Understanding the Problem
– The greater Seattle area is experiencing an influx of Ukrainian refugees as a result of the Russo- Ukrainian War that escalated in February 2022.
– The Ukrainian community has unmet mental health needs because of the war.
Profile Objectives and Anticipated Impact
– Provide insight into mental health needs and barriers to care of Ukrainian refugees in the greater Seattle area.
– Serve as a resource for providers to deliver culturally relevant and respectful care to Ukrainian immigrants, primarily refugees.
– PTSD, anxiety, depression, and somatization are among the mental health issues experienced by Ukrainian refugees.
– Barriers to receiving mental healthcare include stigma, inability to identify mental health problems or their importance, and lack of trust in the healthcare system and mental healthcare in general, including concerns over confidentiality.
– Religion and community are important in Ukrainian culture and should be considered in mental health approaches.
– Some refugees feel they cannot seek mental healthcare because they prioritize addressing their basic unmet needs.
– Some mental health needs are psychoeducation and a trauma informed approach to care.
This profile is intended to be a resource for providers who offer medical services for Ukrainian immigrants and refugees, focusing on how this population may engage with mental health resources. The focus is on refugees in the King County and greater Seattle area in Washington, United States, however this profile may be a useful tool to other communities as well. *See the ‘Resources in Seattle Area‘ section for Seattle-specific resources.
The Russo-Ukrainian War started in Eastern Ukraine in 2014 and escalated in February 2022. This resource describes unique social and cultural characteristics of the Ukrainian community, including impacts of the war on Ukrainians’ engagement with mental health resources and services. These characteristics are important for providers to understand as this may influence their approach to delivering care to Ukrainian patients.
Over 8 million people have fled Ukraine since February 24, 2022 (United Nations High Commissioner for Refugees, 2023). Russia’s unprovoked attacks “have produced one of the largest mass movements of displaced people from their homeland in recent history” (Patel & Erickson, 2022). The US has taken in more than 271,000 Ukrainian refugees since February 2022, who have entered the US through various immigration channels, including temporary or immigrant visas and private sponsorships, including a large proportion admitted along the US-Mexico border, and a small subset through the traditional refugee system (Ainsley, 2023; Montoya-Galvez, 2022). As of February 2023, nearly 16,000 Ukrainian refugees have resettled in Washington state since war escalation in 2022 (Wilkinson, 2023).
Mental Health in Ukraine
Ukraine has a centralized health care system, and mental health services are offered by both public and private providers. Prior to 2022, most people received mental health care through outpatient clinics, psychiatric hospitals, and in psychiatric departments in general hospitals (Shi et al., 2022; Weissbecker et al., 2017). Historically, approximately 90% of mental health funding was granted to psychiatric hospitals, and there was a lack of community-level care (Weissbecker et al., 2017). Accordingly, there were many psychiatrists and fewer psychologists, psychotherapists and social workers. Nonspecialized staff have been limited in the mental health services they offer (Weissbecker et al., 2017).
The psychiatry system was used as a tool of repression in the Soviet era against those opposed to the regime. This has led many people, particularly among the older generations, to be reluctant to seek mental health care. Barriers to seeking mental health care include stigma, lack of information and awareness regarding mental health symptoms and conditions, fear and lack of trust in the health system, and cost of treatment, including unofficial payment to medical personnel. Another concern is the validity of mental health care and providers that offer it (Hook et al., 2021, Weissbecker et al., 2017). Concerns over validity stem from provider education and interventions not consistently being evidence-based, which is partially due to a lack of standardization of curricula; Psychotherapists are not required to complete medical degrees and instead private institutions offer training (Hook et al., 2021, Weissbecker et al., 2017). Cost of training is a barrier that further prevents some psychologists from gaining additional skills that would elevate the care they provide clients (Weissbecker et al., 2017).
In 2017, Ukraine embarked on an ambitious health care restructuring, including reforming a lack of community level mental health care, integrating mental health into standard primary care, and improving access to evidence-based mental health care (Hook et al., 2021; Skokauskas et al., 2020; Weissbecker et al., 2017). The reform included implementation of the World Health Organization’s (WHO) Mental Health Gap Action Programme (mhGAP) which establishes clinical protocols for non-specialist settings as the first points of contact with patients needing mental health support. The reform also involved the creation of Community Mental Health Teams (CMHTs) to provide care to people with severe mental disorders living in remote regions with limited access to mental health services (Kluge & Habicht, 2022; Pinchuk et al., 2021, WHO, 2022).
