace.
If mental trauma and illness in Yemen is left untreated after the frozen conflict has thawed, the nation’s collective trauma accumulated from the conflict will endure into the post-war period. Therefore, it is imperative to examine some of the drivers of deteriorating psychological wellbeing in Yemen (including those which existed pre-conflict), establish the extant medical resources available in the country, and probe the link between mental health and security—the final, key element in convincing stakeholders to prioritize the issue post-conflict. Any attempt to conduct peacebuilding in Yemen that fails to address the country’s mental health crisis will likely fail to provide any meaningful security for the country and its citizens in the long-term.
Yemen’s mental health crisis
According to the World Health Organization (WHO), there is an ongoing global “mental health crisis” caused by stress and anxiety related to the worldwide lockdown and the secondary effects of COVID-19. But for Yemenis, COVID-19 and its attendant anxieties is just one mental health trigger in the country amid a mental health crisis. It has become something of a cliché at this point to say that Yemen is facing a crisis; almost every day we seem to read about how Yemen is “on the brink” of some sort of disaster. Much is written about how and why Yemen is facing disaster from a logistical and practical perspective, how they are physically confronting the next big outbreak of violence and disease, what sort of precautions they are taking, etc. However, not enough is written about how Yemenis emotionally deal with the trauma inherent to living through war, or to the relationship between the psychological welfare of Yemen’s citizens and the country’s basic security.
There is an unprecedented mental health crisis in Yemen. While mental illness has always been a problem in the country, six years of conflict have taken an unprecedented psychological toll on the population. The government lacks the capacity to deal with an issue of this subtlety and magnitude, and the current warring parties do not care about the physical well-being of the people (let alone their psychological wellbeing).
There is a cultural stigma surrounding mental health in Yemen in that experiencing poor mental health and seeking treatment for it are both viewed negatively by society. Despite the increasing prevalence of mental health issues, the disease itself remains in many cases a source of stigma and shame for the families of those affected. A significant number of children, women, and men who experience mental health issues are neglected by their families as a result, and sometimes even abandoned and disowned by them.  People in Yemen generally live in large multigenerational homes where conflict often ensues but is rarely addressed outside the family household. Abuse, both verbal and physical, is often considered an acceptable way of dealing with such issues in the absence of mental health and domestic violence awareness.
In rural areas especially, mentally ill people who are afflicted with any kind of socially unacceptable disorder may be locked away in cages or chained up by family members who do not know how to deal with them. While certain Yemeni methods for managing mentally ill individuals can appear shockingly inhumane, they are often the only options available to most Yemenis, who simply lack the resources and understanding to manage complex illnesses. Alternatively, many Yemenis in rural areas spend all their savings on sending their loved ones to Qur’anic therapeutic centers, which offer hope to families desperate for a cure but do not offer medically sound treatments.
Yemen’s addiction to Qat, a mild narcotic leaf chewed by 90% of the male population, is reflective of Yemen’s mental health crisis. Qat, which produces the required neurotransmitters to induce serotonin, can be considered another form of self-therapy for those suffering from depression, anxiety, and other mental health issues. In my interviews, many doctors claim qat’s popularity is due to it being the only widely available psychoactive substance present in the country that is deemed socially acceptable. Women and men and children of all ages use the plant everyday as a form of self-medication.
Such self-medication reflects the structural barriers to mental health care in Yemen, starting with poor education about mental health and limited resources for those in need of therapy or medication. Chronic mental health illnesses in Yemen often require expensive medication and supervision, and based on my conversations, only 50 mental health specialists exist in the entire country. These specialists are mainly concentrated in cities, meaning that people outside urban areas are often unaware of their very existence and/or could never afford to travel to receive treatment. Those lucky enough to have access to professional psychiatric help can end up at the mercy of specialists who use outdated methods of diagnosis and treatment, such as electroconvulsive therapy, shock therapy, and lobectomy. Even Al-Amal hospital in Sanaa, considered to offer the best mental health care in the country, is compared to a prison by many doctors. These same medical professionals also note many organizations working in the field are present in Yemen, but they simply lack the resources to significantly help their patients. According to one doctor I spoke to, 80 percent of his patients relapse due to family pressure to end treatment for mental health illnesses.
