Implementation of an evidence-based trauma-focused treatment for traumatised children and their families during the war in Ukraine: a project description

ABSTRACT

The full-scale invasion of Ukraine by Russia in February 2022 led to an increase of traumatic events and mental health burden in the Ukrainian general population. The (ongoing) traumatisation can have a crucial impact on children and adolescents as they are especially vulnerable for developing trauma-related disorders such as Post Traumatic Stress Disorder (PTSD) or Depression. To date, these children have only very limited access to trauma-focused evidence-based treatments (EBTs) by trained mental health specialists in Ukraine. The fast and effective implementation of these treatments in Ukraine is crucial to improve the psychological wellbeing of this vulnerable population. This letter to the editor describes an ongoing project which implements a trauma-focused EBT called ‘Trauma-Focused Cognitive Behavioural Therapy’ (TF-CBT) in Ukraine during the war. In collaboration with Ukrainian and international agencies, the project ‘TF-CBT Ukraine’ was developed and implemented starting in March 2022. The project entails a large training programme for Ukrainian mental health specialists and the implementation of TF-CBT with children and their families in and from Ukraine. All components of the project are scientifically evaluated on a patient and therapist level, cross-sectionally and longitudinally, in a mixed-methods design. All together nine training cohorts with N = 133 Ukrainian therapists started the programme, all monthly case consultations (15 groups) and treatments of patients are still ongoing. Lessons learnt from this first large-scale implementation project on an EBT for children and adolescents impacted by trauma in Ukraine will help inform the field on challenges and also possibilities to expand such efforts. On a broader level, this project could be one small step in the process of helping children overcome the negative effects and experience resilience in the context of a war-torn nation.

La invasión masiva en Ucrania por parte de Rusia en febrero de 2022 condujo a un aumento de los eventos traumáticos y la carga de salud mental en la población general ucraniana. La traumatización (continua) puede tener un impacto crucial en los niños y adolescentes, ya que son especialmente vulnerables a desarrollar trastornos relacionados con el trauma, como el trastorno de estrés postraumático (TEPT) o depresión. Hasta la fecha, estos niños solo tienen un acceso muy limitado a tratamientos basados en la evidencia (EBT, en su sigla en inglés) centrados en el trauma por parte de especialistas capacitados en salud mental en Ucrania. La implementación rápida y efectiva de estos tratamientos en Ucrania es crucial para mejorar el bienestar psicológico de esta población vulnerable. Esta carta al editor describe un proyecto en curso que implementa una EBT centrada en el trauma llamada ‘Terapia cognitiva conductual centrada en el trauma’ (TF-CBT en su sigla en inglés) en Ucrania durante la guerra. En colaboración con agencias ucranianas e internacionales, el proyecto ‘TF-CBT Ucrania’ se desarrolló e implementó a partir de marzo de 2022. El proyecto implica un gran programa de capacitación para especialistas en salud mental ucranianos y la implementación de TF-CBT con niños y sus familias en y de Ucrania. Todos los componentes del proyecto se evalúan científicamente a nivel de paciente y terapeuta, transversal y longitudinalmente, en un diseño de métodos mixtos. En total, nueve cohortes de capacitación con N = 133 terapeutas ucranianos comenzaron el programa, todas las consultas mensuales de casos (15 grupos) y los tratamientos de pacientes aún continúan. Las lecciones aprendidas de este primer proyecto de implementación a gran escala sobre una EBT para niños y adolescentes afectados por trauma en Ucrania ayudarán a informar al campo sobre los desafíos y también las posibilidades de expandir tales esfuerzos. En un nivel más amplio, este proyecto podría ser un pequeño paso en el proceso de ayudar a los niños a superar los efectos negativos y experimentar la resiliencia en el contexto de una nación devastada por la guerra.