As aforementioned, the war in Ukraine escalated in February 2022 but the military conflict started in Eastern Ukraine in 2014. Furthermore, Ukrainians have been fighting for independence for centuries (Farmer & Kritovich, 2022; Pinchuk et al., 2021). Common mental health issues among Ukrainians today are depression, anxiety, PTSD, somatization, among others. A nation-wide 2016 mental health survey of internally displaced persons revealed that among people that most likely required mental health care over the past 12 months before completing the survey, 74% reported not receiving care (Roberts et al., 2019; Shevlin et al., 2022). Since 2014, civil society organizations and international actors stepped in to address mental health needs, especially among populations directly affected by the conflict such as people internally displaced and veterans (Weissbecker et al., 2017). However, the delivery of mental health interventions in conflict settings is complex and there is sparce guidance on how to do so, and efforts are sometimes disjointed and not consistently evidence-based (Chaaya et al., 2022; Elvevag et al., 2022; Weissbecker et al., 2017).
After war escalation in 2022, attacks on health infrastructure, including psychiatric hospitals, prevent many people in Ukraine from accessing mental health services. (Chaaya et al., 2022; Kalaitzaki et al., 2022; Quirke et al., 2021, World Health Organization [WHO], 2022). The Ukrainian government and more than 200 partners on the ground further increased investments and delivery of mental health support on the national and community levels. This included remote consultations for people within or outside of the country, addition of psychosocial centers in-country for people impacted by the war, “peace-educating” young people and children about trauma and violence, provision of mental health services in mobile clinics in remote villages and in metro stations in bigger cities, among many others (Doctors Without Borders, 2022; Elvevag et al., 2022; Kluge & Habicht, 2022). Several low-intensity interventions are also being implemented, including psychological first aid delivered by trained lay health workers or community members, and disseminating information to raise mental health literacy (Shi et al., 2022; WHO, 2022).
Importantly, in December 2022 Ukraine launched an Operational Roadmap, in line with the national vision and best international standards, to prioritize activities that address the mental health and psychosocial needs of Ukrainians affected by the war.
Common Mental Health Problems
Anxiety, Depression, Post Traumatic Stress Disorder (PTSD), and Somatization
Psychiatric disorders such as depression, anxiety, and post-traumatic stress disorder (PTSD) were prevalent among people in Ukraine prior to war escalation in 2022 (Quirke et al., 2021; Roberts et al., 2019; Shevlin et al., 2022, Weissbecker et al., 2017). Many Ukrainian refugees experience or are at risk of experiencing increased anxiety (including separation anxiety), depression and PTSD. These conditions are expected to affect many future generations because of or exacerbation by the 2022 war escalation and COVID-19 pandemic (Kalaitzaki et al., 2022; Patel & Erickson, 2022; Shevlin et al., 2022).
A national survey on parents completed in Ukraine in September 2022 revealed that people reported increased anxiety, depression, loneliness, and hazardous drinking since escalation of the war (Hyland et al., 2022). The greatest needs are in areas directly impacted, but people in relatively safer areas also experience anxiety, sleeping issues, fatigue, anger and unexplained somatic symptoms (Kluge & Habicht, 2022). We make the assumption that these problems are prevalent for refugees in the Seattle area but acknowledge there may be differences between the population in this study that resided in Ukraine versus refugees abroad. However, several counselors interviewed for this profile confirmed that they have seen higher rates of PTSD, anxiety and depression in their Ukrainian refugee clients, and two counselors added that their patients experience insomnia, which is both a symptom and a diagnosis.
Prolonged Grief Disorder (PGD)
Prolonged Grief Disorder (PGD) often occurs after the death of a loved one, after which an individual longs for and is preoccupied with the deceased. Many Ukrainians are likely to experience traumatic and prolonged grief because of the emotional pain caused by the number of Ukrainians killed during the war. Although the scientific community is not certain which patients are most likely to develop PGD because it is a relatively newly studied disorder, some experts believe that Ukrainians experiencing war are vulnerable to developing it (Shevlin et al., 2022).
