‘The spectre of war was ever-present’

As a result of the Russian invasion of Ukraine in February 2022, there has been an upsurge in the number of people in Ukraine sustaining spinal cord injuries (SCIs) and traumatic brain injuries (TBIs) due to war-related injuries from bomb blasts and gunfire, for example. Due to the increase in clinical need, an international multidisciplinary humanitarian team was deployed to establish the need for specialist rehabilitation support, and to help develop a National Rehabilitation Centre.

The team included medicine, nursing, occupational therapy, physiotherapy, psychology, and interpreters. Dr Alistair Teager is a Consultant Clinical Neuropsychologist working at Manchester Centre for Clinical Neurosciences (MCCN), and he spent several months as a part of this humanitarian mission in Ukraine.

We asked him about that work.

Has your work in trauma in the UK prepared you for this?

I've been fortunate enough to work in inpatient major trauma and neurorehabilitation for a number of years, and more recently we have developed a spinal cord injury service at MCCN. I also had some experience of major incidents, having led the acute psychosocial support provided at MCCN following the Manchester Arena Attack. My clinical experience was therefore pretty decent, but applying those skills in another country, during wartime, through interpreters, was a real challenge personally and professionally.

A large part of the work was developing training for the psychologists and other MDT members at the National Rehabilitation Centre in Ukraine. I felt pretty comfortable with what needed to be delivered, as lots of it was around core psychological principles such as goal-setting, MDT-working, and motivational interviewing. But were other elements that I was less familiar with, such as sex and sexuality after SCI, and equipment procurement.

Fortunately, however, there were people such as Dr Jane Duff, Consultant Clinical Psychologist at the National Spinal Injury Centre in Stoke Mandeville, and specialist networks such as the British Psychological Society's Division of Neuropsychology (DoN) and the International Spinal Cord Society (ISCoS), that I was able to lean upon and draw support from.

What has it been like, on a personal and practical level?

I was doing two weeks away in Ukraine, and two weeks back in my normal job, but with a fair amount of juggling both at the same time. It takes a good two or three days to get there as you can't fly commercially in or out of Ukraine at the moment, so that was draining, and it usually took me a few days when I got back to recalibrate. To some degree, it was actually really good to continue with some aspects of work back in the UK, as connecting with my colleagues for supervision and to check-in was quite grounding.

Being able to fully experience Ukraine and its culture was great, but the spectre of war was ever-present. The army were always around, there are curfews every night, power supplies come and go, and air raid sirens go off most days, but as we were based in North West Ukraine, the sense of threat was less than if we were in areas that have been heavily targeted, or nearer the frontline, for example. My wife and parents were incredibly proud and supportive, if a concerned for my safety, but after my first trip out there in December 2022 I think they felt a bit better about it all.

What are some of the differences you've seen in terms of providing psychological support?

The most obvious is that care is being provided during an ongoing conflict; everyone in Ukraine is at risk of harm, and everyone knows someone who's fighting, been hurt, or been killed as a result of the war. In essence, the psychologists at the National Rehabilitation Centre are providing support to people who have individual traumas, but against a backdrop of collective trauma.

The vast majority of patients at the National Rehabilitation Centre are young men, and many are concerned about what their lives will look like, and how they could contribute to Ukrainian life moving forward. Displacement is also a huge issue; many of the patients and their families cannot be discharged home because where they lived is in an occupied territory, or may even have been destroyed. As such, families have moved to live on-site at the Centre, and discharges can be really tricky to plan.

Where does this work go next?

The humanitarian work in Ukraine is ongoing, with the next phase focusing on upskilling teams earlier in the patients' journeys and establishing regional rehabilitation units so that they have more consistent care across the pathway. For me, however, I have returned to my usual role in Manchester, as I could only commit to a relatively short-term contract, and I am very grateful to MCCN for loaning me out. I have felt quite blessed to have been able to contribute, but I also feel really conflicted in that I know that there is more to do.

