'People have started to understand that we have a soul, that we have a psychology'

Psychology, psychotherapy and culture in Ukraine: an interview with two clinicians.

Dr Matt Wilkinson (centre): Clinical Psychologist and Society member. Asks the questions, of…

Mariana Franko (R) Psychologist and psychotherapist, Director of the Sens Psychology Centre, Lviv, Ukraine. Mariana is a practicing Cognitive Behavioural, EMDR and Gestalt therapist.

Oksana Nakonechna (L) Psychotherapist. Oksana is a practicing Emotionally-focused therapist and EMDR therapist, and is the acting chair of EMDR Ukraine.

What would you say is the attitude of people in Ukraine towards mental health?

O: We still have the stigmatisation, because we have the post-Soviet legacy. In the Soviet Union we had almost no psychotherapists at all. So psychotherapy and psychology was more absent than at present, and psychiatry was the punishment for people.

M: When you didn’t like someone, due to political reasons, you could put them into a psychiatric clinic and start to treat him, but he is not sick.

They would give them medication?

O: Yes, yes. It was a very common thing in the Soviet Union. That is why people generally are thinking that ‘psycho-’ – psychotherapy, psychology, psychiatry – they cannot differentiate it from this and are afraid of it. They think it’s strange, its dangerous, and that if you go to a specialist they will say that you are more ill than you are, that you will have to go to a hospital for all your life. But I think that it is really getting better year to year, and I think that especially in the last 4-5 years with the war, a lot of people have started to understand that we have a soul, that we have a psychology and an emotional life. People realise that they can go and get help from a psychologist or a psychotherapist.

You think that the war has actually helped to make people think that these approaches are useful?

O: Yes, you never have something absolutely bad. Always there are good things. The war is bad, but the good thing is that people are starting to understand that they can go not only to the general practitioner, but can go to a psychologist or psychotherapist.

M: Otherwise in the past they would just go to the general practitioner, they will give them medicine and that’s all. There has not always been a good connection with the family doctors, even sometimes now in Lviv.

If I was to go to a doctor now in Lviv and say that I was depressed, what would happen?

O: It depends, for example if you go to the public psychiatric hospital here, it’s probably 50/50, they may give you only medicine or they may give you medicine and psychology too – they have their own psychologists working there. We also have some small clinics run by the government that are trying to get some grants, and it is trying to be like a nice private clinic. If you go there they will provide psychotherapy. If you go privately to the psychiatrist they will typically send you also for psychotherapy.

Do you think it is different in other regions of Ukraine?

O: Yes I think that in the east of Ukraine they are more psychiatrically focused, so they will give only medicine. But here I think it is more psychotherapeutically focused. We also have some regions where we have no psychotherapists. For example in Volyn (north-western region of Ukraine), it is a problem to find a psychotherapist. But in the Lviv region it is almost too many psychotherapists!

What has your involvement been in providing mental health support to combatants from the East?

O: I am the coordinator of the crisis psychology service in Lviv. Mariana and I set up this voluntary organization together. We started in December 2013 working with injured people from Maidan, and then we worked for two years in the military hospital working with soldiers. Now we are working with soldiers privately but also not for money. They can call us and ask for help: if the work relates to shell shock then we will work with them for free.

Would that tend to be with EMDR?

M: Yes. It can be very effective. It varies but we would usually see them for around 10 sessions.

And this is often to treat the classic PTSD symptoms of nightmares, flashbacks, guilt…?

O: It depends, you can see that some people go to the emotional symptoms, some to the physical symptoms, problems with sleeping, nightmares, flashbacks, body symptoms. It depends on the person what kinds of reactions, or what channel they react through to help them.

M: The symptoms are not very different, but some may need more stabilisation, some may need more memory processing, some may need more cognitive reconstruction, or some may need more emotional support

O: But the reaction of the person to the traumatic event is pretty similar in some ways. It doesn’t matter whether it’s war, earthquake or a car crash, the reaction is plus/minus the same.

Are there any particular cultural factors in Ukraine that make people more vulnerable to mental health difficulties? Or any factors that protect people against such difficulties?

M: It’s my opinion, but I think we have problems with assertiveness. Our people are very clever, I think they are kind and we can do things that we are specifically asked to do, but we have problems with being spontaneous. We can’t assert ourselves in situations, with politics, with our laws and with our human rights

O: We do not know how to express our emotions sometimes and we even don’t know how to identify our emotions, particularly negative emotions, or our non-comfortable emotions. Especially with aggression: adults are always telling their kids ‘You have to be polite, you have to be kind’ ‘You should never say anything about your negative emotions, it’s not good'… It’s about psychological violence. 

M: Yes, moral/emotional violence

So problems with expression, with assertion, with being repressed and unable to express what you want and to get what you want?

O: Yes, yes.

And are you thinking that this causes problems at the individual level or at the political level?

O: Both. To express your rights, to fight for your territory, for your own private territory. This meta-level works in the group level.

M: We do not always understand that if it’s your freedom you should fight for it. It’s your problem. It’s not just a problem with the abuser, they are an abuser. 

So there is a problem with submitting? That you need to be stronger to resist this?

M: You need to be strong, to have more patience, but patience to fight for our rights. We can do this every day, every week, every month, every year, but it is too long and it’s hard for all the people. It’s our national problem. We have had many hundreds of years that we were not free from other countries. We have had Russia here, we have had Austria here, we have had Poland here. We have needed to be submissive to stay alive.

O: We have a lot of transgenerational trauma here, a lot.

M: We are alive but we don’t know what do do with our freedom, and we have already had it two or three times in the last 20 years but we can’t take it. We don’t know what to do with it. That is why we have the war now. It is very sad. 

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