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Learning together: Offering support to traumatised people affected by the Ukraine war

Meera Bahu

We are practicing in unprecedented times. The Ukraine war creates a new humanitarian crisis in Europe that evokes fear and uncertainty at different levels for the diverse population. The global Covid pandemic left people vulnerable and anxious, and depressed; the war in Ukraine has heightened this further. The fear of wider European war can leave people in panic and anxiety.

Ukrainians are fleeing their country to seek safety in neighbouring lands, and those who had moved to Ukraine for work, study, and other purposes are also leaving the country. There was prioritisation around who could go first, who would be supported and offered a visa etc. Black and Asian students reported racism and discrimination at the borders and described this as a dehumanising experience. 

The level of complexities in war trauma can evoke conflicting feelings in clinicians providing care for the refugees arriving in the UK. As a senior clinician working with war trauma from different communities, I learned the importance of learning from the clients, linking with mutually supportive community organisations and sharing experience and knowledge rather than acting as an ‘expert’ (Guidelines for psychologists working with refugees and asylum seekers in the UK, 2018).

The forced migration experience is complex; it disrupts family, culture, and separation from one's ethnic group/community. Dangerous travel and displacement creates unsafety and hardship in borders and transit countries, including racism, trafficking, and sexual violence.

Furthermore, lack of information and uncertainty related to immigration status and potential hostility from host countries can cause anxiety and fear in refugees and asylum seekers from different ethnic groups.

The experience of multiple exposures to violence and war trauma can severely impact people's mental health. The traumatic exposure can be direct or indirect. The direct exposure occurs for those who have personal experience related to the war, such as witnessing shelling, bombing, and experiencing death and destruction around them. Conversely, indirect exposure happens through media, significantly impacting and causing severe distress in the wider population and in us as therapists. Racial trauma adds more stress and can profoundly impact an individual's sense of self, ethnic identity, and relationship with others.

The experience of war takes place at multiple levels and has a more significant social impact, and can be defined as collective trauma, with "shared injuries to a population's social, cultural, and physical ecologies” (Saul, 2013). Here we are not just speaking about war trauma as collective trauma but the intergenerational and racial trauma. The losses are multiple; this could include family members, friends, relationships, culture, house, land, language, employment, personal/professional identity, dignity etc. 

In summary, we are looking at ongoing traumatic experiences versus single traumatic events where a constant sense of threat keeps people in fight or flight mode, thus alert. How can we, as therapists, offer meaningful help?

Creating a safe place for refugees

Adults and children exposed to war trauma respond differently to the stressors depending on the severity of the trauma, duration of exposure and frequency, and children are at risk of developmental problems. However, there are protective factors that can positively influence the children's development, and these are identified as family and societal care. 

Concerning collective trauma in Sri Lanka, Sriskandarajaj et al. (2015) discussed how parental care moderates the relation between mass trauma experience and children's internalising behaviour problems. The findings suggested that parental and societal care may be so decisive that it can "annihilate" the effect of mass trauma on children's psychological wellbeing.

Community care and support seemed to be essential in providing a safe place for traumatised individuals and families, thus prioritising emotional support and care for the refugees arriving in the UK. A welcoming space offers refugees the opportunity to make sense of the past as they adjust to their new life in the host country. 

However, this may not be possible as refugees are often subject to racism and bureaucratic processes in the host country, which can add to the stress experienced by refugees. The UK Home Office has been criticised for poor-quality decision making over asylum claims for the treatment of refugees from Afghanistan, Syria, Sri Lanka etc. For clinicians, creating a safe place for refugees can become quite tricky and feel like an overwhelming experience, leading to burnout. Relevant and adequate resources should be provided to protect both clients and clinicians for this rewarding yet demanding work. 

How do we offer support that promotes resilience and growth?

In terms of offering support, we are looking at both direct exposure and indirect exposure of the trauma, ongoing war trauma, intergenerational trauma, social trauma, inequality, marginalisation, racism and poverty, and historical trauma.

Trauma-informed care seemed to be the most suitable approach in this context. The principles include trauma awareness, safety, choice & empowerment and strengths-based (SAMSA, 2014). The framework can be adapted to unique situations, people, and services. The approach also promotes working together and linking with different organisations to offer support. The approach includes culturally responsive principles, service recipient involvement (collaboration and co-production) and staff development. This framework acknowledges resilience, the ability to bounce back, cope with adversity and endure difficult situations using cultural knowledge.

Cultural knowledge is essential to understand the behavioural expressions of distress. This would enable the clinicians to collaboratively interpret and respond to the clients' pain/distress using coping strategies that are culturally relevant. It is essential to link up proactively with mental health professionals from Ukraine who are seeking refuge in the UK and support them personally and professionally to help their communities. This would help us to learn from them.