俄罗斯在 2022 年 2 月对乌克兰的全面入侵，导致乌克兰普通民众的创伤事件和心理健康负担增加。（持续的）创伤会对儿童和青少年产生重要影响，因为他们尤其对如创伤后应激障碍（PTSD）或抑郁的创伤相关障碍易感。至今，这些儿童获得由乌克兰受训的心理健康专家提供的聚焦创伤的循证治疗 (EBT) 非常有限地。在乌克兰快速有效实施这些治疗对于改善这一弱势群体的心理健康至关重要。 这封致编辑的信描述了一个正在进行的项目，次项目在战争期间在乌克兰实施了一种名为“聚焦创伤认知行为疗法”(TF-CBT) 的创伤聚焦 EBT。 在乌克兰和国际机构的合作下，“TF-CBT 乌克兰”项目于 2022 年 3月成立并实施。次项目需要为乌克兰心理健康专家提供大型培训计划，并在处于和来自乌克兰的儿童及其家人实施 TF-CBT。 此项目的所有部分都在患者和治疗师层面进行了采用混合方法设计的横断面和纵向科学评估。 共有 133 名乌克兰治疗师的9个培训群体开始了这一计划，所有每月个案咨询（15 组）和患者治疗仍在进行中。从这个针对乌克兰受创伤影响的儿童和青少年 EBT 的第一个大规模实施项目中汲取的经验教训将有助于启发对这一领域挑战以及扩大此类努力可能性的理解。 在更广泛的层面上，此项目可能是帮助儿童在遭受战争摧残国家克服负面影响并体会心理韧性过程中迈出的一小步。

KEYWORDS:

• Ukraine
• war
• child
• trauma-focused treatment
• TF-CBT

PALABRAS CLAVE:

• Ucrania
• guerra
• niño/a
• tratamiento centrado en el trauma
• TCC-CT (TF-CBT)

关键词:

• 乌克兰
• 战争
• 儿童
• 聚焦创伤治疗；TF-CBT

1. Introduction

The ongoing Russian invasion of Ukraine represents a tremendous humanitarian crisis. At the time of writing this letter to the editor, more than 5.9 million Ukrainian people are internally displaced and more than eight million people have fled the country (Ukraine Refugee Situation, n.d.). The UNHCR estimates that 17.6 million people in Ukraine will need humanitarian assistance in 2023 (Ukraine Emergency: Aid, Statistics and News, n.d.).

It is well-documented that war-affected populations have significantly higher levels of trauma-related mental health disorders such as PTSD, depression, or anxiety (Charlson et al., 2019). Prior to the 2022 invasion, psychiatric disorders were already prevalent among Ukrainian residents (Weissbecker et al., 2017). However, results from a recent study which assessed N = 2004 adults in Ukraine in the summer of 2022 found an apparent exacerbation of mental health challenges with high rates of war-related trauma and trauma-associated mental health problems (Karatzias et al., 2023). War-affected children and youth constitute a particularly vulnerable cohort for experiencing trauma and developing mental health problems as a consequence. They are in a crucial developmental phase of their lives and rely on parents or other caregivers to help them heal from such painful adversities. Addressing their mental health needs early on should thus be a top priority in reducing Ukrainians’ mental health burden.

The effective treatment of trauma-related disorders is well documented and EBTs are currently being disseminated in many countries around the world. These approaches need to be sustainably implemented with international and Ukrainian experts on an equal footing to cater to the needs of the Ukrainian population. Next to the ongoing war with its concomitant reduced mental health capacities, there are many additional hurdles to implementing trauma-focused EBTs in Ukraine. Most notably, no trauma-focused EBTs for children and adolescents had been systematically implemented in Ukraine until March 2022, due to several structural (e.g. lack of trainers) and individual barriers (e.g. mental health stigma; Goto et al., 2023; Hook et al., 2021; Quirke et al., 2021). Health care workers in Ukraine indicated that they were not previously aware that targeted, time-limited psychological treatments exist, but would be interested in learning more about these approaches (Hook et al., 2021). To our knowledge, several international and national expert groups now started implementing training programmes on EBTs in Ukraine. This research letter aims to describe a large-scale training and implementation programme of ‘Trauma-Focused Cognitive Behavioural Therapy’ (TF-CBT; Cohen et al., 2016) for Ukrainian therapists to treat traumatised children and youth.

2. Description of the project ‘TF-CBT Ukraine'

The project ‘TF-CBT Ukraine’ was developed immediately following the Russian invasion in February 2022 and is currently implemented in Ukraine. Among the collaboration partners are the TF-CBT treatment developers, certified international TF-CBT trainers, the National Psychological Association of Ukraine, the National Child Traumatic Stress Network (USA), the Ministry of Health of Ukraine and Ministry of Education and Science of Ukraine, and the ‘Mental health for Ukraine Project’, implemented by GFA Consulting Group GmbH. We also currently build additional collaborations with the European EMDR Association and the CARES Institute in the US. This project received ethical approval by the Ulm University (Number: Cl/Sta) in Germany and the Zhytomyr Ivan Franko State University (Number: 9-08072022) in Ukraine. All therapists gave their written informed consent prior to study inclusion. The project started in March 2022 and is anticipated to end in May 2024.

