What It’s Like to Be a Therapist in Ukraine Right Now
Reading Time: 7 minutesOne year after Russia’s invasion, mental health workers are navigating the trauma of war alongside their clients., War and mental health: What it’s like to be a therapist in Ukraine.
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In June, Anna Trofymenko, a Ukrainian psychotherapist, was on the phone with a patient when a missile struck the shopping center outside her office in Kremenchuk, a town in central Ukraine. The explosion, which she says felt like Armageddon, knocked out the windows in her building. She fled for safety, but she couldn’t shake off the horrific scenes she’d witnessed: the flames, the screams, the grisly debris. ‘I froze, I had a really hard time,’ she said. She felt that she needed to take a step back from seeing her patients and take care of herself.
Since Russia’s invasion last February, Trofymenko has been helping her Ukrainian patients through the shock, trauma, and crises that come with living through war. On the phone, Trofymenko helped evacuate a young woman under shelling, anchoring her in the present through each step so she wouldn’t freeze from shock. She’s worked with victims struggling with panic attacks and sleep disorders, women grieving the deaths of children and spouses, and refugees navigating a loss of identity as a result of displacement. She knows firsthand what it’s like to leave home: After the start of the conflict in eastern Ukraine in 2014, she left her hometown of Luhansk to start from scratch in central Ukraine. Carrying her patients’ stories alongside her own trauma often feels paralyzing. There are days, she says, when she can’t get out of bed: ‘Sometimes, the pain is unbearable when you come in contact with such grief.’
As Ukraine marks the first anniversary of Russia’s invasion, Ukrainian mental health workers are stretched to the brink and overwhelmed by requests for help. Many work long hours in person and virtually—and frequently for free—while also living through the same traumas of the war as their patients. They draw from a patchwork of workshops and grassroots networks led by local and international experts that offer peer support. Although depleted, they bring to their work relentless commitment and purpose: Trofymenko, for example, is bolstered by moments when her patients discover strength to move forward amid uncertainty and tragedy. ‘The job of a therapist is to be next to the person as they figure things out on their own,’ she said.
Even prior to Russia’s invasion, Ukraine had alarming rates of mental illness (such as depression, anxiety, and post-traumatic stress disorder, as well as alcohol-use disorder), which was estimated to affect 30 percent of the population at some point in their lives, according to the World Bank. Compared to other European countries, Ukraine already had baseline higher rates of depression. According to the World Health Organization, Ukraine’s rate of death by suicide was nearly three times the global average. The protracted armed conflict in eastern Ukraine that began in 2014 has also had detrimental effects on mental health. As a result, in January 2020, Ukraine was selected as a priority country for the WHO’s Special Initiative for Mental Health. But then came the war, which over the past year has dramatically strained Ukraine’s already scarce mental health resources. It compounded a shortage of psychologists, psychotherapists, and social workers, leaving some of the most vulnerable pockets of the population without access to mental health care.
Iryna Deineka, a Ukrainian psychotherapist from Odesa, tries to reach some of those people. With a mobile brigade that’s part of the nonprofit STEP-IN, she travels to towns and mountainous villages in western Ukraine, where she often works with refugees who have resettled from the hotbed of the war in the east. The winter before the invasion, she finished trainings on trauma in crisis and eye movement desensitization and reprocessing, or EMDR. She was already trained in the Gestalt approach, a form of psychotherapy aiming to center the person on the present. ‘When the war started, I happened to be equipped with the right tools,’ she said.
Deineka sees four to eight patients a day, in hospitals, school gyms, and shelters—some on a continuous basis, others for just a session or two. None of this is ideal for delving into deeply vulnerable conversations about trauma, but Deineka works with what she has. ‘It’s important to establish contact quickly, build trust, assess the person’s emotional and psychological state to figure out how to help,’ she said. Many of her patients resist accepting, partly as a defense mechanism, that they, too, were psychologically impacted by the war.
Amid wrenching uncertainty, Deineka’s approach with her displaced patients aims to root their identity in the present, while their thoughts remain with family members, pets and cattle, or homes they left behind. ‘They can’t assimilate to the present because they’re so tied to the past, so my work is to help them let go of the past and find themselves in the present, without looking too far into the future,’ Deineka said. She equips her patients with grounding techniques that they can use during moments of emotional dysregulation: the resource-tapping technique, the butterfly hug, the box breathing exercise.
A refugee herself, Deineka is renting an apartment in Uzhhorod, a city in western Ukraine, while her son stayed back to work and volunteer in Odesa. Deineka sees her own challenges as a connective tissue between her and her clients. ‘I’m limited in every way I can possibly be, but it’s something I can use to connect with my patients, even if it’s on a different scale,’ she said. ‘I’m living the same thing that they are.’