I spoke to several Yemeni doctors to try to assess the current situation on the ground in terms of the country’s mental health and understand how the conflict has exacerbated the country’s mental health issues. They note that cases of mental illness, particularly depression and anxiety resulting from trauma related incidents, are in the hundreds of thousands, if not the millions, but society has yet to acknowledge this. They further observed that the situation on the ground for patients and practices is grim. Pre-war resources, which were never sufficient, are even less than they were at the beginning of the conflict because the war has decimated health care facilities. There are now more barriers to receiving care and fewer resources for people suffering—meaning there are more people suffering today than ever before. This is because the current war has created an unprecedented mental health crisis in the country. Which means that on top of the people suffering from mental illness pre-war, the country now must deal with millions of people who are suffering from conflict related anxiety and depression and other more serious mental issues and disorders. While the conflict has taken a toll on everyone, children are increasingly vulnerable. An entire generation has, in effect, been desensitized to violence, which they view as normative. The country’s economic decline means that few people have the money to afford food and basic health care, let alone mental health treatment. When people can afford to see a doctor, they will generally prioritize their physical suffering over their mental health.
Post-conflict, transitional period and the future of development and security in Yemen
Despite widespread acknowledgment of the situation by mental health professionals, Yemen’s political leaders fail to understand the depth of the crisis. Because of this, they have failed to raise the issue of developing the mental health and psychotherapy sector in Yemen, either amongst themselves or with the donor countries. For example, it is unlikely that Yemen’s political leaders know that the WHO defines mental health as an essential and integral part of health. Psychologists feel abandoned by the government, which is offering zero solutions to the country’s myriad of mental health challenges. For example, one in five people living in a war region suffers from depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia. These figures are significantly higher compared to the prevalence of these diseases in the general population. Indeed, outside conflict zones, they concern one in 14 people. Addressing this crisis, therefore, will likely fall disproportionally to the international and governmental organizations in Yemen, who, despite having a lot to take on from a humanitarian perspective, must prioritize mental health by committing resources to psychiatry and raising awareness about mental illnesses throughout the country.
From a security standpoint, poor mental health is a key driver of radicalization and violence. Individuals who have experienced trauma and have no way to processes it are susceptible to radicalization and violent extremism. Much of the recruitment for the war effort has preyed upon mentally ill people, who are already susceptible to delusions. Left unaddressed, Yemen’s mental health crisis has the potential to negatively impact regional and international security. Even prior to the conflict, the absence of a functioning Yemeni state meant that individuals and bottom-up community approaches were truly in charge of security. Disregarding the emotional toll of cyclical conflict and trauma on Yemeni people—those who actually provide security in the Yemen—will have long-term effects on any attempts to rebuild the country. Yemeni human security, that is: environmental security, personal security, food security, economic security, and political security; all of these depend on the wellbeing of individuals in society. Yemen’s human capital provides the foundation for its social, economic, and political infrastructure. Even if these structures can be rebuilt, they will not stand for long on unstable ground.
While the Yemen conflict will eventually end, the feelings and beliefs generated by it will endure well into the future, affecting generations. Individuals and communities who survived the scourge of violent conflict (large-scale executions, dismemberment, torture, displacement, land theft, landmines, etc.) bear the scars of these experiences, which serve as an enduring reminder of what they have collectively been through. Whether these scars eventually fade for Yemenis, or whether they become more pronounced in the post-conflict narrative, engendering more conflict and violence, is due in large part to psychosocial interventions. In the absence of large-scale psychological intervention, the communal desire to avoid future victimization can be sublimated into the collective need for revenge against those perceived as responsible for their original suffering. Weaving a narrative of victimhood, victims of war may become agents of the same kind of violence they were once subject to. Often these targets can be soft targets, such as refugees, who lack the capacity to defend themselves.
So, what is to be done? As a first step, the Yemen’s mental health system needs reform. This can start by increasing the capacity of doctors to obtain the knowledge and skills needed to practice in the field. This can only be achieved by expanding opportunities for Yemeni doctors and professionals to travel within the country and outside of it, to meet experts and develop their skills to meet the unprecedented challenge before them. Facilitating this should be on the agenda of any donor involved in funding the reconstruction phase. In the meantime, Muslim sheikhs will continue to capitalize on mental illness by spreading anachronistic beliefs (such as sorcery) and extremist groups will continue to target a generation traumatized by the devastation of war.
Donor funding must be secured to improve and provide treatment and rehabilitation both for those suffering from serious mental illness and those who are experiencing generalized conflict-related anxiety and depression. There is large economic incentive for investing in mental health care: a World Health Organization (WHO)-led study determined that there was a low cost-benefit for scaled-up depression and anxiety treatment across country income groups, including war-affected zones. We are nearing the end of a violent war full of hate speech and revenge. Both the civilians and the combatants returning from battle will need psychiatric care and counseling to process what they have experienced; ignoring the collective mental health of Yemenis risks turning individuals into threats against the state and society. From a security standpoint, the link between individuals who experience conflict-related trauma and go on to commit further acts of violence must not be ignored. It is therefore important to stress that addressing Yemen’s mental health crisis will also positively affect regional, and international security.
