IIn March 2022, one of us, Kristina, was in Ukraine leading a training session on a cold day. A few hours into the training, one of the soldiers’ face began to break down to the point of tears. The unit had just completed combat stress management skills training, including a boxing breathing exercise, in the field outside the converted military base in Chernihiv, near Ukraine’s borders with Belarus and Russia. The training included discussion of common responses to acute stress, including the freeze response that can make people stunned, and how breathing exercises can promote emotional regulation and return to function.
The soldier said, “I wish I knew how I could have helped in the past when one of my friends was captured because he was frozen like this.”
His comment took Kristina’s breath away as well. That is why we wanted to do this work as part of an organization called Sane Ukraine.
Sane Ukraine grew out of the zeal of Ukrainian psychologists and activists to respond to the ongoing conflict in their country and its impact on the mental and physical health of its people. The program is unusual in that it uses a prevention model that provides Ukrainians with mental health tools and group support immediately, rather than waiting for symptoms to appear or diagnostic criteria to be met, or for the conflict to end. Our experience and results to date indicate that this model has not only increased mental health awareness and coping skills for thousands of Ukrainians, but also offers an important new path to improving mental health in conflict areas.
As of September 2023, the United Nations has verified 9,614 civilian deaths, as well as more than 5 million internally displaced people and 6.2 million refugees in Ukraine since the war began. In addition to these numbers, most Ukrainians have experienced at least some of the many horrific adversities associated with the war, including exposure to chronic violence, torture of civilians, displacement, death of loved ones, sexual assault, captivity, job loss, lack of stability, and post-migration stress. Not surprisingly, these conditions have led to a deterioration in mental health for many Ukrainians, causing depression, anxiety and trauma- and stress-related disorders. Research conducted six months after the start of the war found that more than one-third of participants showed symptoms of anxiety, more than 40% showed symptoms of depression, and more than 70% had symptoms of stress.
In response to this need, Sane Ukraine was created in March 2022 by Mark Walsh – a UK-based trauma psychologist with experience treating people affected by combat – and colleagues from the Ukrainian Crisis Psychologist Group, just weeks after the Russian invasion began. Sane Ukraine was founded at the end of a 10-day course under Walsh, and he invited Ukrainian psychologists from the Ukrainian Catholic University to join him in its expansion. One of us, Kristina, was the first member of the Ukrainian team together with psychologists Kateřina Timakiva and Eugenia Korolová. (The other two of us, Marina and Samantha, support the spread of Sane Ukraine’s work.) Walsh and the Sane Ukraine team immediately began providing mental health training to mental health professionals from different regions of Ukraine.
These initial trainings taught mental health task sharing, a model in which both mental health professionals and non-therapists were trained to provide information about traumatic stress and recovery, as well as how to create trauma-informed support groups. Trainees took these skills back to their communities and remained part of Sane Ukraine’s network of psychosocial support activities.
Of the initial 60 trainers, half went on to actively train others, creating a cascade of interventions. Many of them aimed specifically to serve internally displaced people from eastern and southern Ukraine who had fled to western Ukrainian cities such as Lviv. These internally displaced families and individuals often lived in schools, theaters and other community buildings, completely disconnected from their pre-invasion lives and supported by a network of volunteers who worked in these community centres. Healthy Ukraine identified IDPs and those who work to support them as one of the most vulnerable populations of the time.
One woman in her 40s from Kharkiv, a border city that was one of the hardest hit at the start of the invasion, lost her home and part of her family to the conflict. When Kristina met her in May 2022, she was living in a gymnasium in Lviv, made largely of glass, which felt less secure from attack. When she learned about the symptoms of panic attacks at training, she shared that she finally understood what was happening to her. Since the beginning of the war, she had found she could no longer be in crowded places – she was reminded of this when she fled Kharkov and found herself in a dense crowd at the train station, all desperate to get out. As she waited for the next train, the shelling began.
After the training, she turned to Sane Ukraine to tell her story and ask for help. She was often short of breath because she had so much tension in her body. Kristina and colleagues helped her practice breathwork techniques, such as diaphragmatic breathing, to reconnect with her body, a skill she could use the next time a panic attack hits.
But as Russia’s spring 2022 attacks escalated and threatened cities across the border, trainers quickly realized that individuals in their own communities in Lviv and Kyiv would also benefit from these interventions, and were inspired to share them with first responders. The second “Train the Trainers” program expanded the reach of the project by training 100 additional trainers to offer preventive interventions, self-assessment and self-care to Ukrainians in these cities.
In total, more than 160 trainers were trained. Currently, about 30-40 trainers work full-time on the project, while the rest apply this knowledge in other work. An evaluation of the program conducted between March 2022 and September 2022 shows that Sane Ukraine offered more than 500 trainings attended by 13,867 first responders, soldiers and their families, funded by only two small grants from the Red Cross. Trainers work for very low fees or on a voluntary basis, especially when training soldiers, and all training is offered free of charge to participants. These trainings are ongoing, but exact numbers of participants are not available at this time.
Together, these trainers work to prevent the worsening of mental health symptoms through mental health education and resource activation. However, funding and support for these programs is limited because they contradict the typical practices of Western medicine.
Usually, psychological interventions are applied after the onset of a significant stressor. Unlike physical health, where wellness visits are common, most mental health interventions are designed to address mental health symptoms after they have coalesced into a recognized disorder. But Sane Ukraine asks: What if we started mobilizing in times of significant stress to protect mental health?
A growing evidence base shows that preventive mental health care can reduce the onset of psychiatric disorders, including traumatic stress, although this area of science is relatively new. And initial evaluations of the program suggest that Sane Ukraine’s intervention reduces anxiety symptoms in those who struggle the most and improves their own well-being.
While Sane Ukraine was created in the midst of conflict as trained psychologists saw a need and opportunity to help their country, this program has the potential to help reshape the way we think about mental health interventions. It is time to review our cultural assumptions about mental health and increase funding and research into prevention models that support those in the midst of conflict and other potentially traumatic stressors. As the soldier on that March day reminds us, Sane Ukraine offers powerful tools that can fuel the resilience of Ukrainians fighting for their lives and homeland.
Kristina Bohdanova is a doctor and clinical psychologist working in Ukraine as part of the Sane Ukraine program. Marina Weiss, Ph.D., is a clinical psychologist and postdoctoral fellow in implementation science at the Center for Innovation in Mental Health at the CUNY Graduate School of Public Health and Health Policy. Samantha Weckesser, MA, is the project coordinator and PhD student in community health and health policy at the CUNY Graduate School of Public Health and Health Policy.
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