Mental health in youth and elderly
Research has shown that wartime often has lasting detrimental effects on the mental health of young people (Elvevag et al., 2022; Shevlin et al., 2022). A study of adolescents in the Donetsk region following the Russian incursion in 2014 found that greater risk of PTSD, severe depression, and anxiety correlates to higher numbers of war events, when compared to peers in peaceful regions of Ukraine not directly exposed to war (Hodes, 2023). In a 2022 survey in Ukraine about changes in parents’ and children’s lives during the war, parents participating in the survey reported their children’s mental health had deteriorated, also accompanied by anxiety, mood swings, sleep disorders, poor appetite, memory and attention impairment, aggression and reduced desire to communicate after the war started, compared to the pre-war period (Kaufman et al., 2022; Solerdelcoll et al., 2022). Interviewees for our profile supported the assumption that these problems persist for adolescents who have experienced war, even once they relocate as refugees. The war and COVID-19 pandemic have increased mental health needs in both children and their caregivers, which magnified the negative effects on children (Hyland et al., 2022; Solerdelcoll et al., 2022).
For many Ukrainian children, their aspirations relate to Ukraine’s victory because they wish to return home, and some experts believe they have potential to overcome this threat towards posttraumatic growth rather than stress (Schwartz et al., 2022). Timely prevention and intervention strategies may promote children’s mental health and sustained recovery from trauma (Kaufman et al., 2022). One interviewee mentioned that it is not uncommon for children to become refugees in another country with their mother while their father stays in Ukraine, for example, and this familial separation likely leads to further mental health challenges.
Another interviewee stated that grants and other funding types for refugees are typically created for children, but elderly people are actually one of the largest subgroups in need of mental health support. Elderly refugees often experience isolation as they often depend on their families for transportation and interact with their community less. Younger generations grasp the new language more quickly and serve as their families’ “cultural liaisons”, creating a unique shift in the familial power dynamic.
Barriers to Mental Health
Stigma toward having a mental health condition and receiving care
Stigma is a major barrier deterring Ukrainians from seeking mental health care (Hook et al., 2021; Weissbecker et al., 2017). During the Soviet Union era, people who opposed the Soviet regime were often repressed by being labeled as mentally ill and imprisoned for long periods of time in psychiatric hospitals (Van Voren, 2013). Ukrainian people fear that a mental illness diagnosis will result in being labelled negatively by their communities and interfere with their opportunities for employment (Weissbecker et al., 2017). An online survey conducted in Ukraine in 2020 confirmed that stigma against people experiencing mental health conditions persists, and even though they indicated a high degree of empathy, many respondents believed that individuals with mental health conditions should not hold certain jobs. This study also found that a large proportion of respondents did not want people with mental disorders as friends or colleagues, which were similar findings as in a 2018 study in Central Ukraine (Quirke et al., 2021).
All interviewees for our profile identified stigma as a primary barrier to mental health care for Ukrainians, though also noting that it is becoming less significant for younger generations. Several interviewees informed us that men in particular, as leaders of their household, experience pressure to not admit mental health challenges they experience, and one counselor observed that Ukrainian men are pursuing counseling less frequently than Ukrainian women in Seattle. They added that local community organizations in Seattle avoid using words like “depression” or “mental health care” when talking about mental health services, in hopes of not scaring off potential clients for whom stigma is a concern.
Inability to identify mental health issues and/or their importance
Stigma toward mental health is intertwined with and intensified by a lack of understanding and awareness about mental illness. Many Ukrainians are unfamiliar with treatment options, thus are unable to distinguish the level of care needed for disorders and often assume that any diagnosis will result in a psychiatric hospitalization (Weissbecker et al., 2017). An online survey conducted in Ukraine in 2020 regarding mental health stigma indicated that there was limited knowledge of mental health disorders among the public, in addition to beliefs rooted in stigma discussed in the previous section (Quirke et al., 2021). In a 2020 qualitative study aimed to solicit perspectives on mental health training and services in community clinics offered in Ukraine, participants also noted that patients often lack understanding about mental health treatment, which leads some patients referred to mental health services to resist treatment (Hook et al., 2021).
