Kim Mills: In the two months since Russia invaded Ukraine, more than 4 million Ukrainians have had to flee the country as refugees. More than 6 million others have been internally displaced, and tens of millions more are living through shelling, food shortages, and other traumas of war. In March, the director general of the World Health Organization said that services for mental health and psychological support were urgently needed to help Ukrainians cope with the effects of war.
What does that need look like on the ground? What are the most pressing mental health issues during wartime, and what kind of support can psychologists and other mental health providers offer? What do we know about the short and long-term effects of living through war for both children and adults? And how have telemedicine and remote services changed the kinds of mental health support available in this war compared with past conflicts?
Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills.
Our guest today is Dr. Laura Murray, a senior scientist at the Johns Hopkins University School of Public Health, where she was co-founder of the Applied Mental Health Research Group. Dr. Murray is a clinical psychologist by training and works to develop mental and behavioral health programs in low-resource countries. She and her colleagues have been working in Eastern Ukraine since 2015, helping people affected by the ongoing conflict there. Dr. Murray's work has also taken her to Zambia, Lebanon, Cambodia, Honduras, and many other parts of the globe. Her focus is on studying the effectiveness, acceptability, and scalability of a wide range of evidence-based treatments for mental and behavioral health problems with a particular specialty in researching and treating trauma and grief.
Dr. Murray, thank you for joining me today.
Laura Murray, PhD: Wonderful to be here. Thanks so much, Kim.
Mills: Let's start with the first question I asked in the introduction. I mentioned that the World Health Organization said recently that there's an urgent need for mental health support for Ukrainians. What does that look like? What are people's most pressing mental health needs right now, and what kind of support can mental health providers give during wartime?
Murray: I agree that mental health needs are extreme and going to be extreme for years to come, given the situation in Ukraine. When you ask what are the most pressing mental health needs, it will change over time. It's very dependent on a large number of variables right now. Ukraine is a little bit different in the context that some people are still in country and in country in places that are different levels of safety. Some are in country and safe. Some are in country and not in safe places. Then, of course, as you mentioned, there are millions of refugees who have fled the country and are in different locations. So what we see is a vast array of variables that are affecting this humanitarian crisis.
The mental health needs are going to be vast. They're going to be very different, and they're going to be ever-changing. It's not a stretch to say that in any humanitarian context or war, what we see is an increase in anxiety, and stress, and post-traumatic stress disorder, and depression, and some substance use. One of the biggest things that we focus on is the difference in time. So, for example, Kim, you mentioned, what is the need now? Right now, when people are living through this situation, that elevated anxiety is very normal, and it's really important not to pathologize that and say that that's abnormal. Right?
So many people might look like they're agitated, and that's good. That will serve them well, especially if they're still in an unsafe context. So mental health needs really vary right now. What we're seeing is that there's a lot of need for psychological first aid. That's an evidence based, an approach that really is given in the context of ongoing disasters, wars, humanitarian settings, focuses more on support and prevention, and that's really critical. I would say in the past week, we've started to see some movement towards needing more than psychological first aid, particularly for those people that are now somewhere safer. So they're out of the immediate danger, and they're starting to experience some exaggerated symptoms or some additional struggles.
Mills: So how does providing mental healthcare during a war differ from other kinds of mental healthcare?
Murray: Yeah. So, during a war, what we want to really be careful of is what I alluded to earlier, that in the context of a war, many reactions that might look like a mental health problem are actually very normal. So if anyone was in that context, they would—it would be very normal to have reduced sleep and couldn't function as much. It would be hard to problem solve, and we would be anxious.
And so that's one of the biggest differences. In regular mental healthcare, we're looking for symptoms like that to indicate this is, might be an area where we want to intervene to help reduce that. In a disaster or war setting, what we want to be careful of is taking into account the context and what's a normal response to a really awful situation, and then, how is the best way that we can help them? The other difference I will say is that in a like Ukraine and many other wars and disasters, for example, we really want to get basic needs first, because that really causes a lot of the stress. So in a war context, that's going to look differently in that even though someone looks anxious, our response wouldn't be to provide mental healthcare. Our response would be to say, “What is going on? Do you have food? Do you have water?”
Mills: Right. You need housing. Right. Yeah.
Murray: Housing, “How are your children? Do you have an injury?” And so it's—mental health usually comes later or is more preventive in nature, for example, like the psychological first aid.