Culturally relevant screenings are most suitable and can be applied in community settings and clinical settings such as refugee camps, places of worship, schools, clinics, GP surgeries, etc. Offering screenings and support in community settings can normalise the experience and reduce the stigma related to mental health care.

Adapting relevant evidence-based approaches such as CBT, EMDR, NET and third wave CBT approaches such as Compassionate-based CBT would be useful in offering therapeutic support and stabilisation for the people. While acknowledging the importance of one-to-one support, a compassionate space/group setting maybe most relevant where people can use self-help skills that can support people to tap into their resilience, resources, and cultural coping strategies.

Where trauma is ongoing, the CFT model (Gilbert, 2010) could be most relevant as it acknowledges the continuing threat response, whether internal or external. CFT stresses the importance of compassion from others and self-compassion in the adaptive regulation of emotional reactions to threats. A safe place where people can be kind, understanding and mindful towards the self when things are difficult becomes crucial to feel cared for and understood. This space will then reduce the feelings of threat, defeat, shame and failure. Furthermore, a safe group setting offers the opportunity to perceive one experience as part of a larger human experience versus seeing them as separating and isolating in pain and failures (Neff, 2003).

Mental health care for refugee communities 

It is common knowledge that the wider health and care system is working under severe financial constraints, and thus there were high levels of burnout among healthcare staff during the pandemic. Furthermore, mental health services have suffered a lack of funding over the years, and the resources are scarce. Adequate funding and resourcing mental health services for BAME communities is needed to offer quality care. However, structural racism is also at play, and we can see the broader impact of inequalities and how these are maintained in policy, economics, and wider society. This is reflected in the IAPT BAME Positive Practice Guide (2018). The report indicated that the BAME communities are not only less likely to access mental health services but also less likely to achieve “full recovery”.

In the context of offering support to refugees it is essential to acknowledge these issues so we can creatively overcome the difficulties so that the marginalised communities are not further disadvantaged.

To maximise the resources, collaboration and partnership in working with relevant communities are vital. This can bring together separate organisations so all parties can benefit from pooled expertise, cultural knowledge resources and sharing. We can also link with wider with European mental health services to offer and access training and support. The partnership models such as the networking model, the referral systems, the consortium model and the multiagency model can also be used to maximise person-centred care (James and Cross, 2021).

For example, CBT experts from BABCP and other psychologists offered a few hours to train Tamil GPs in CBT skills to screen and offer self-help support to refugees and asylum seekers from the Tamil community in the UK due to suicidality during the pandemic. The GPs assessed risk and severity and referred the clients to the relevant services. People involved with the voluntary service reported this as an enriching and rewarding experience. Overall working together using partnership models can address the difficulties related to financial constraints, racism and resourcing.

Self-care for clinicians

Finally, what can make a clinician competent in working with war trauma?

Openness to ongoing learning, beginners' mind and willingness to look after themselves. Self-care of clinicians is paramount. Culturally sensitive therapy and supervision, access to quality translated materials, regular debriefings, peer support, education, and training can support clinicians look after themselves while caring for people who have experienced severe trauma.

References

Beck, A., Naz,S., Brooks, M. & Jankowska, M., (2019). Black, Asian And Minority Ethnic Service User Positive Practice Guide Available at https://www.babcp.com/Therapists/BAME-Positive-Practice-Guide

Gilbert, P. (2010). Compassion focused therapy. Routledge.

Guidelines for psychologists working with refugees and asylum seekers in the UK | BPS. Bps.org.uk. (2022). Retrieved 18 April 2022, from https://www.bps.org.uk/news-and-policy/guidelines-psychologists-working-refugees-and-asylum-seekers-uk

Neff, K. (2003). The Development and Validation of a Scale to Measure Self-Compassion. Self And Identity2(3), 223-250. https://doi.org/10.1080/15298860309027

SAMHSA’s Trauma and Justice Strategic Initiative (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Available from: https://ncsacw.acf.hhs.gov/userfiles/files/SAMHSA_Trauma.pdf

Saul, J. (2013). Collective Trauma, Collective Healing: Promoting Community Resilience in the Aftermath of Disaster (Routledge Psychosocial Stress Series). Routledge.

Sriskandarajah, V., Neuner, F., & Catani, C. (2015). Parental care protects traumatized Sri Lankan children from internalizing behavior problems. BMC Psychiatry15(1). doi: 10.1186/s12888-015-0583-x

Woodall, J., & Cross, R. (2021). Essentials of health promotion. Sage

This article was originally published in CBT Today magazine May 2022.

While we have checked the links in this article at the time of publication, BABCP is not responsible for any subsequent changes to these.

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