Interviewees for this profile confirmed that many Ukrainians believe in more obviously presenting conditions such as psychosis to be mental health conditions that warrant treatment. However, conditions that may present less obviously, such as anxiety and depression, are considered by many as not warranting professional support. One interviewee mentioned that many people from former Soviet countries do not want to admit that they have mental health issues due to hopelessness; they are unaware of available tools that could help them, thus do not want to admit their problem for which a solution or support do not exist. Furthermore, when people experience symptoms that are a result of a mental health problem, they often somaticize the symptoms rather than believing the symptoms indicate a mental health problem.
Lack of trust in mental health care and privacy concerns
There is additionally a lack of trust of mental health care in Ukraine that extends to the US when refugees arrive here. Many Ukrainians generally distrust both the public health care system in Ukraine and mental health care in general (Weissbecker et al., 2017; Hook et al., 2021). They fear that information about their mental health may be shared with others (Weissbecker et al., 2017). Additionally, due to reported negative encounters from others, many people do not believe the qualifications and experience of mental health professionals within Ukraine to be competent (Hook et al., 2021).In a qualitative study that solicited perspectives on mental health training and services in Ukraine, physicians reported less willingness to refer patients to psychologists due to negative perceptions about their qualifications, making the referral process less effective (Hook et al., 2021).
People in Ukraine prefer to seek treatment anonymously due to the stigma and shame, and fear of having a mental illness diagnosis in their public medical record, potentially decreasing their job prospects (Weissbecker et al., 2017).
According to our interviewees, this lack of trust transcends borders, and some Ukrainians have similar concerns regarding seeking mental health care in the US, as Ukrainian refugees in the Seattle area also worry about stigma and others in their community finding out that they are seeking mental health services. One counselor mentioned that concerns of confidentiality are stronger in this population than what they have observed in other refugee/immigrant populations.
Adjusting to host country
Relocating as a refugee to a new country is complex and challenging for many reasons. These include separation from and worry about family and friends, difficulty in accessing health care, finding employment, legal uncertainties regarding staying in the host country, delays in the asylum application result, social isolation, among many others (Kaufman et al., 2022; Hodes, 2023). These post-migration factors make refugees vulnerable to mental health problems. Psychiatrist Dr. Kaufman and colleagues recommend that mental health treatment be integrated into an overall care plan for refugees; one that also ensures that basic needs are met (2022).
Interviewees for our project noted that Ukrainian refugees in the Seattle area have reported feeling welcome and supported by Americans in their communities. One interviewee mentioned that language barriers and logistical difficulties, such as figuring out the public transportation system, have slowed assimilating into society. One individual said that there is typically a delay of around 9 months from arrival into the US to starting to engage in mental health services, and that they are working to narrow this time gap.
Several interviewees noted that some Ukrainian refugees have expressed a need in mental health care but feel that they do not have the time to pursue care before other needs of their children and families are met, such as schooling and employment. One interviewee referenced Maslow’s Hierarchy of Needs to illustrate how mental health is not deemed a priority when refugees feel they haven’t yet had their fundamental needs met.
Sex and age impact engagement with mental health services
Sex and age influence how individuals’ psychological distress manifests and how they engage with mental health resources, implying that these characteristics need to be considered when tailoring mental health support (Hyland et al., 2022). Of note, most Ukrainian refugees outside Ukraine are women and children, as men aged 18-60 years were conscripted into the armed forces shortly after war escalation and many have not been permitted to leave (Hodes, 2023).
Older generations are more reluctant to seek mental health care as many lived through the Soviet regime in which the psychiatric system was used as a tool of punishment and repression against those who opposed the regime (Weissbecker et al., 2017). Interviewees for this profile confirmed that older generations are more likely to be firm in their beliefs regarding mental health care, while younger generations are more receptive to learning about and engaging with services.