In addition to increasing mental health resources, a public conversation must be had about mental health in the country. This is perhaps the first step toward breaking the stigma of mental illness in Yemen. Yemeni health professionals and political leaders should lead this conversation. For this to happen, political leaders must be educated about mental health so that they can recognize the extent of the crisis and take steps to address the issue and demand resources to confront it.
While hunger and physical suffering are prioritized by aid organizations, Yemen’s mental health crises cannot continue to be ignored. This is particularly critical in the inevitable post-war period, to ensure the durability of a post-conflict reconstruction plan and prevent a total collapse in security. Yemen’s collective mental health will provide the foundation for any post-conflict reconciliation efforts, anti-sectarianism measures, and security provision. Going forward, any attempts to rebuild the country must therefore invest in Yemen’s human capital. If Yemen is going to have any kind of future stability, the country will need to psychologically rebuild. Serious efforts must be made to heal the collective trauma experienced by Yemenis living throughout six years of war, those who must confront, on a daily basis, the chronic and cyclical violence, disease, poverty, and general climate of despair which has characterized the country for over half a decade. This, coupled with a country-wide addiction to qat and the general ignorance of psychological tools and resources, paints a grim picture for the future of mental health in Yemen. Without addressing these issues collectively as a nation, we should not expect serious and meaningful human development to occur; or long-term gains in Yemen’s human security. For these reasons, reform at all levels and the engagement all actors, particularly religious authorities and medical staff, will pave the way for a more durable peace post-conflict.
The outbreak and identification of so-called frozen conflicts engenders a parallel responsibility (particularly for those in the realm of politics and global affairs) to reexamine this descriptive term. Paying attention to the language used to describe conflicts has real-world implications that may begin in academia, but reverberate well outside it, affecting how they are analyzed and ultimately (hopefully) resolved by policymakers and peacemakers alike. This is especially relevant because frozen conflicts have consistently proved resistant to the dominant conflict-resolution mechanisms and apparatuses. Conflict-related trauma in general and Yemen’s poor mental health in particular reveals the limitations of the frozen-conflict paradigm as a descriptive term. A conflict cannot be “frozen” so long as the trauma generated by it endures. Post-war collective trauma is a protean thing-depending on how it is processed; it may be sublimated into understanding and acceptance, or morph into bitterness and recrimination. The course it follows will be a decisive factor in the durability of peace post conflict-in Yemen, and in “frozen” conflicts around the world.
“COVID-19 Disrupting Mental Health Services in Most Countries, WHO Survey.” World Health Organization.
October 5, 2020. Accessed October 16, 2020. https://www.who.int/news/item/05-10-2020-covid-19-
“The Brutal War on Children in Yemen Continues Unabated.” UNICEF. February 25, 2019. Accessed October 19,
ACLED. August 29, 2020. Accessed October 16, 2020. https://acleddata.com/2020/08/04/a-great-and-sudden-
Bhui, Kamaldeep, Adrian James, and Simon Wessely. “Mental Illness and Terrorism.” The BMJ. September 13,
- Accessed October 16, 2020. https://doi.org/10.1136/bmj.i4869.
Boseley, Sarah. “One in Five People in War Zones Have Mental Health Conditions – WHO.” The Guardian. June 11,
- Accessed October 16, 2020. https://www.theguardian.com/society/2019/jun/11/war-zones-
El-Menyar, Ayman, Ahammed Mekkodathil, Hassan Al-Thani, and Ahmed Al-Motarreb. “Khat use: history and heart
failure.” Oman Medical Journal 30, no. 2 (2015): 77-82.
Karasapan, Omer. “Yemen’s Civilians: Besieged on All Sides.” Brookings. March 31, 2020. Accessed October 19,
Karasz, Palko. “85,000 Children in Yemen May Have Died of Starvation.” The New York Times. November 21, 2018.
Accessed October 19, 2020. https://www.nytimes.com/2018/11/21/world/middleeast/yemen-famine-
Marquez, Patricio V., and Melanie Walker. “Mental Health Services in Situations of Conflict, Fragility and Violence:
What to Do?” World Bank Blogs. November 1, 2016. Accessed October 16, 2020.