Mills: So what are providers in Ukraine experience right now? One big question that I had is, are there still mental health providers on the ground in Ukraine, or have they left as well? And for those who are there, they must be going through their own trauma, so how are they helping other people when they need help themselves?
Murray: I'm so happy you brought this up, Kim. We, in our time there, we have trained over 200 mental health professionals, and I will tell you, it's so challenging for them. Yet we see such resilience and such desire to care for their fellow Ukrainians. I will say, as far as location, they're all over. There's many that are still in Ukraine. There's many that are sort of around the outskirts of Ukraine in safer areas. There's many that still are moving quite a bit, and then there's many that probably have left and have gone outside of the country.
What are they doing? I think it varies a lot. There are some that are having to take care of their elderly parents. We know some that have not only their young children with them but many other families' young children. So there's a lot of people taking other people's minor, because maybe something happened to the parents, or, as we all know, many men are still in country fighting and/or they're not allowed to leave. And so there's a lot of additional family members that some of these providers are taking on.
We are seeing, in our team, they're still responding to needs. You see them very active on social media, on Facebook, posting good prevention things, telling people how to take care of themselves. They have a great network online of support that they're providing, and I would say one of the biggest roles that our team has played is making sure that we check in with these providers to say, “I know you want to work all the time, but you're still in a place of you just left. You've lost everything. You haven't had time to process what just happened to you.” So even though oftentimes for all of us, it's our natural instinct to dive back into work or help each other in this situation, we're also very mindful of, how can we make sure we help these providers take care of themselves and take the time that they need? As you said, Kim, they just went through horrific things. Even if they're somewhere safe now, that journey out, as we know, has been awful for so many.
Mills: So are there stages to care in a situation like this? I think you alluded to that, that you start with mental health first aid, and you also deal with getting people the basics that they need to survive. But then what?
Murray: Right. So, of course, in wars and humanitarian, everything is basic needs, medical supplies, things like that. We want to address all of that first, and the real—anytime mental health would come into play there would be psychological first aid, which is really just about asking what they need for basic support, trying to elevate who do they have to support them. Who can you call? How are you connected with them? What do you need to get connected with them? So it's a wonderful prevention tool and a very supportive intervention.
From there, well, one of the things we've done in our global work is think about different stages of treatment, and so there's a lot of great prevention work that's still very evidence based, for example, these one-session things that are still evidence based. They're sessions, but you're teaching people a skill that they can use in the future. That might be a next stage. So, for example, in psychology, we have an evidence-based CBT tool called “cognitive coping,” which is just a fancy way of sort of saying we learn to think about things differently or use different self-talk, which can really affect our emotions.
So, for example, instead of constantly saying, “My life is over. Everything's changed. I'm never going to get back. I'm never going to learn about my family.” Those thoughts, if you say them to yourself all day long, they're not going to help you. So in a situation where you can't change the context right now, one of the most powerful tools we have as individuals is to change the way that we think about it. Now, that doesn't mean your thoughts become ridiculously positive. Right? We're not saying you're thinking, “Oh. Everything's great,” but a minor change to that thought. So, for example, “I have lost so much, but at least my children are safe with me.”
Even that little change gives our brains just an amazing ability to have an impact on our feelings, change the chemicals that are going around. There's so much great evidence that really can move you towards a more helpful, positive demeanor, if nothing else, even just to help your brain get a little bit more healthy so that you can start problem solving, which we know a lot of people are having to do constantly. So some of those types of short, skill-based, but yet very scientifically strong interventions can be really helpful as very short, helpful programs.
From there, I think there's a couple things I would say. One is you really need to start looking at very short assessments that can help triage. That's one of the biggest things in disaster and humanitarian. You also don't want to send everyone to mental healthcare. Not everyone will need it. It's hard to imagine, but people are amazingly resilient. So there's a lot of who will go through horrific experiences and actually be okay. And so it's really important to think about mental healthcare not only in the context of serving people, but serving them in correctly triaging to the appropriate service. And so someone might just need a little tweak, a little help. Maybe they just need more psychological first aid, and then these short assessments can also really say, “Wow. You're really struggling a little bit more. We'd like to send you to what we would consider more of a full treatment.”
Mills: So you mentioned children a moment ago, and many of the refugees and other victims of the war in Ukraine are kids. I saw an estimate that the war has displaced more than half of Ukraine's children. What do we know about the long-term mental health effects of experiencing war as a child?