A national survey on children and parents in Ukraine which completed in September 2022 found that younger people had increased feelings of loneliness as opposed to older people. Females reported increased symptoms of anxiety and depression and increased feelings of loneliness. Females have a greater risk for worsening mental health among civilians in regions affected by war generally, not necessarily in Ukraine specifically (Hyland et al., 2022). One interviewee mentioned that elders who are refugees experience isolation as they often depend on their families for transportation and interact with their community less. Younger generations grasp the new language more quickly and are their families’ “cultural liaisons”, creating a unique shift in the familial power dynamic.
Finally, the survey on children and parents also found that younger people and males were more likely to drink alcohol as a coping mechanism for experiencing negative mental health effects. There is considerable evidence that, in general, alcohol use disorder is more common in male rather than female war veterans, and study findings support that this effect exists in civilian populations exposed to war as well (Hyland et al., 2022).
Several interviewees for our project confirmed that men, as leaders of their household, experience pressure to not admit mental health weaknesses or otherwise, and one counselor informed us that Ukrainian men are pursuing counseling less frequently than Ukrainian women in Seattle.
Cultural Contextual Characteristics
Present wartime, and historical and political context
The devastating situation in Ukraine is not entirely new as of February 2022, as the military conflict started in 2014, and furthermore Ukrainians have been fighting for independence for centuries (Farmer & Kritovich, 2022; Pinchuk et al., 2021). Most older Ukrainians and many younger Ukrainians living today have family members who were persecuted or killed, including before the 2014 war. Multiple generations of oppression and loss are present in their lives (Farmer & Kritovich, 2022).
One interviewee noted that being tactful in the way that Russia-Ukraine relations and political stance on the war is brought up could influence the relationship between client and mental health professional. The relationship is sensitive and important to the delivery of effective mental health care.
Role of spirituality and religion
Religion is an important aspect of life for many Ukrainians and the dominant religion is Eastern Orthodox Christianity. The second most common religion is Catholicism, and a small percentage of Ukrainians observe Protestant, Jewish, Muslim and other faiths. Many attend faith-based services and celebrate religious holidays (Farmer & Kritovich, 2022). The inability to follow religious practices may have a negative impact on the mental well-being of displaced Ukrainian people (Kaufman et al., 2022).
For many Ukrainians, clergy are informal community providers who offer a vital source of mental health support (Weissbecker et al., 2017). Interviewees for this profile confirmed that religion is integral to Ukrainians, spiritual leaders serve as unofficial therapists, and confession is a form of talk therapy for many. Our interviews revealed that some Ukrainians believe that experiencing mental health issues is indicative of demon possession or not having enough faith, that receiving mental health care is frowned on by their church and that attending church, praying more, fasting, etc. are the only approaches that could improve mental health issues.
Importance of community
Family has been central to Ukrainians for decades because in the presence of family, they felt they could be themselves without fearing persecution. This sense of security is often felt beyond immediate family, but among wider friend and church communities as well (Farmer & Kritovich, 2022).
Most Ukrainians in the US have extensive connections to family and other loved ones who remain in Ukraine, for whom they constantly worry (Farmer & Kritovich, 2022; Wilkinson, 2022). Some refugees feel guilty being outside of the country (Farmer & Kritovich, 2022).
Interviewees confirmed that community is central to Ukrainians and many newcomers are reuniting with family and friends when coming to the US. Most choose to relocate to where they have the most family and friends. They typically spend lots of time with other Ukrainians through their social networks and through attending church regularly.
Wartime may offer a window of opportunity for mental health
A national media campaign to stress the importance of mental health care was launched in Ukraine in 2022, with an emphasis on seeking care without worry of stigma or discrimination (Kluge & Habicht, 2022). Three interviewees mentioned that though greater mental health needs are a consequence of a devastating circumstance, the war has perhaps created a window of opportunity to break down stigma and other barriers associated with seeking mental health care. One person added that the COVID-19 pandemic also resulted in mental health needs and contributed to this window of opportunity. One interviewee, however, felt that Ukrainians’ perception of mental health has not changed, even considering recent events.