The project consists of a large training programme on TF-CBT for therapists in and from Ukraine. The training programme entails the following components for therapists: (1) complete the web-training (https://tfcbt2.musc.edu/) or read the Ukrainian/ Russian TF-CBT manual; (2) participate in a virtual three-day basic training on TF-CBT; (3) participate in at least 10 out of 12 monthly case consultation calls; (4) assess and treat 3–5 patients during one year after the basic training. The therapists could only participate in the basic training once they submitted a confirmation that they read the manual/ completed the web-training, so they would know the model before learning about it in more detail and practicing the methods in the basic training. If the therapist completes all training steps, he/she will receive a TF-CBT therapist certificate. The training cohorts are supervised by 1–2 international trainers who deliver the basic training and case consultations, offered via video conference with simultaneous translation. In the first three basic trainings, there was no funding for translators, which is why the first three cohorts received an English basic training, however had case consultations with translators present.

During the trainings and case consultations it became clear that several topics on trauma assessment and treatment needed to be addressed in more detail, which is why we offered extra (optional) sessions for the therapists by trauma experts in the field. The topics were: Traumatic grief, trauma and PTSD assessment, additional treatment-related assessments, caregiver involvement in TF-CBT and strategies for implementing TF-CBT for ongoing trauma. Most basic trainings and all extra sessions were recorded in English/ Ukrainian for therapists to re-watch afterwards.

3. Project participants

We applied several inclusion criteria for Ukrainian therapists so they could benefit from the training sufficiently: (1) be a mental health care professional in or from Ukraine; (2) have basic knowledge of CBT principles; (3) be willing to participate in the full programme. There were no criteria for patients who could be treated by the therapists as they were not official study participants. However, therapists learnt during their basic trainings that TF-CBT patients should have experienced a traumatic event and report at least moderate PTSD symptoms. Therapists were also encouraged to plan all sessions in advance as patients could relocate during treatment and to make sure that there was a caregiver available to support the child‘s treatment.

4. Recruitment

The TF-CBT trainers were invited via email which was sent to all certified international TF-CBT trainers worldwide. Altogether N = 13 TF-CBT trainers supported the programme. Ukrainian therapists were informed about the project via information leaflets posted in social media channels by our Ukrainian partners. They were able to sign up to the programme by completing a survey which assessed our inclusion criteria.

5. The intervention TF-CBT

TF-CBT is a short-term (12–16 weekly 90-minute parallel or conjoint sessions with caregivers), component-based EBT for traumatised children and youth. TF-CBT integrates cognitive, behavioural, interpersonal, and family therapy principles and consists of three treatment phases: stabilisation and skills building (sessions 1–4), exposure and cognitive processing of the trauma (sessions 5–8), and fostering safety and future development (sessions 9–12). All materials for patients (e.g. workbook) were translated into Ukrainian and Russian.

6. Scientific evaluation

In order to scientifically evaluate the programme, we established several quantitative and qualitative assessments. All research parts are currently ongoing. 1) The therapists are asked to complete an anonymous online survey before and after their project participation. Next to sociodemographic information, we assess their professional quality of life with the ‘Professional quality of life’ questionnaire (ProQoL; Stamm, 2010) and their attitude towards EBTs with the ‘Evidence-Based Practice Attitude Scale’ (EBPAS-36; Rye et al., 2017). In the post-project survey, we further ask therapists for general feedback on the project. We also invite the therapists who participated very regularly in the case consultations (assessed by the trainers) to Focus Groups in which they discuss with a Ukrainian psychologist their motivation for and experiences with the project as well as the treatment itself. In order to investigate the effectiveness of TF-CBT in this context, we ask the therapists to assess all their TF-CBT patients and caregivers with the Child and Adolescent Trauma Screen 2 (CATS-2; Sachser et al., 2022) pre and post-treatment and to add this data to an anonymised online survey during their one year of case consultations. We further ask them to add information on the age, gender and whether the patient is still located in Ukraine. We refrain from assessing other measures as we do not want these assessments to impose too much workload on the therapists in the ongoing war situation. All therapists received extra training and information material on how to administer the assessments. Lastly, we ask the trainers to document any lessons learnt on the basic trainings, the case consultations, and the general project. All measures and surveys were translated into Ukrainian.