Murray: Yes. It's awful to see what's happening with children. We know that with children, just like adults, the impact of war can be devastating. Some reactions, again, include behavioral problems, depression, anxiety, post-traumatic stress disorder. Often, in kids, problems are presented that look more behavioral, even like something attention-deficit-hyperactivity-like. Sometimes, it's functional impairment. Big disruptions and eating and sleep can happen. In wars, there tends to be a much greater number of children affected by mental health rather than the general population.
I should also add, though, again, children are amazingly resilient. I think one of the challenges we often have is that people see a war, and they assume everyone's going to have PTSD. Science tells us that is incorrect. We know that kids also can be resilient. One of the best things to do for kids, again, is make sure those parents are healthier, or as healthy as they can be, because that's a huge preventative factor for kids, them feeling safe and connected, and then just some of that prevention work for kids, because, again, kids are so resilient, and then really identifying what children are really having ongoing problems based on the war.
Mills: Now, you and your colleagues have been working in Ukraine since about 2015, right?
Murray: Correct.
Mills: What took you to Ukraine at that point, and then the program, what's it like that you've been running in Ukraine all of these years?
Murray: Yeah. So USAID Victims of Torture Fund has been providing resources for us to work in Ukraine for about eight years, really responding to the ongoing war in the East, and so we had a couple stages in this. One, we always go into a new setting where we haven't worked, and we try to do some qualitative work to understand what does the local population say are the biggest problems and maybe the holes in services. As many of you likely know, Ukraine is a very educated country. They have a lot of psychologists and mental health professionals, so that qualitative look is really important to understand what services already exist. Let's not bring services that aren't needed. Where are the areas that need help?
Then, USAID supported us to make sure we had some valid tools to assess and triage. That was one of the missing pieces and a very practical tool. So for those of you that are psychologists out there, sometimes, we can spend hours and hours doing assessments that are really nice and rigorous. In the field, we really want to make sure that we have something that's practical, usable, and quick, but also very valid and just as strong, and so USAID supported us to do that.
Our third big project there was to actually run a trial to understand if CETA, which is the Common Elements Treatment Approach, is more or less effective whether it's given at its normal length versus a shortened version. So we were testing, could you give a five session version of CETA, and what was the differential effectiveness to the average, which is around eight? So we did that evaluation, and then, the last few years, what we've been really doing is working on scaling, sustainability. So we've built supervisors and trainers of the CETA program, the CETA system of care. So they understand assessment. They understand triage. They understand implementation. They understand all the different levels of the CETA system of care.
Then, finally, what we did the last year or so is we've been finishing a separate study on these single sessions that I mentioned before. So what does it look like, for example, if we pull people in via a single session, especially those that are more hesitant to engage in mental health care, pull them in for a single session, get them oriented, diffuse some negative aspects that might be out there, negative opinions of psychological treatment, and then triage and refer for those that need additional help?
Mills: So you're the co-developer of CETA, the Common Elements Treatment Approach, which, as I understand it, is a, it's a blueprint for using evidence-based techniques to provide mental healthcare internationally. Can you talk a little bit about how it was developed and the basic elements, and I know it's being deployed in many places, not only in Ukraine.
Murray: Yes. Absolutely. We talk about CETA as really a system of care where we really want to start with understanding at really solid implementation science, which then goes to assessment and triage and all the different levels of treatment. The reason we started focused on developing the CETA system of care was that in our global work, as well as domestic work, we realized some problems. One of those problems is that we tend to address problems in silos. So someone will be treated for depression, and usually a psychologist specializes in one area or another. So if you know an evidence-based protocol for trauma, you don't know how to treat anxiety necessarily. You don't know how to treat substance use, et cetera. So that's one of the challenges we found.
A second challenge we found was that assessments were very long and just couldn't be done in a lot of these low-resource settings. Although in high-resource settings, they cost us a lot of money anyway. So we sort of noticed that as a problem that we wanted to fix. So we wanted to address multiple problems. We wanted to come up with an assessment that addressed multiple problems, but in a way that was just as strong. Then, we also wanted to create a treatment that could be age-agnostic. So the other silo we really figured out was you're either trained to treat children, sometimes even specialize in just adolescents or adults, and we found that that was a challenge.