Therapy, Psycho-Education and Other Approaches
Psycho-education: a critical mental health need
Interviewees identified psychoeducation as one of the greatest mental health needs among Ukrainian refugees. Psychoeducation is the “process of teaching clients with mental illness and their family members about the nature of the illness, including its etiology, progression, consequences, prognosis, treatment and alternatives” (Barker, 2003). This includes teaching people techniques to try when feeling anxious, and how to recognize when they should seek help. One interviewee noted that mental health organizations started sharing information about mental health via social media, and that books on the topic are starting to get translated into Ukrainian more often. Another added that it is important for people to understand that there are resources available to them that are not rooted in religion. One interviewee mentioned that today, some spiritual leaders openly talk about the benefits of mental health support and how a psychotherapist may be better suited to help them than the spiritual leaders themselves. In addition, interviewees emphasized their organizations’ focus on helping Ukrainians understand that they offer mental wellness-based (rather than mental illness-based) services, and that seeking support doesn’t designate them as “problem people” among their communities.
Psychiatrist Arash Javanbakht, MD published a suggestion for strategies to reduce long-term impacts of trauma and stress for Ukrainian refugees, which included recommendations for non-medically trained staff. He believes that even case workers that interface with refugees upon arrival and drivers transporting refugees be trained in “mental health basic first aid” and identifying symptoms of consequences of mental health trauma that need treatment (2022). *See the ‘Online Resources‘ section for an example of this resource.
Approaches to Trauma and Grief
Mental health experts recommend that a trauma-informed assessment of the presence of significant mental illness should be a critical component of the welcoming process for all refugees. Such an approach includes acknowledging links between trauma and mental responses to it (Kaufman et al., 2022; Shi et al., 2022). The “golden hours” is the early phase after exposure to trauma in which supporting people’s mental health can limit short-term memories from becoming long-term memories and accordingly long-term damage (Henriques, 2023). One interviewee for this profile expressed the importance of a trauma-informed assessment of mental illness and integrating trauma care into therapy for Ukrainian refugees, which is an issue for many escaping the war. Counselors are trained in talk therapy for other conditions, but could benefit from practicing trauma releasing exercises, eye movement desensitization and reprocessing (EMDR) and other techniques to address trauma, which may be unrelated to talk therapy as some techniques do not include a spoken element.
Some mental health experts caution providers against reinterpreting and over pathologizing all feelings into depression, anxiety or PTSD, among Ukrainian refugees seeking mental health care in safe settings. This is because the losses that individuals experience must also be understood and grieved, and interrupted grief can damage mental wellbeing, leading to mental consequences that can be felt years after. In a 2022 International Medical Corps MPHS Needs Assessment report from Ukraine, focus group participants described how loss was prevalent in all aspects of their lives: loss of loved ones, safety, language, among many others. The ongoing war often interrupted the mourning process, for example, participants reported that the mourning ritual was lost when people identified bodies of loved ones in mass graves and reburied them in a dignified manner. When migration for survival is the most urgent concern, people often don’t have a space to properly mourn (Schwartz et al., 2022).
Interviewees emphasized the need for individual therapy to be accessible to Ukrainian refugees. Some clients prefer in-person appointments while others prefer telehealth, including those who may not have a car or prefer a counselor who lives far away. All interviewees believed it was important to most refugees to work with Ukrainian (or Russian) speaking counselors or other mental health providers (in the language preferred by the client), to be able to communicate with clients directly, and because understanding of shared culture and background helps build the client-provider relationship. One interviewee, a counselor who had used interpreters before, believes use of interpreters can complicate lines of communication between client and provider, and ultimately negatively influence their success in treatment.
Several counselors mentioned that acknowledging that each client is unique, and building rapport and trust is important. One counselor stressed the importance of initially creating space for the client to talk and release pain that they have been keeping within themselves. Asking clients questions about coping strategies that work for them may evolve into a discussion about psycho-education and awareness of other strategies that could work. It is best to provide and explore suggestions rather than directly advising clients. As described previously, many Ukrainians are religious and may rely fully or partially on their religious beliefs rather than seeking mental help to address their mental health issues, so it is important to integrate recommendations with clients’ existing beliefs.
