Lessons from Ukraine on protecting mental health during conflict

In March 2022, one of us, Kristina, was in Ukraine, running a training on a chilly day. Several hours into the training, one of the soldiers’ faces began to crumple, close to tears. The unit had just received a combat stress management skills training, including a box breathing exercise, in the field outside of a converted military base in Chernihiv near Ukraine’s borders with Belarus and Russia. The training involved discussing common acute stress responses, including the freeze response that can stupefy people, and how breathing exercises can support emotional regulation and return to function.

The soldier said, “I wish I’d known how I could help in the past, when one of my friends was captured because he was frozen like that.”

His comment took Kristina’s own breath away. This is why we wanted to do this work, as part of an organization called Sane Ukraine.

Sane Ukraine grew out of Ukrainian psychologists’ and activists’ zeal to respond to the ongoing conflict in their country and its toll on the mental and physical health of its people. The program is unusual in that it uses a preventative model, providing Ukrainians with mental health tools and group support immediately, instead of waiting for symptoms to emerge or reach diagnostic criteria, or for the conflict to end. Our experiences and results so far suggest this model not only has increased mental health awareness and coping skills for thousands of Ukrainians, but also offers an important new path for improving mental health in conflict zones.

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 start of the war. Beyond the numbers, most Ukrainians have experienced at least some of the many horrible adversities that come with war, including chronic violence exposure, torture of civilians, displacement, death of loved ones, sexual assault, capture, loss of employment, lack of stability, and post-migration stress. It’s no wonder that these conditions have led to the deterioration of mental health, inducing depression, anxiety, and trauma- and stress-related disorders in many Ukrainians. Research conducted six months after the start of the war found more than one-third of participants showed symptoms of anxiety, over 40% showed symptoms of depression, and over 70% had symptoms of stress.

In response to this need, Sane Ukraine was created in March 2022 by Mark Walsh — a psychologist based in the U.K. specializing in trauma treatment, with experience in treating people affected by combat — and colleagues from the Ukrainian Crisis Psychologists Group, just weeks after the Russian invasion began. Sane Ukraine was founded at the end of a 10-day course led by Walsh, and he invited Ukrainian psychologists from Ukrainian Catholic University to join him in its expansion. One of us, Kristina, was the first Ukrainian team member, along with psychologists Katerina Timakiva and Eugenia Korolova. (The other two of us, Marina and Samantha, have been supporting the dissemination of Sane Ukraine’s work.) Walsh and the Sane Ukraine team immediately began providing mental health trainings to non-mental health professionals from disparate regions of Ukraine.

These initial trainings taught mental health task sharing, a model in which both mental health professionals and non-therapists were trained in providing 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 the Sane Ukraine network of psychosocial support activities.

Of the initial 60 trainees, half went on to actively train others, creating a cascade of interventions. Many aimed to specifically serve internally displaced eastern and southern Ukrainian people who had fled to Western Ukrainian cities, such as Lviv. These internally displaced families and individuals were often living in schools, theaters, and other community buildings, completely disconnected from their lives before the invasion began, and being supported by a network of volunteers who had been workers in these community centers. Sane Ukraine identified the internally displaced and those working to support them as one of the most vulnerable populations at that time.

One woman in her 40s from Kharkiv, a city on the border that was one of the hardest hit at the outset of the invasion, had lost her house and some of her family to the conflict. When Kristina met her in May 2022, she was living in a gym in Lviv, made largely of glass, which felt less safe from attacks. When she learned about the symptoms of panic attacks in the training, she shared that she finally understood what was happening to her. Since the war started, she found that she could no longer be in crowded places — they reminded her of when she was fleeing Kharkiv and found herself in a dense crowd of people at the train station, all desperate to get out. As she waited for the next train, the shelling began.

After the training, she approached Sane Ukraine to tell her story and ask for help. It was often hard for her to breathe because she had so much tension in her body. Kristina and colleagues helped her practice breath work techniques such as diaphragmatic breathing to reestablish her connection to her body, a skill she could use the next time a panic attack would strike.

But as the Russian attacks escalated throughout the spring of 2022 and threatened cities beyond the border, trainers quickly observed that individuals in their own communities in Lviv and Kiev would also benefit from these interventions, and were inspired to share them with first responders. A second “Train the Trainers” program extended the reach of the project by preparing 100 additional trainers to offer preventative interventions and self-assessment and self-care instruction to Ukrainians in these cities.

In total, more than 160 trainers have been trained. Currently about 30-40 trainers are working full-time within the project, while the remainder apply this knowledge in other work. A program evaluation 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, with funding only by two small grants from the Red Cross. Trainers work for very low fees or volunteer, especially when providing training to soldiers, and all trainings are offered for free to participants. These trainings continue, but accurate counts of the participants are not currently available.

Together, these trainers are aiming to prevent mental health symptoms from worsening by using education about mental health and activation of resources. But funding and support for these programs have been limited because they go against typical Western medicine practices.

Usually, psychological interventions are applied after the onset of a significant stressor. Unlike physical health, where wellness checkups 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 began to mobilize during times of significant stress to protect mental health?

A growing base of evidence demonstrates that preventative mental health care can reduce the onset of psychiatric disorders, including traumatic stress, though this field of science is relatively new. And an initial program evaluation suggests that the Sane Ukraine intervention curbs anxiety symptoms for those who struggle most, and improves self-reported well-being.

While Sane Ukraine was created in the midst of a conflict because trained psychologists saw a need and opportunity to help their country, this program has the potential to help reshape how we think about mental health interventions. It’s time to reexamine our cultural assumptions about mental health and increase funding for and research into preventative models which 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 which can foment resilience for Ukrainians fighting for their lives and homeland.

Kristina Bohdanova is a medical doctor and clinical psychologist working on the ground 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, M.A., is a project coordinator and doctoral candidate in community health and health policy at the CUNY Graduate School of Public Health and Health Policy.