Miller, Kenneth E., and Andrew Rasmussen. “War exposure, daily stressors, and mental health in conflict and post-
conflict settings: bridging the divide between trauma-focused and psychosocial frameworks.” Social
science & medicine 70, no. 1 (2010): 7-16.
Saleh, Maan A. Bari Qasem, and Ahmed Mohamed Makki. “Mental health in Yemen: obstacles and
challenges.” International Psychiatry 5, no. 4 (2008): 90-92.
Wessells, Michael G. “Post-conflict healing and reconstruction for peace: The power of social mobilization.” Fear of
persecution: Global human rights, international law, and human well-being (2007): 257-278.
Wood, Reed M., and Christopher Sullivan. “Doing harm by doing good? The negative externalities of humanitarian
aid provision during civil conflict.” The Journal of Politics 77, no. 3 (2015): 736-748.
 Karasz, Palko. “85,000 Children in Yemen May Have Died of Starvation.” The New York Times. November 21, 2018. Accessed October 19, 2020. https://www.nytimes.com/2018/11/21/world/middleeast/yemen-famine-children.html.
 Karasapan, Omer. “Yemen’s Civilians: Besieged on All Sides.” Brookings. March 31, 2020. Accessed October 19, 2020. https://www.brookings.edu/blog/future-development/2020/03/31/yemens-civilians-besieged-on-all-sides/.
 Since the emergence of the pandemic, Yemen has had the largest increase in the number of organized political violence events of any country in the ACLED dataset. Pavlik, Melissa. “A Great and Sudden Change: The Global Political Violence Landscape Before and After the COVID-19 Pandemic.” ACLED. August 29, 2020. Accessed October 16, 2020. https://acleddata.com/2020/08/04/a-great-and-sudden-change-the-global-political-violence-landscape-before-and-after-the-covid-19-pandemic/.
 Wessells, Michael G. “Post-conflict healing and reconstruction for peace: The power of social mobilization.” Fear of persecution: Global human rights, international law, and human well-being (2007): 257-278.
 “The Brutal War on Children in Yemen Continues Unabated.” UNICEF. February 25, 2019. Accessed October 19, 2020. https://www.unicef.org/press-releases/brutal-war-children-yemen-continues-unabated
 “COVID-19 Disrupting Mental Health Services in Most Countries, WHO Survey.” World Health Organization. October 5, 2020. Accessed October 16, 2020. https://www.who.int/news/item/05-10-2020-covid-19-disrupting-mental-health-services-in-most-countries-who-survey.
 Saleh, Maan A. Bari Qasem, and Ahmed Mohamed Makki. “Mental health in Yemen: obstacles and challenges.” International Psychiatry 5, no. 4 (2008): 90-92.
 El-Menyar, Ayman, Ahammed Mekkodathil, Hassan Al-Thani, and Ahmed Al-Motarreb. “Khat use: history and heart failure.” Oman Medical Journal 30, no. 2 (2015): 77-82.
 Based on the author’s interviews with doctors in Yemen (October, 2020)
 Based on the author’s interviews with doctors in Yemen (October, 2020)
 Based on the author’s interviews with doctors in Yemen (October, 2020)
 Boseley, Sarah. “One in Five People in War Zones Have Mental Health Conditions – WHO.” The Guardian. June 11, 2019. Accessed October 16, 2020. https://www.theguardian.com/society/2019/jun/11/war-zones-mental-health-issues-world-health-organization-data.
 Bhui, Kamaldeep, Adrian James, and Simon Wessely. “Mental Illness and Terrorism.” The BMJ. September 13, 2016. Accessed October 16, 2020. https://doi.org/10.1136/bmj.i4869.
 Miller, Kenneth E., and Andrew Rasmussen. “War exposure, daily stressors, and mental health in conflict and post-conflict settings: bridging the divide between trauma-focused and psychosocial frameworks.” Social science & medicine 70, no. 1 (2010): 7-16.
 Wood, Reed M., and Christopher Sullivan. “Doing harm by doing good? The negative externalities of humanitarian aid provision during civil conflict.” The Journal of Politics 77, no. 3 (2015): 736-748.
 Marquez, Patricio V., and Melanie Walker. “Mental Health Services in Situations of Conflict, Fragility and Violence: What to Do?” World Bank Blogs. November 1, 2016. Accessed October 16, 2020. https://blogs.worldbank.org/health/mental-health-services-situations-conflict-fragility-and-violence-what-do.
 Op. cit. Wessells, “Post-conflict healing and reconstruction for peace.”