But to build these connections, mental health workers first must contend with distrust and skepticism. In Ukraine, there’s a longstanding stigma around mental illness—particularly among the generations brought up in the Soviet Union, where seeking help was cloaked in shame and perceived as a sign of weakness. Today, Ukrainian mental health workers find themselves at the forefront of changing the culture around mental health. ‘We need to popularize psychological help—explain to people why it’s necessary,’ says Nataliya Zamula, a Ukrainian psychotherapist from Zaporizhzhia, a city in southeastern Ukraine, who moved to Germany in March, when the Russians began shelling the nuclear power plant in the area.
Earlier this year, Zamula experienced her own bout of burnout after she dove into work, mostly on a volunteer basis, while still disoriented after relocating to Germany with her youngest child. ‘In the moment of shock, you don’t understand who you are, you lose all your identities, there is nothing to lean on,’ she said. Only after she began working with an individual therapist and joined group therapy did she start to feel she had internal resources to begin seeing her own patients. Now, she works with patients in Ukraine and Europe, and she’s taking classes. ‘What helped me get out of my depressive state is that I was able to understand my main identity,’ she said. ‘I realized that I’m a therapist and that I can help people.’
Leaning on a support network of peers and supervisors is crucial for mental health professionals, particularly during the ongoing crisis. In the past year, Ukrainian therapists have drawn on international experts and initiatives that have sprouted up in Europe and the U.S. to offer support. For instance, Health Tech Without Borders, an international nonprofit, launched a mental health initiative, Helping Healers Heal, which offers peer-to-peer support and coaching to Ukrainian mental health clinicians.
‘If they don’t have the opportunity to process the trauma they’re experiencing, no matter how much they love their profession and patients, they most probably will experience burnout and will eventually leave,’ said Eva Skinner-Regel, clinical director of the Helping Healers Heal initiative, who is based at Massachusetts General Hospital. Since July, she has been meeting with several Ukrainian psychotherapists (including Trofymenko, Zamula, and Deineka) weekly in virtual individual sessions, free of charge. They discuss how to manage their stress, help build resilience, and best support their patients through the crisis of the war. ‘It’s important to understand that mental health professionals hold people’s pain and trauma and also need someone to hold theirs,’ Skinner-Regel said.
Deineka, who has been working with Skinner-Regel for several months, says that having an independent supervisor outside of the war zone has been valuable and restorative. ‘It’s helpful to have someone who is not under shelling, who is in a safe position and can be objective,’ she said. Deineka and her colleagues have also attended training sessions with psychologists from Italy, France, Israel, and other countries. Gestalt institutes in Europe have opened up their training and conferences to Ukrainian mental health workers, who also gather in group chats on WhatsApp to share resources. They often swap coping mechanisms and ‘mental health hygiene’ ideas to help them restore body and mind after especially challenging sessions. Because trauma is so embodied, Deineka practices various grounding and somatic techniques, like tapping on her chest during stress, swimming, massage, meditation, and even martial arts. She paints and practices Zen and neurographic art to relieve stress and process her feelings about the war. Zamula, in Germany, practices ‘internal gaze’ exercise, which entails imagining looking inward and analyzing her own psychological state. ‘Just as you brush your teeth, you need to take care of your soul,’ she said.
While these measures provide temporary relief, individual and collective healing will require significant resources and policy change. The war’s impacts on mental health are already staggering, but Ukraine likely won’t see the full scale of its mental health crisis until the end of the war and the years after, when soldiers and volunteers begin the process of reintegration into civilian life and people accept the post-traumatic impacts of the war. The WHO estimates that approximately 9.6 million people in Ukraine—about a quarter of the population—may have a mental health condition after the war, which could range from mild depression or anxiety to psychosis.
To address those forthcoming needs, the Ukrainian mental health system needs to change, Zamula says. Currently, there is no licensing system for psychologists and psychotherapists, which can result in people making it to the therapist’s chair without proper qualifications. For Zamula, implementing a licensing system is an obvious and urgent step. Modernizing and better regulating the mental health field would help combat stigma, normalize seeking mental health care, and streamline mental health assistance, she said. This kind of reform could reinforce the legitimacy of mental health services and increase trust in mental health professionals.
Some steps toward reform are already underway. Since the beginning of the war, Ukraine’s first lady Olena Zelenska has focused on expanding access to mental health care and initiated the All-Ukrainian Mental Health Program in partnership with the WHO. Among the initial outcomes of the program are a needs audit and development of a communications campaign to reduce stigma. Ukrainian health officials have also met with their counterparts in Belgium and Great Britain to study how to implement mental health system reform.
But in the meantime, Trofymenko, the psychotherapist in Kremenchuk, is bracing for the magnitude of the mental health crisis yet to unfold. As she does so, she’s guided by her conviction of why she came into the profession. ‘I became a therapist because therapy helped me,’ she said, recalling leaving her home after 2014. ‘At the end of the day, I know why I do this work.’
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