Healing the Mind

Introduction
Around 7.6 million Ukrainians have had to flee their country. Since the start of the war, a total of 83,000 of them arrived in the Netherlands. According to the Dutch government, they will number 100,000 by the end of 2022. The vast majority are women, often accompanied by their children. They have been uprooted from their lives and separated from their loved ones. They are feeling the impact of witnessing the war. According to UNHCR, around 22% of them are suffering consequences in terms of their mental health (https://www.who.int/news-room/fact-sheets/detail/mental-health-in-emergencies). The symptoms of their suffering range from nightmares and depression to PTSD, bipolar complaints and outright schizophrenia.
In 2016, a Ukrainian survey indicated that 74% of the population suffering from mental health problems did not receive the care they needed. From this statistic we may conclude that access to mental health treatment was already a nationwide issue even before the start of the war. Statistics show that over 16,000 Ukrainians who managed to reach the Netherlands are
affected by mental health problems. As for the Dutch population as a whole, according to GGZonline.nu, around two million people are suffering from a mental disorder. The 100,000 of them who are wait-listed for treatment may have to wait up to 12 months. For Ukrainians, there are further constraints. A major one is the language barrier. Since the majority of the refugees speak only Ukrainian or Russian, they are at risk of never receiving the help they need. In such cases their condition is likely to deteriorate, making it impossible for them to integrate in Dutch society and opening the way to becoming suicidal. Another limitation is the lack of professionals able to provide mental healthcare to people from war zones.

The current project aims to help Ukrainian refugees cope with the challenges facing them, such as emotional suffering, stress and trauma. If our counsellors identify more severe conditions, clients will be referred to specialized Dutch healthcare for emergency treatment.

Our procedure
We aim to provide no-threshold access to high quality mental healthcare which is culturally sensitive and caters for the specific needs of Ukrainian refugees in the Netherlands. The target population includes:
● Refugees experiencing severe mental health problems, including PTSD, psychotic symptoms and suicidal tendencies
● Refugees with mild and moderate mental health problems (e.g. anxiety, depression)
● Refugees not currently diagnosed with mental health issues but in need of support to build mental resilience

A package of services will be delivered that is tailored to meet the individual care needs and to facilitate access to at-home care. Since the refugees are geographically spread across the country, services will often be provided remotely through telehealth. These services include:
1. In-person individual and group counselling by Ukrainian mental healthcare specialists who are refugees themselves and currently living in the Netherlands.

2. Remote counselling and psychotherapy (through telecare) delivered by Ukrainian mental healthcare specialists and by licensed, fully trained therapists from various other European countries, who are fully conversant in Ukrainian and English. Given the number of available professionals, there is a limit to what the Ukrainian specialists can provide. Therefore, we will provide mental healthcare by therapists residing in culturally similar countries. They will be trained by us, also in emergency contexts. This approach offers the opportunity to scale up the project to meet current needs. To improve efficiency, individual counselling and psychotherapy will be blended with evidence-based self-administered e-health interventions, which will be prescribed and supervised by specialists.
3. Intensive group and individual supervision of the mental health professionals. This will be delivered by team members specialized in training and supervision at scale. Individual supervision and consultation of people in urgent need of help (e.g. cases of psychosis and risk of suicide) is also included.
4. A system of referral for clients who urgently need specialized mental healthcare, through the EUCOMS network (https://eucoms.net/) and in partnership with Dutch mental healthcare providers. Concretely, this implies establishing a referral pathway to acute inpatient services, if and where needed, for suicidal people and those in mental health crisis, including psychosis.
5. The use of state-of-the-art technology designed for cases of anomie. Anomie is a condition of instability resulting from a breakdown of standards and values, resulting in this case from rapid change. VR anomie software (www.anomie.digital) for in-person therapy enables users to express themselves without words whilst simultaneously giving therapists
and coaches customizable tools to guide or assist during remote or in-person sessions. Clients have agency; they can draw, paint, bring in 3D models and role play in VR, guided by a therapist from a computer.
6. Outreach services among the Ukrainian refugee population to identify those with mental health needs who are currently under the radar, to facilitate their engagement with our specialists. Potential clients are alerted to our project through the networks we have established in the last eight months.
7. Mental resilience interventions targeting the entire Ukrainian refugee population, regardless of their mental health status. Delivery of such interventions is critical for vulnerable groups such as refugees who have fled conflict zones. Research from similar groups has shown the decades-long impact of conflict on the mental health. Investment in the mental resilience of those affected can prevent psychological issues occurring in the future.