The fourth one that I'll just mention is we found that treatment care is rarely a system. It's either you're a full-fledged treatment or you're a separate prevention, and nothing really flowed together. So recipients of mental healthcare have to sort of bounce around different organizations and understand, and there's no real connection of triage through the different levels of severity of need. As we all know, as humans, we sort of fluctuate between those needs throughout our life. Right? Sometimes, we're doing good. Sometimes, we need a little help. Sometimes, we need a lot of help, and then we fluctuate back. So we developed CETA really to address those areas, where we said, “This is what we see as scalable and sustainable mental health system of care.” Over the past 20 years, we've been very systematically studying different parts of this all over the world, in both low, middle, and high-income settings.
Mills: Part of this involves training laypeople. Is that right? Why would you be training laypeople? Why is that an important facet of what it is that you're doing?
Murray: Yeah. Well, in many of the contexts we work in, low and middle-income countries, there are no mental-health-trained providers. So that's a little different in Ukraine, but in most of the world, that is the case. Global mental health as a field has actually taken on what the World Health Organization calls task shifting, which is treating—using psychological programs and treatments and training lay providers to deliver those. So that happens with a lot of treatments. It's not just CETA. That's been a movement in the global mental health arena, and the reason that's an important, Kim, is there was no workforce in a lot of these places. So there was often no choice.
I will say, though, that a second reason, and one that I think is equally as powerful, is there's an engagement challenge with mental healthcare. There's so much stigma. There's a real distance, often, between those that are providers and maybe the community they're trying to help, and there's often trust issues. And so what we found is by training lay providers who were part of the community we wanted to treat, you just got rid of all that. There was no stigma. There was automatic trust. I will tell you, in Ukraine specifically, one of the populations we worked with a lot was veterans, and those veterans were much better found, addressed, treated by fellow veterans.
I think we know that across most of the world, including the United States. And so what our research, as well as so many others in the global mental health space, has shown is that lay providers can be taught evidence-based treatments, perform them very well with fidelity, and get very good results. I think that's a little bit controversial in countries where there are providers, because we don't want to take those jobs away. And so in Ukraine, we did train some lay providers in some aspects, but we also made sure that we were utilizing their existing mental health providers that were trained and had degrees.
Mills: Yeah. So Ukraine has endured great upheaval through history and certainly going back to the early 20th century, right, when the Bolsheviks invaded. Then, I mean, that's continued pretty much until this day, even after the demise of the Soviet Union. Now, since you've worked in Ukraine for the last eight or so years, what can you say about the collective mindset of a nation that has been a longtime target of one of its closest neighbors?
Murray: Wow. That's an amazing question, and I, gosh, and I love history. I-
Mills: I mean, they've had the Russians breathing down their necks for centuries.
Murray: Absolutely, as have many other countries in that area.
Mills: Yeah.
Murray: I'm not sure I'm the best to speak to this, but I can speak to the qualitative work and what so many of our colleagues have said in country. There is definitely a lot of trust issues, and there's a lot of clarification of sides within the country. So just as an example, there was often a question of, “Do we translate the tool into Russian or Ukrainian?” Right? Because a lot of people come from the area of Russia, have family in Russia. The older generations may speak Russian better than they speak Ukrainian, or more comfortable with them. So it's a real challenge. It's something that you're constantly working with and managing.
I think feelings run really deep about that context. We heard a lot of just fatigue in the eight years that we worked there, that this war was just ongoing. Like I said, we worked with both veterans and internally-displaced persons, and a lot of the world didn't realize this was going on for a long time. There's already a lot of displaced people that had their homes and just their place of life taken away from them. And so I think there's a lot of anger and frustration. It's such a good question. I can only imagine how challenging it is for so many of them, and sure, for sure worse right now.
Mills: So, Dr. Murray, you were quoted in a recent Washington Post story about how people around the world, including here in the US, are providing remote mental health services to Ukrainians. How has the availability of remote or virtual services changed the kind of work that mental health providers can do during a war or another natural disaster?
Murray: Wow. The advances in technology, in our ability to deliver mental health care via technology has really been a game changer. We actually started studying this quite a few years before COVID hit, but when COVID hit the world, it propelled that at a speed and a rate of development that was awesome. And so we were really able to learn a lot about who's able to deliver technology, what are the pros and cons, how do we handle safety situations? So, again, for mental health providers out there, it's nerve-wracking to be on the phone or maybe even on video with someone, and then they say they want to kill themselves. How does that work with technology? Maybe a phone drops. We actually did a study with Syrian refugees on the border where we couldn't reach them, delivering technology-based interventions.
