By Roderick L. Ingram Sr.

People in countries around the world experience challenges to their health due to their nation’s unique geographic, historic, social and environmental circumstances. Traumatic events — natural disasters, massive violence, war — also have a negative impact on the well-being of many, particularly those concentrated in one place, as they are either displaced or left to grieve and deal with the uncertainties of what’s next. As constant reminders, the rough terrains and carnage have immediate and lasting effects on people, communities and entire nations.

For the health professionals within such areas, everything is compounded as they are simultaneously vital resources for community recovery and victims of the same trauma. And everyone is compromised. The collective trauma of the survivors makes it difficult for providers to care for all of the injured. For mental health providers in particular, who need to screen large populations for the possible diagnosis of post-traumatic stress disorder, the trauma seems never-ending as they treat the physically injured, friends and families of those who have lost loved ones, witnesses of the tragic events and others. And at some point, the mental health providers must find time to take care of themselves.

CARING FOR SOLDIERS, CIVILIANS AND SELF

Having traveled around the world to communities experiencing such devastation, the dilemma of providing care while coping with large-scale trauma is very familiar to Randon Welton, M.D., The Margaret Clark Morgan Chair of Psychiatry at Northeast Ohio Medical University.

Dr. Welton previously served for 24 years as a member of the United States Air Force where he reached the position of psychiatry consultant to the Air Force Surgeon General and was selected for the Department of Defense/Department of Veteran Affairs work groups to create clinical practice guidelines for PTSD and bipolar disorder.

“I was part of, and for a while led, the mental health section of the Defense Institute for Medical Operations. This is a tri-service virtual organization which provides training to military medical departments across the world,” said Dr. Welton. “In 2004 I was part of a weeklong mission to Kiev where we trained about 40 Ukrainian military medical officers on the management of combat stress and post-traumatic stress disorder. At the time the Ukrainian military medical model was highly influenced by Soviet doctrine. They had trouble generalizing the symptoms of PTSD to non-military populations. They talked about a post-Vietnam syndrome and a post-Afghanistan syndrome but did not agree, for example, that these same symptoms would be seen in a woman who had been raped. They did not use Diagnostic and Statistical Manual of Mental Disorders (DSM) — the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders — or the International Classification of Diseases (ICD) — a standardization of methods of recording and tracking instances of diagnosed disease all over the world — and did not have access to the wide variety of medications which were readily available in the West.”

And many, explained Dr. Welton, had personal experiences that ranged from serving with the Soviet military in Afghanistan to helping with the response to the Chernobyl nuclear power plant accident.

After Kiev, Dr. Welton led weeklong missions to Poland, Columbia and Estonia where he discussed the mental health response to disasters, combat stress and PTSD.

Developing workshops for mental health providers to learn to take care of themselves when they too are experiencing violence and trauma, Dr. Welton disseminated best practices to mental health providers in locations from South America to Europe.

PREPARING, ASSESSING, RESPONDING

Shortly after Russia’s invasion of Ukraine, Feb. 24, 2022, the Preparation, Assessment, Response (PAR) Foundation had connected with the Ukraine Psychological Association and the Angelia Adventist Healthcare system in Ukraine. PAR was informed that there was a need for experts on the management of extreme stress.

So, it should have come as no surprise to Dr. Welton when a colleague reached out to him on behalf of PAR, which was seeking mental health panelists.

Dr. Welton obliged.

“I became a regular participant in two-hour-long question-and-answer sessions with members of the Ukrainian Psychological Association. I was there at the request of PAR, a volunteer organization devoted to helping communities respond to the mental health consequences of disaster and mass trauma,” said Dr. Welton.

In addition to Dr. Welton, the panel included a psychologist, a chaplain and a peer-support individual — each of whom were members of the PAR Foundation with extensive experience in disaster response, especially Critical Incident Stress Management approaches.

Between 30 and 75 Ukrainian psychologists from throughout the country participated in each of the five sessions that PAR has held in 2023. Some would take the calls in their basements because of the bombings. Others would have calls dropped due to time limits and power outages. One of the psychologists provided translation services.

“We communicated one paragraph at a time which gave her the opportunity to translate what was said,” Dr. Welton noted. He added that they have since found funding for instantaneous translation, which will allow them to speak more freely in the future.