'The war has determined who I am now'

We also heard from a colleague of Alistair's, Nadiya Rechun.

Could you tell us about your typical day working in Ukraine with people with spinal cord injuries (SCIs) and traumatic brain injuries (TBIs) as a result of the war?

I've been working as a psychologist with patients at the National Rehabilitation Centre since November 2022. My work week is from Monday to Friday, every day starts with me waking up (often to the sound of air raid sirens) and traveling to work. It takes me about an hour to get to work, and I use this time to read the news and mentally prepare myself for the day. This is because it's highly likely some terrifying news will emerge about attacks on hospitals or residential areas, or that somebody I know has been killed in action or missing, so I feel like I need to 'steel' myself before I start my job.

At 9am, my team and I go to the shift handover to understand what changes in patients have occurred overnight, usually there are more patients every day, because the war does not stop for a moment.

Together with colleagues, we set goals for the day and going forward, sometimes we discuss the future of patients whose stay in the centre is coming to an end, as defined by the by law, because many of them no longer have their own homes because they were destroyed by shelling. I divide my working time with patients into different stages: visiting, triaging requests for consultations, and planning. I visit patients in their wards, get to know those who have been hospitalised, and provide psychological support to the patients' families. I also spend time triaging referrals or requests for consultation. A lot of time is also spent trying to plan my time, as I have so little time for 20-25 patients assigned to me, who might have SCIs, TBIs, or both.

How does the war affect your work as a psychologist?

Actually, in a certain way, the war has determined who I am now. Although I received a Master's degree in psychology back in 2019, it was difficult to find a job for young professionals. Now, in the 14 months of war, the need for mental health professionals has increased significantly and our country is on the way to integrating psychological help into people's lives, because, to be honest, before working with a psychologist on mental health was not a priority for many Ukrainians.

Working as a psychologist during the war is a challenge for me, because most of my patients receive their injuries in the hot spots of Ukraine, and who have been side by side with my relatives who are now also defending our independence and life. In these conditions, supervision, interviews, and training help me maintain my integrity and professionalism. Supervision sessions, interviews with colleagues, and support groups for psychologists help to maintain their integrity and professionalism, of which there are many, thanks to the work of various international humanitarian organisations.

Are there psychological implications of the patients being mostly young men?

Definitely. After all, this is the age when a man strives for achievements in his career and family, and in general, realises his full potential. In my practice, I observe that young men who suffer from SCI, TBI, or those who lose limbs, are in a depressed psycho-emotional state, especially in the acute period, immediately after the injury. They are now faced with the question of accepting their bodies, which now works differently, looks differently. They are worried about the possibility of further sexual life, whether they will be able to satisfy their partner, be attractive for him/her. They are worried about how they can provide financially for themselves, their spouse, and how to raise children, how to self-actualise in society, whether it is possible to enjoy life now, and sometimes whether it is worth to continue living.

What have you learned, and how have services developed, in the past year?

The last year has been very fruitful in terms of learning: I continue to study counselling in the field of positive psychotherapy. I constantly attend seminars and workshops where I learn the peculiarities of working with the victims of war, the program from Dr Alistair Teager on working with patients with TBI and SCI, and the training methods of psychological assistance in case of loss of loved ones due to death, and many others. The challenge of the year was my decision to work in the hospital, because I do not have a medical education and have not worked in a medical institution before, so I had to learn many subtleties of organising the rehabilitation process.

How has the input from the international team / overseas Psychologists helped you?

The international team and, in particular, the psychologist Dr Alistair, introduced us to the experience of different countries in organising the rehabilitation process and compared it with ours. This helped us to choose the best approaches in dealing with complex traumas and combined cases from around the world, and we have already started to work by following their example.

I hope that our cooperation with the international team will not end at this stage, but will only be the start of further projects.

What needs to happen next?

We will continue to study, work, improve ourselves and the quality of rehabilitation services to our patients, because everyone, even if they have sustained a complex injury, has the right to live their happy life in a free, prosperous, mentally healthy country!