Over the past months, the world has witnessed momentous events in Ukraine. What started as a protest by students in favor of an associate agreement with the European Union, turned into a people’s uprising against an autocratic and corrupt regime. After three months of mass demonstrations at the Maidan in Kyiv, and later in cities all across Ukraine, the Ukrainians won and made the old rulers flee the country. But the revolution came at a very high cost. Thousands of demonstrators were wounded, some losing eyes or limbs, and at least one hundred activists were shot dead by riot police and snipers operating from buildings around the square. Undoubtedly, the number of dead will rise considerably, as many people are unaccounted for and there are fears dozens might have been killed and left in mass graves in the forests.
During this period, hospital services were set up at the Maidan, for a very urgent reason: wounded demonstrators who were delivered to regular medical services were abducted by riot police, beaten up and in some cases killed. For example, on February 19, riot police broke into the intensive care unit of the Emergency Hospital in Kyiv, turned off all the equipment and abducted the critically wounded demonstrators who were undergoing medical care to an unknown destination.
The Maidan medical teams, all volunteers of various ages and backgrounds, performed heroic deeds. They worked at the front line, rescuing wounded activists, while they themselves were under constant attack. In violation of all rules of engagement and conventions, riot police and snipers were specifically targeting medics. They were wounded by snipers, they were beaten, abducted or even arrested for performing their professional responsibilities. They put the Hippocratic Oath into effect and deserve our support and admiration.
Although the future of Ukraine and its relations with Russia are still unclear, and bloodshed at Maidan might be only the beginning of a long, protracted and bloody conflict, it is urgently necessary to develop a structure for trauma and bereavement care that meet a number of essential preconditions:
- Honors the contribution of those who stood and worked at Maidan during difficult hours and fulfilled their professional duties, and provides a platform to them to continue their work in this field;
- Connects trauma and bereavement services with existing mental health services and avoids a situation that services remain isolated, dependent on external donors and will permanently face issues of sustainability;
- Avoid the creation of a repetition of the old “institutional model” and focus primarily on the creation of community based services, that is ambulatory care, mobile teams, hotline(s) and only in extreme cases the possibility of clinical care in specialized settings);
- Guarantee independence from the state in case of any future conflict with authorities. Although this might sound awkward in a post-revolutionary situation, we should be realistic enough that there might be a time when victims of state violence are in need of specialized support independent from government funding.
While the work of the Maidan medical teams is now partially taken over by regular medical services, both in Ukraine and abroad, the main challenge is now to take care of those traumatized by the events. These include a number of clearly defined target groups:
- Activists who fought at the front line and who saw their buddies being wounded or killed;
- The relatives of those killed, with special attention for the children;
- The volunteers of the Maidan hospital, who saw the wounded and killed being brought in by the dozen, and who had to perform operations in hotel lobbies and churches and treat the wounded right at the battle zone;
- Members of the Internal Armed Forces and police who fought on the other side, voluntarily or under coercion, and who experienced the same traumatic events from the other side.
Our project is focused on helping those dealing with trauma and grief by providing specialized trauma care, offered by experts from the region who know the circumstances and environment, and who speak the language of those affected.
The current project is based on a collaborative effort with the following partners:
- Ukrainian Psychiatric Association, Kyiv, Ukraine
- Federation Global Initiative on Psychiatry, Hilversum, The Netherlands
Through the Federation Global Initiative on Psychiatry, expertise will be sought from one of its main partner organizations in Georgia, the Georgian Center for the Rehabilitation of Torture Victims, an organization that during its long existence worked both at the front line during military conflicts in Georgia, and with victims of torture by state institutions (demonstrators, prisoners, etc.). Their experts have both an understanding of the needs, of post-Soviet reality and know the Russian language. In addition experts will be brought in from the Global Initiative on Psychiatry-Tbilisi (GIP-Tbilisi), which has a long experience in working in this field and have among its staff experts in psychotrauma care.
The main goal of the project is to develop sufficient expertise in Ukraine in the field of psycho-traumatology to make the services in the country independent for external expertise (apart from hiring short-term experts in specific cases, which is a normal situation in any country) and to develop a conduit for the experience gathered and knowledge acquired.
Conceptually, we wish to develop a structure that is on one hand flexible enough to meet the possibilities and wishes of the volunteer staff that worked (and continues to work) at the front line (e.g. Maidan), and on the other hand allows to organize a structure that is community oriented, both professionally and economically effective, and while being linked into existing mental health care structures has sufficient independence to be able to treat those who are not accepted by governmental structures, now or in the future. This is a challenge that demands from us high flexibility, the avoidance of politicizing the situation and at the same time making use of the enormous potential that is available right now.