7. Quality assurance

Next to the therapist evaluation post-project and the lessons learnt from the trainers we ask therapists to complete a brief anonymous evaluation survey after each training and extra session. We ask several open questions, and ask participants to rate their overall satisfaction with the basic training/extra sessions from 0 (very dissatisfied) to 10 (very satisfied). The survey data are directly analysed and reported to the trainer/speaker. In regular meetings with the trainer team, our Ukrainian partners, and the treatment developers, we discuss challenges and solutions of the treatment and the overall project.

8. Preliminary results on the feasibility of the project

Since May 2022, a new training cohort has started almost every month, with nine training cohorts (15 case consultation groups) being currently enrolled in the project. The last cohort started in February 2023. At the time of writing this letter, altogether N = 243 therapists signed up to the programme, n = 137 completed the anonymised pre-training online survey, n = 133 (54%) completed the web-training, and n = 130 (53%) attended the basic training. From the therapists who completed the anonymised online survey pre-training, n = 4 (2.9%) were male and n = 133 were female (97.1%). For more information on the therapists, please see Table 1.

Table 1. Description of the therapist sub-sample who completed the online survey before the basic training.

	n (%)
Job title
Psychologist	122 (89.1%)
Psychiatrist	4 (2.9%)
Psychotherapist	28 (20.4%)
Social worker	2 (1.5%)
Others	6 (4.4%)
Project manager (mental health and psychosocial support)	1 (0.7%)
University professor	2 (1.5%)
Teacher	2 (1.5%)
Senior researcher	1 (0.7%)
Field of study
Psychology	129 (94.2%)
Medicine	8 (5.8%)
Social work	4 (2.9%)
Social pedagogy	4 (2.9%)
Pedagogy	14 (10.2%)
Teaching profession	11 (8.0%)
Other	6 (4.4%)

Note: In both job title and field of study, multiple answers were possible.

Regarding the extra sessions, between 58–89 participants (therapists and trainers in the project) signed up per session and 22–35 actually participated (overall participation rate: 37%). All 15 case consultation groups (5-13 participants per group) of the nine training cohorts are still ongoing and n = 51 therapists have already started treating a total of N = 137 patients (63.5% female; M_age= 11.83 (range: 4-21)), as indicated by them adding the data to the patient assessment online survey. There might be more therapists who already started treating cases but haven’t uploaded the patient data to the survey yet as they can enter the data anytime within one year of the basic training to receive their certificate. In order to sufficiently evaluate the feasibility, the data will be analysed once the data collection is completed.

In the quality assurance surveys after the basic trainings, the therapists rated their overall satisfaction with M = 9.76 (SD = 1.03) as High. For the extra sessions, the satisfaction was also High with a mean rating of 9.24 (SD = 1.14). In sum, the therapists were Very Satisfied with the programme, but attendance rates were lower than expected after the signing up process. From our experience and conversations with the therapists, this is mainly due to the fact that most of the therapists are in a war situation in which basic needs are not always met and electricity or internet to participate is limited.

9. Conclusions

The current evidence indicates that training for TF-CBT can be successfully implemented and is well received by therapists during times of war with sufficient international and local support. The most important lesson learnt of this project is that project organisers, trainers and trainees need to be flexible and adaptable to the changing war situation (e.g. offer extra case consultation sessions to those who could not participate, train and consult therapists who live in war-affected regions and may experience similar events like their patients, work with patients relocating several times during treatment digitally). Another lesson learnt is that digital learning can be one solution to bring together trainers and trainees from all over the world. This project (including the new collaborations with EMDR EUROPE and CARES) is a testament of good collaboration between international and national experts working together to try to empower mental health forces in the most challenging situations with expertise to apply EBTs for children and adolescents. Future aims of the project are the sustainable implementation and dissemination of the programme into the Ukrainian mental health care system on a community-wide basis, while maintaining its scientific underpinnings. We hope that this project represents one step forward in implementing more scalable trauma-focused EBTs to heal the psychological wounds of those affected in Ukraine and worldwide.

Acknowledgements

We would like to thank the translators Oksana Mykytka and Olia Thyshkovets for their great and flexible translation service, Mr. Marko Bubniak from mh4u project for his support in organising the trainings and case consultations, our Ukrainian colleague Ms. Maria Hrynova at Ulm University for her expertise in Ukrainian mental health, and the Ukrainian therapists and patients for participating in this project. Additionally, we would like to thank all collaborators and funders for their ongoing support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

As this is a programme description there is no additional data to be made available.

Additional information

Funding

Among the funders are the Swiss Cooperation Office, Porticus Foundation, Save the Children, and the Medical University of South Carolina.