Content warning: This story contains a reference to child sexual assault.
In 2014, Bell Shakespeare performed Henry V, set in the basement of a London school during the Blitz. I saw the play with my parents, both of whom had been children in industrial Manchester during World War II, and had huddled in shelters as the bombs fell. When the play ended, with the sound of the siren that signalled the “all clear” at the end of a bombing raid, my then 83-year-old mother burst into tears.
That’s the thing about trauma – it lives on in us, long after the danger has passed.
The children and adolescents of Ukraine are yet another generation learning to live with the terror of falling bombs. It may seem as if we have learnt very little but, in the nearly eight decades since 1945, we have at least learnt something about the lasting and debilitating effects of trauma. We are beginning to find ways of mitigating them.
As soon as the war in Ukraine began, a group of professionals leapt into action. Psychologists trained in trauma-focused cognitive behavioural therapy (TF-CBT) from all over the world responded to an email from Dr Elisa Pfeiffer, mental health expert and head of the Clinic of Child and Adolescent Psychiatry and Psychotherapy at Ulm University in Germany. She called for volunteers to help teach TF-CBT to mental health specialists in Ukraine, where it was relatively unknown.
The therapy was developed by Tony Mannarino, Judy Cohen and Esther Deblinger two decades ago in the United States to help children deal with trauma and so limit the havoc it can sometimes wreak if left untreated into adulthood. TF-CBT now has trained providers in many countries around the world. Two Australian psychologists trained in the therapy jumped on board.
“We responded within minutes,” says Natalie Cabrera, co-director of Psychology Training and Supervision at TF-CBT Australia. “We saw such a need for children and adolescents affected by trauma, and we knew the benefit of being able to help the most vulnerable people with evidence-based treatment.”
According to Natalya Mosol, associate professor in psychology at Zaporizhzhia University in Ukraine, there is a cultural resistance to therapy in her country. “In Ukraine some people are not ready for psychological support,” she tells The Saturday Paper, although she says the number of those who are is increasing.
Mosol is currently being trained by two Australian international TF-CBT practitioners: Cabrera and clinical psychologist Gavin Moffitt, co-director of TF-CBT Australia.
Vitalii Klymchuk, mental health policy development expert with the Mental Health for Ukraine Project, agrees. “In 2018, we were moving through mud regarding the importance of psychology. Now it’s much easier to engage those at the top level and ordinary people.”
A key component of TF-CBT is that it also focuses on incorporating other family members.
“The therapy helps them put a name to what they are going through and so helps them understand,” says Moffitt. “We normalise PTSD [post-traumatic stress disorder], validate it to them, and then we include the parents or caregivers and teach them all the skills to manage their distress … Terrible experiences do not go away unless they are processed.”
Pfeiffer stresses that TF-CBT has proved to be useful for children and young people affected by many different traumatic events. “Trauma-focused treatment is necessary everywhere in the world.”
Natalie Cabrera says the therapy has been used to help children from flood zones in Australia and child soldiers from the Congo.
But the trauma experienced in a war zone has some unique characteristics. “You’re dealing with a mixture of post-traumatic stress disorder,” Klymchuk says, referring to the reaction to the traumatic event just experienced, “and pre-traumatic stress disorder as you anticipate the next one”.
Mosol says people in Ukraine are seeking support for all sorts of reasons – it’s not only about the war. She describes the war as almost a backdrop to day-to-day living. “An apartment in the centre of the city was destroyed. One day a big apartment block, next a hole. You could still see a fridge up there and mirrors on the wall. You could just feel that many people have died.” A psychology student of Mosol who walked past the bombed apartment block every day could not look at it for a week. “It was like a wound,” she told Mosol. But when the student’s parents asked her if she wanted to leave, she refused. “After that one week, I looked through the window and I saw the wound,” she said. “I knew I should stay here. I want to help people and I want to help my country.”
It is not the direct experience of the war that the children find most stressful, Mosol says. “There is some rise in suicide attempts among teenagers,” she tells The Saturday Paper, “but when we ask why, war is not the first reason. It’s in the background. It’s about relationships, friends, parents. A teenage boy told me, ‘We don’t really worry about the war, we just live here.’
“So now there is denial and we do know that if you don’t speak about trauma, it will come back and haunt you. We try to support them now so that they can come back and deal with the trauma later. You can’t live in awareness all the time, so denial is a protective strategy.”
Then there are the stories that Mosol hears that she knows will continue to haunt her, too.
“Sometimes it is very heavy,” she says about her work. She spoke to the mother of a six-year-old girl who befriended a girl a year older when they were sheltering for two weeks in a basement in Irpin, near Kyiv, during the occupation by Russian troops. When they escaped, the friend stayed behind. Later she was found raped and killed. The six-year-old kept asking her mother what had happened to her friend. “I know I should answer something,” the mother told Mosol, who has a nine-year-old daughter herself. “But I go away from it. But one day I will have to answer.”
That said, Mosol finds the training itself therapeutic. “When I work with students, I see their resilience. They become stronger and more determined. And in this situation, to stay alive you must be strong. Doing this training helps students feel stronger because they are useful. You should do what you can do because that helps.”
Even more importantly, it may help break the cycle of unprocessed childhood trauma. “TF-CBT is preventative,” says Cabrera. “If you deal with the trauma as and when it occurs in childhood, there is less likelihood of physical and mental health issues occurring in later life.”
The TF-CBT practitioners want their work to inform future treatment for children. Pfeiffer points out that there is no scientific evidence as yet about the different traumas suffered by children in Ukraine, but they are conducting surveys on their different histories to develop a model. “It’s about treatment, training and scientific research.”
Vitalii Klymchuk says that they have much to learn from this experience of treating mental health during the war. “I am an absolute believer that if you do something, you should learn from it and collect narratives, adding to the pool of evidence about psychotherapy.
“The cascading effect of trauma goes on forever without something to break the cycle,” he says. “A few sessions of good therapy can break that pattern of misery, including projected misery.”
But he knows that even the most enthusiastic and highly trained therapists can’t solve the ongoing effect of trauma alone. “We will never solve this problem just with professionals,” Klymchuk says. “We need the whole society to believe it’s okay to speak about your trauma and not be ashamed.”
This article was first published in the print edition of The Saturday Paper on January 21, 2023 as "Ukraine’s children".
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