The structure that we are looking at consists of the following components:
- Legal/organizational: development of the appropriate package of operational instructions and decrees that form the juridical basis for specialized trauma services in Ukraine, with a guaranteed (partial) coverage from regular governmental financial sources.
- The development of a knowledge center where expertise on these issues is gathered and which acquires the possibility to train professionals from other parts in the country, with their own experts as well as foreign colleagues, develops leaflets and other necessary publications and follows up with recommendation and backing;
- The development of a crisis unit in Kyiv, that functions as a model for the rest of the country. This crisis unit should be community oriented and will probably be developed with active participation of the Maidan psychological services. However, setting up this services is not part of this project;
- The development of a SOS hotline, initially on an ad-hoc base but preferably as soon as possible as a well-organized structure with appropriate training and facilities. Also in this case the development of the service itself is not part of this project, although the necessary expertise will be provided;
- The development of adequate supervision- and intervision programs for the emergency teams, as burnout is a constant threat and human resources are extremely valuable. This program can be set up with Georgian help, and where necessary external support can be brought in.
The following target groups can be descerned:
- “Maidanovtsy”. This is an issue that is becoming urgent because the “maidanovtsy” created a totally “new life” behind the barricades and at some stage will need to return home to their original lives and families. For many this will be difficult – as well as for their families. The feeling of victory will be replaced by a sense of loss – a loss of their newly created “brotherhood” combined with the question whether they really won and whether it was worth.
- The families of those who perished. These families will need help, and special attention should be paid to the children of those who died.
- The medical teams at Maidan. Many of the volunteers at Maidan are facing burnout, yet the system of psychological support for them is very rudimentary and needs to be upgraded quickly, and special attention should be paid to their potential trauma.
- Members of the Internal Army (MVD) and of Berkut.
- IDP’s. This category very much depends on the future development. So far the number of refugees is limited to several thousand from the Crimea, but it would be wise to keep them as a potential target group.
- Mental patients who came to Maidan. This is a difficult category that is mostly an issue that mental health services in the country need to deal with. There are probably considerable numbers of persons with mental illness who were attracted to Maidan and the special atmosphere there, who found a new “social environment” or home there and who are now running into trouble as Maidan is losing its special attraction and the tension has eased.
- Society as a whole. Ukrainian society went through an extraordinary phase of nation-building, with fantastic examples of unexpected solidarity and commitment, yet at the same time the events are of course rather traumatic. One should think of how to address these issues.
Activities and Objectives
1. Knowledge Center on psychotraumatological assistance
On basis of the Maidan Psychological Service a new Association will be set up that unites professionals who are engaged in providing specialized assistance to those who have been traumatized by the events in Ukraine. Currently, the initiative group for the association consists mainly of members of the Maidan Psychological Service, but it should expand its network also to other (mental) health and social services and other parts of the country.
The association will function, in collaboration with other medical bodies in Ukraine, as a framework within which training is provided, manuals and other literature is published and disseminated, and knowledge is gathered both with regard to psycho-traumatology and with regard to the effects of the revolutionary events in Ukraine (e.g. epidemiological research or the oral history archive which is currently under development).
The Association will be supported by FGIP and the UPA and will, together with the UPA, develop the knowledge center that provides professional backup to those working in this field in Ukraine.
2. Training in psychotraumatology for selected target groups.
On basis of the Maidan Psychological Service a pilot in being set up providing specialized help to traumatized persons on a multi-disciplinary basis. Within the framework of this project the staff of the Maidan psychological service will be trained by Georgian colleagues and partners of the Federation Global Initiative on Psychiatry, and will also be trained in running an organization, fundraising and teambuilding.
Three trainings in psycho-traumatology are planned for May-June, September and November.
In organizational management the trainings will take place in May, June-July and September. In both cases there will be ongoing consultation by internet and skype.
3. Support to regular mental health care services
Part of the persons traumatized by the revolutionary events, in particular those who were attracted by Maidan because – or in spite of – mental health care problems, will turn to regular mental health care services for assistance. In particular now, when the population at Maidan is changing and an increasing percentage of those there are either people who have an unusual lifestyle, or are homeless, or have a mental health background, the call to regular mental health care services will increase. It is of importance that they are equipped with adequate understanding of the problems and needs, and are able to respond in an effective manner. To this end trainings and consultations should be carried out there as well.
Copyright: Ukrainian Psychiatric Association (Kyiv, Ukraine), Federation Global Initiative on Psychiatry (Hilversum, The Netherlands)
Image: Vasily Fedosenko / Reuters