Ukraine refugees’ trauma creates ‘crisis on top of a crisis’ for Eastern Europe

Millions of Ukrainian refugees have streamed into Eastern Europe over the past six weeks, their lives uprooted and loved ones left behind.

Many will need specialist help to come to terms with the displacement and deal with anxiety, depression and post-traumatic stress disorder (PTSD). For the ones who have lived through fighting and witnessed atrocities perpetrated by invading Russian troops, the need for therapy will be greatest.

Yet they will be leaning on a mental health infrastructure that is already tottering, in a region where psychological wellbeing has suffered decades of neglect and where depression and trauma were stigmatized under communist rule.

“This is a crisis on top of a crisis,” said Natasha Azzopardi Muscat, director of health policies and systems for the World Health Organization's Europe region.

Mental health workers, like their medical colleagues, are suffering from burnout and overwork related to the coronavirus pandemic, she added. Rates of anxiety and depression have surged in the past 18 months, sparked by isolation and fear of infection.

Nearly 5 million people have fled the war in Ukraine, most to Eastern Europe, the United Nations High Commissioner for Refugees estimates. At least 7 million more are internally displaced, according to sister agency the International Organization for Migration.

Not enough resources

The WHO is at work trying to quickly build up capacity, creating “psychological first aid” toolkits — informational materials for schools and social workers to help provide an initial buffer.

"This may not be enough for everyone," Azzopardi Muscat explained. "Then there’s a process of identifying those at heightened risk to ensure you have a system in place to refer them to services.” 

However you add up the numbers, there's no squaring them with the projected needs facing the women and children leaving their home country, now a war zone, behind.

“We do not have psychosocial services with the capacity to even cover Slovaks. There's no way we can cover Ukrainians,” said Andrej Vršanský, chief executive officer for the League for Mental Health Slovakia. 

Slovakia, which has taken in more than 300,000 Ukrainian refugees, has just 45 child psychologists to cover the whole country, according to the mental health-focused NGO. On average it takes three months to get an appointment to see a psychiatrist. 

The region as a whole trails Western Europe when it comes to the attention and money it invests in psychological help — and it shows in the numbers. A 2016 survey from the EU's statistics agency in the region found that Poland — the country that has taken in the most refugees from Ukraine — had just nine psychiatrists for every 100,000 people. That's a third of the rate in Germany.

Using a ready-made pool of Ukrainian mental health specialists among the refugee population, who have linguistic and cultural skills their counterparts in host countries lack, will be essential for governments to have even a shot at meeting the needs of the war-shocked arrivals.

In Slovakia, Vršanský said, the League for Mental Health has set up a Ukrainian-language helpline and appointed a psychologist with conflict experience from the separatist-controlled Donbas region to head it. "She had been working as a cleaning lady in Slovakia for the past three years," said Vršanský.

The European Commission has recommended that member countries recognize the qualifications of Ukrainian professionals, which would allow them to quickly join their host country's health services. Earlier this week, the Commission announced €9 million in EU funding for NGOs working on the topic, as well as to provide trauma support and counseling.

Scars of war 

But the big wave of need is still to come. For now, experts say that refugees are in survival mode, focused on adapting to their new environments. The process of healing and dealing with trauma will only begin once they have solved more immediate problems like finding accommodation and getting kids into school.

Agnieszka Popiel, a Polish psychiatrist specializing in trauma who runs the cognitive behavioral therapy unit at Warsaw's SWPS University, said it’s important to distinguish between the basic help and understanding that all refugees need, with the specialized care that can only be provided by a professional. She was helping to organize both PTSD courses for therapists, as well as more basic training in counseling for psychology students.

“The majority of refugees do not need a psychologist,” said Popiel. Still, research from previous waves of conflict-driven migration from Syria points to a high proportion requiring psychological care.

“Usually, 30-40 percent is the lowest rate of PTSD in post-war areas," said Popiel.

The same process is also playing out inside Ukraine, with people fleeing the frontlines for the relative safety of the western half of the country.

Child psychiatrist Oleh Romanchuk is assisting internally displaced Ukrainians. Romanchuk, who directs the Institute of Mental Health ​​of the Ukrainian Catholic University in Lviv, said he had faith in the resilience of Ukrainians to overcome the collective trauma of the war.

Already before the war, the government had made strides in modernizing mental health treatment, helping to overcome a legacy of stigma around mental health issues linked to political repression and the country’s communist past. The generation born after the fall of the Soviet Union is much more open, and even eager, to speak about mental health issues, the psychiatrist said.

And treatment can make inroads even in the worst cases. He recalled one child receiving treatment who had witnessed the death of his mother at the hands of Russian soldiers. The child displayed symptoms of post-traumatic stress disorder, but he was responding to therapy. He was writing letters to his deceased mother about his hopes and dreams. 

“He's becoming more filled with light and love,” the child psychiatrist said. 

“I don’t think this will be a generation of trauma,” added Romanchuk. “I'm very hopeful.”