We instituted this in Ukraine. So we were very well-aware of how to use different apps, what apps worked well in different areas. We created completely separate manuals for, how do you coach a provider to check in in different ways, especially if you don't have video. Right? There's a need to just say, “Where are you? How are you? Who's in front of you? What's around you? Are you still with me?” especially with kids, who we all know struggle with attention span sometime. So we have learned just so much about it, and I do think, in this context, what's unique about this war and disaster is that we're not seeing all their refugees gather in refugee camps like we often do globally. They're moving, and they're very spread out already.
And so that's a real difference in a humanitarian response, because they're not all in one area. And so technology is going to be incredibly needed in responding to this, because they're not all in one place. They are all over, and we've got to be able to find services in their local language, ideally, and ideally, someone who understands their culture and some of that history and context, which, of course, comes up in the delivery of mental health services. So it has really advanced a lot.
The other thing I will say is that USAID has been wonderfully supportive in also funding us to develop and refine a way to train providers from afar. That is huge. It's one thing to deliver services, but to be able to train providers using technology from afar, where you don't need to be there in person, is a huge advance and something that we're starting to use a lot with, for example, Ukrainian speakers all over the world who just want to help and give some of their time to be able to respond.
Mills: So that raises another question, and I think this will be our final question. So as members of a helping profession, psychologists are often looking for ways to use their skills to help during major disasters, but not every psychologist is equipped to do this. As you've mentioned, there are language barriers. Sometimes, there are cultural barriers. So what do you say to psychologists and other mental health providers who really want to do something, especially when the disaster is in another country?
Murray: Yeah. First of all, thank you. I love how care providers are just right there, ready to help, even though I'm sure they're very busy themselves. So I just love that spirit. I will say that, in general, it's not good to go to places. That's one of the things that we talk a lot in global mental health. They actually have names for this negative group—negative ways of describing groups that sort of drop in and then fly out. Not very helpful. Honestly, in a context like this, one of the best things to do is to just find someone who's maybe doing this work that needs to be supported financially. I know there's a lot of providers who are willing to do this, but, of course, they have no jobs. Their organizations folded in. They're living in a different area. And so that's one way to help.
People have been very responsive, also, all over the world. We put out a call to say, "Would you be available? We could train you in the CETA system of care to respond,” and I think that's a good way to help, in this context, better if you speak Ukrainian. But the other thing that we've actually put a call out for that I think I see a lot of need in humanitarian is being the voice on the other end that helps supervisors in these countries. So oftentimes, supervisors often, or higher-level, higher-educated folks might speak English.
So that's an opportunity for English speakers, for example, to be the one that that supervisor can come to. Because that's often a lonely position. You're holding all that trauma and all that stuff of all your providers, and all your providers have multiple clients. So that's a good place for people who are distant to come in with that level of need and support for them.
Just one more comment, Kim. I so appreciate that you mentioned the cultural aspect, because although we want to help, there are such deep cultural and historical aspects that you brought up earlier in the interview, also, that if you don't understand, it can be hard to support and to adequately respond. So I would just say look for opportunities where you feel like you might be needed. I know there's a lot of people asking for donations just to be able to continue their work since this happens to be a country that does have a lot of professionals already.
Mills: Well, Dr. Murray, I want to thank you for joining me, and I also want to thank you for the very important work that you are doing in Ukraine and elsewhere.
Murray: Wonderful to be here. Thanks so much, Kim.
Mills: For more information on how mental health providers are helping in Ukraine, go to APA's website at www.apa.org. You can find previous episodes of Speaking of Psychology there and also at speakingofpsychology.org or on Apple, Stitcher, or wherever you get your podcasts. If you're listening on Apple, please leave us a review. If you have comments or ideas for future podcasts, you can email us at speakingofpsychology@apa.org. Speaking of Psychology is produced by Lea Winerman. Our sound editor is Chris Condayan. Thank you for listening.
For the American Psychological Association, I'm Kim Mills.
Laura Murray, PhD, is a senior scientist at Johns Hopkins University, School of Public Health in the department of mental health and international health. She and her colleagues have been working in Ukraine since 2015. Murray, a clinical psychologist by training, is a leader in global mental health having conducted and led programs and studies in multiple low- and middle-income countries. Her focus has been on studying the effectiveness, acceptability, scalability, and teaching process of a wide range of evidence-based treatments for mental and behavioral problems in children, adolescents, and adults. Murray is co-developer of the 