Communication and documentation
We use our social media channels to spread information about the Healing the Mind mental health project among our audience. A web link will be included in the Google form used to sign up. Clients are also asked to fill out a short questionnaire. This will enable us to gain insight into their mental health and collect basic information about the individuals. Via Google Drive all counsellors are given access to the completed documents, so that they can evaluate potential clients and their needs. When the client has been matched with the most suitable counsellor, the latter uses email or other channels to establish contact and arrange a first meeting. All data collected from potential clients is handled to the highest privacy standard. All relevant General Data Protection Regulation (GDPR) provisions are followed. During the first meeting, counsellor and client start getting to know each other, discuss the rules and sign a contract and a waiver. On this occasion the client also fills out CBT
(Cognitive Behavioural Therapy) standard questionnaires (PHQ-9, GAD-7, WHODAS-12), which will help evaluate the client’s condition. In order to track progress, a client again fills out the CBT standard questionnaires at the conclusion of the therapy cycle or pilot project. The therapists use professional techniques to stabilize the clients’ anxiety, help them find
understanding and acceptance for their mental issues and guide them through processing these. Furthermore, for affective conditions and trauma, evidence-based protocols using CBT techniques including exposure will be deployed. At the end of each session, the counsellors fill out a Session Report Form where the session is evaluated and the mood and risks until the next appointment are assessed. Most importantly, the form assesses the
impact the therapy has on the client, while also establishing whether the consultant is acting appropriately and observing treatment dynamics.
At the end of the pilot project or counselling cycle, each client fills out a Client Satisfaction Survey. The information from this survey will allow us to create user stories for the upscaling of our project. When the therapy cycle has ended, the counsellors will contact their clients to check on their psychological condition. This systematic approach will allow us to gain insights into the project’s accessibility, outcomes and perceived satisfaction, enabling us to optimize our services.

The current state of the project
We have rented and refurbished a consulting space in central Amsterdam. This location can be used for individual sessions and for group sessions of 10 to 12 people. So far, we have attracted around 40 counsellors, and for the pilot project contracts have been signed with four of them. Currently, 33 specialists are on our waiting list. We have been approached by municipalities outside Amsterdam with requests to help refugees in their
jurisdiction. There is a clear and urgent need to professionalize and scale up our services. Right now, we observe a huge unmet need for counselling among Ukrainian refugees – a need we cannot satisfy due to limited capacity.
In the next phase of the project we aim to work with Erasmus University Rotterdam (Professor Dr. Rutger Engels) and Amplio Health (Dr. Ionela Petrea) to scale up our services, including remote mental healthcare and referrals. Both have ample experience in setting up and running mental healthcare operations, in Eastern Europe and elsewhere. Dr. Petrea has,
for example, worked with displaced persons from countries in the former Soviet Union.

According to a survey we conducted, the primary mental health issues currently facing Ukrainian refugees are the following:
● Anxiety
● Unstable emotional state
● Increased tearfulness
● Panic attacks
● Insomnia
● Eating disorders.
● ADHD
● Dependencies and addictions
● Neuroses
● Problems related to children
● Burnout
● Nervous tics
● Sense of isolation and insecurity
● Sense of loneliness
● Disruption of identity
● Adaptation challenges
● Relationship issues
● Difficulties with changed family roles
● Difficulty integrating into group/society
Building the capacity of the Ukrainian mental health professionals identified from amongst the refugees will not only enable them to provide care that meets the needs of their co- national refugees but is also a worthy investment in the future of the Ukrainian mental health system. Many of these professionals are likely to return to Ukraine once circumstances allow, and their improved competencies will bring value to the mental health services. They will be
much better placed to support both post-conflict mental health efforts related to trauma care and the overall transformation of the country’s pre-war mental health system, its shift from institutional-based services to community-based recovery-oriented care.

Last but not least, we believe this project has the potential to not only expand across Europe, Canada, the USA, Australia and New Zealand, but also across various refugee-related caseloads.