One counselor stressed the importance of not telling clients that they understand their pain if they have not fled from war themselves, as this may be aggravating to some. Instead, she suggested commending clients for their bravery and resilience, and emphasizing that the counselor’s role is to help them process their emotions and share in their pain so that clients do not have to experience it alone. One consequence of war that people have trouble processing is that they did not choose these circumstances, but these circumstances were chosen for them. For example, some families wanted to move to the US, but not under these circumstances, and they long to return home but are not sure when and if this will happen.
This counselor referenced psychiatrist Victor Frankl in that people often wait for an event, such as victory or loss, but don’t live in the present. She believes guiding clients to focus on what is important today is needed to alleviate some worry of the current reality and future, which we can never know with certainty. Refugees from Ukraine have experienced overwhelming loss (ranging from loss of home, job, loved ones, purpose, and identity) and it is important to guide clients to think about how to move forward and what they can gain from this loss. Since living through and surviving these traumatizing situations, and since adapting and feeling safer, many do not know what comes next and what their purpose is. Many clients are hard on themselves for feeling different than before, being less productive, having less desire to do things, not knowing what they want to do with their lives, etc. Several counselors advised that providers convey that it is normal to be experiencing mental health issues under these abnormal conditions. One counselor shared that she often reminds clients why they are experiencing these feelings and that she is there to make sure that they are temporary.
Several interviewees mentioned already existing programs or plans to create programs that include group-based interventions. One example is establishing partnerships between community organizations that provide therapy and schools to develop therapy groups in school. At community events, local organizations typically have group therapy activities such as singing songs and dance. Group-based interventions can be used for reducing stress and improving coping skills, especially for subthreshold symptoms, to address mental health challenges. These interventions often do not require complex training for facilitators and can be effective in overcoming cultural barriers and stigma. Examples include mindful dance and movement and art therapies for refugee children (Javanbakht, 2022). One counselor mentioned the importance of social groups for elderly people, who are often overlooked as a group in great need, and for whom it is important to know that they are not alone in their pain and that there are resources available and other people who are going through similar processes. She said that an emphasis of group therapy is to help people find meaning in life.
Interviewees additionally reported that most newly arriving mental health specialists in the Seattle area from Ukraine are not licensed in the US so are unable to work as mental health specialists in the same capacity as they did back home. Local community organizations and public health departments across the US are collaborating to identify ways in which specialists can support the mental health of their community in the US, and a leading way may be in the form of facilitating group therapy sessions.
Interviewees informed us that Ukrainian people, including refugees, engage in practices including making art, meditation, diet, distraction, breathing techniques and physical activity to combat feelings of stress and other symptoms. One counselor mentioned that people may be bothered if a coping mechanism that worked for them yesterday doesn’t work today, but the truth is that what works changes daily, and that is normal.
Psychotropic and herbal medicine
Some people living in Ukraine took antidepressants or other psychotropic medicines for their mental health concerns prior to 2022, and in recent years most drugs used in the West were also commercially available in Ukraine (Weissbecker et al., 2017). One counselor interviewed for our profile recommends a combination approach of therapy and medication for some clients and finds herself recommending this approach more among people escaping war. Though there is limited literature on psychotropic medicine use in Ukrainian refugees, mental health experts stress the importance of these medications being available to impacted people inside and outside Ukraine (Chudzicka-Czupała, et al., 2023). Several interviewees revealed that though stigma toward use of psychotropic medications persists, Ukrainians, especially younger generations, are becoming more open to the use of these medicines.
Two interviewees mentioned that valerian root is a popular herbal medicine used today to help calm the nerves of individuals experiencing stress. This over-the-counter medication is commonly used by people from countries formerly in the Soviet Union.
Relying on community
As described previously, sense of community is vital in Ukrainian society. One interviewee from Ukraine mentioned that Ukrainians, especially younger people, rely on their friends for mental health support and may discuss mental health challenges with friends over coffee, for example, often not identifying that their challenges are “mental health issues,” per se.
The 2022 Internally Displaced Persons Mental Health Survey in Ukraine revealed hazardous alcohol use in 14.3% of men and 1.7% of women (Shevlin et al., 2022). Psychiatrist Kaufman and other authors believe that a significant proportion of Ukrainians will likely develop alcohol and substance use disorders which will be intensified by trauma (2022). Alcohol use was prevalent before the 2022 war out-break, as well (Weissbecker et al., 2017, Quirke et al., 2021). Interviewees for our profile confirmed that some Ukrainians, including refugees, cope with alcohol and marijuana.