SHARING BEST PRACTICES

The sessions were recorded and made available — along with articles and handouts — to all members of the association. Dr. Welton, who leads NEOMED’s Department of Psychiatry and disseminates a variety of mental health treatment best practices through its Coordinating Centers of Excellence, provided several solutions to pivotal questions he received during the Ukrainian Psychological Association sponsored sessions.

How do you screen large populations rapidly for the possible diagnosis of PTSD?

Dr. Welton recommended use of the Primary Care PTSD Screen and the PTSD Checklist, developed by the National Center for PTSD. He discussed and provided materials for reference.

How do you help communities deal with the collective trauma of ongoing warfare?

The most widely accepted guide to managing the initial impact of collective trauma is the Psychological First Aid (PFA) manual, which is an evidence-informed modular approach to help children, adolescents, adults and families in the immediate aftermath of disaster and terrorism. In it, the goals of eight PFA core actions by mental health providers are listed:

• Contact and engagement: Respond to contacts initiated by survivors, or initiate contacts in a non-intrusive, compassionate and helpful manner.
• Safety and comfort: Prioritize immediate and ongoing physical safety as well as provide physical and emotional comfort. This includes connecting individuals with safe places to live and sleep and reliable sources of food and water.
• Stabilization (if needed): Calm and orient emotionally overwhelmed or disoriented survivors.
• Information gathering on current needs and concerns: Identify immediate physical, emotional and social needs and concerns, gather additional information from outside sources (e.g., Red Cross, government agencies), and tailor PFA interventions to meet the needs of the community members.
• Practical assistance: Offer practical help to survivors in addressing immediate needs and concerns.
• Connection with social supports: Help establish connections between survivors and their primary support persons and other sources of support, including family members, friends and community helping resources.
• Information on coping: Provide information about stress reactions and coping to reduce distress and promote adaptive functioning.
• Linkage with collaborative services: Link survivors with available services needed at the time or in the future, while focusing on immediate needs.

How do mental health providers take care of themselves when they too are experiencing violence and trauma?

Use the basic approach found in Stress Inoculation Training, which involves several steps:

• Identify the sources of stress (primary, secondary, tertiary, etc.)
• Recognize internal and physical manifestations of stress (e.g., elevated heart rate, muscle tension, abdominal pain)
• Discuss usual ways of coping with stress symptoms.
• Come up with new strategies to address stress (for example, mindfulness, delegating non-essential tasks, relaxation, visual imagery, exercise, meditation, napping or positive self-talk).
• Learn and practice new problem-solving strategies and coping skills.
• Learn to keep track of stress levels after applying these new strategies.
• Continue practicing techniques that work.

When might it be best for a provider to stop caring for patients because the provider is suffering?

Providers are often driven by an intense desire to help others and an overwhelming sense of duty, but if they are being adversely impacted by stress they may be unable to truly help others.

• This is similar to aircraft passengers being told to put on their own masks before helping others. If someone is incapacitated, they can’t help someone else and will further bog down the system.
• In addition to self-monitoring, providers should have a trusted and respected colleague who is monitoring their performance and behavior. That colleague should be given authority and permission to say “you need to take a break.” 

How can providers build up their resilience during the stress of war?

• Practice the Stress Inoculation Training techniques described previously.
• Maintain social connections with friends, family and faith communities.
• Remind themselves of the reason behind their actions. Look for meaning and significance in the work they are doing and the sacrifices they are making.

How can providers best help survivors in the immediate aftermath of combat trauma?

• Ensure that they are in as safe of a place as possible.
• Focus on connecting with a variety of medical and social supports.
• Educate about the normal emotional, physical, spiritual, social and behavioral responses to stress.
• Help them to find a space where they can examine and discuss their responses to stress.
• Offer reasonable reassurance and hope.
• Screen for those with more serious problems and connect them with providers.

But questions linger more than ever after the start of the Russian-Ukraine war. Millions have been displaced in Ukraine. And thousands have lost their lives.

At the Jan. 13, 2023 United Nations Security Council briefing, Rosemary DiCarlo, Under-Secretary-General for Political and Peacebuilding Affairs, talked about the horrific impact of the Russian Federation’s invasion, particularly on the displaced. She told the delegates that the war is leaving invisible scars and that nearly a quarter of Ukraine’s population is reportedly at risk of developing a mental health condition.

And even when wars end, they leave behind battlegrounds of mass trauma that loom large, especially when left untreated.