Resources in Seattle Area
Interviews for this profile were conducted in King County and the greater Seattle area. Below are a few organizations in our community that provide mental health support to Ukrainian refugees. Interviewees mentioned that organizations often reach community members at outreach events.
- Nashi Immigrants Health Board has a mission to: “partner with Ukrainian and Russian speaking communities in WA state to meet the broad range of health and social needs of our people and advocate through community engagement, empowerment and connection to resources”. Their website lists mental health resources, including free and low-cost clinics that offer counseling: https://nashisupport.com/programs-and-resources/
- Refugee Women’s Alliance (ReWA) provides immigrants and refugees with social services in over 50 languages and dialects, including mental health services such as counseling in Ukrainian, often at no cost to patients. They also help new arrivals with mental health system navigation, training counselors and recruiting refugees and immigrants into the field, and are creating an assessment tool for culturally adapting mental health interventions: https://www.rewa.org/
- The Ukrainian Community Center of Washington (UCCW) supports Ukrainian refugees and immigrants in Washington, including providing individual and family counseling, case managers to connect patients with psychosocial resources, and home visits: https://uccwa.org/
For patients and Providers:
Post Traumatic Growth (PTG) Article [ENG]: Positive Psychology Article on PTG beneficial for both clients and clinicians, and includes suggested books for further reading
Rozmova Therapist Portal [UKR, ENG, RUS]: Platform that clients can use to connect with therapists. Personal, couple and child therapy are offered
Mental Health for Ukraine (MH4U) [UKR]: Project aimed at improving care for people with mental disorders in Ukraine. The website provides a myriad of resources to empower patients to participate in decision-making regarding their health and treatment
Psychological First Aid (PFA) [UKR, ENG]: PFA for Red Cross and Red Crescent Societies details a direct response and set of actions to help someone in distress.
PORUCH Mental Health Support Group [UKR, ENG]: Intended for negatively impacted youth, parents and teachers. This project offers free in-person and online sessions lead by psychologists and specialists about how to manage psychological challenges during wars and national conflicts. It provides an opportunity for participants to share their worries and learn coping techniques from specialists.
Visit Ukraine Blog with Mental Health Resources [ENG]: Blog describing 10 psychological help resources for patients, including individual and group therapy.
DisasterReady Videos on Mental Health Topics [UKR, ENG, RUS]: Series of free videos on mental health topics to support refugees, internally displaced people, host families, humanitarians, and at-risk communities in Ukraine and neighboring countries.
Child Mind Mental Health Resources for Clinicians [UKR, ENG, RUS]: Instruments and resources to aid clinicians responding to children’s mental health needs, including a trauma screening.
Trauma Measures Global Resources [UKR, ENG, RUS]: Mental health materials for clinicians and researchers, including psychological assessments and therapeutic stories for children.
Methods and Sources
This work was done as part of a Master of Public Health Practicum at the University of Washington.
a) A Literature Review was done by searching for literature related to mental health among Ukrainian refugees in the US, and data from the review are incorporated within this page. The search was done on PubMed, Google Scholar, and Google Search Engine.
b) Primary Data was collected via individual interviews (key informant Interview) and details are provided below.
Primary Data: Interviews and Focus Group Discussions:
We interviewed a total of 9 participants via 3 semi-structured in-depth individual interviews and 2 focus group discussions, recruited by purposive and snowball sampling. Interviews were conducted with mental health specialists and Ukrainian community leaders and members in the Seattle area, and one in Vancouver, Washington. Separate interview guides were created for community members and medical professionals. Participants were leaders from local community organizations that work extensively with these communities (4), one of whom is also a nurse that works with Ukrainian immigrants and refugees in Seattle, a medical doctor from Ukraine with a specialization in psychotherapy (1), and mental health counselors that work with this population (4). One mental health counselor was newly arrived from Ukraine while the others are from or have been in the Seattle area for longer. All participants resided in Washington at the time of the interview and are kept anonymous in this profile. Interviews were transcribed and analyzed to extract relevant themes and are referenced in the profile.
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