"When the safe place is not safe": therapists' perspectives on implementing TF-CBT during the war in Ukraine

Since the beginning of the Russian war against Ukraine in 2022, various evidence-based trauma-focused therapies have been implemented in a region that was previously structurally underserved. Despite the high demand for psychotherapeutic care, little is known about the practical implementation of these therapies under conditions of war. The aim of this qualitative study was to explore the experiences of Ukrainian therapists in delivering Trauma-focused Cognitive Behavioral Therapy (TF-CBT) for children and adolescents during the war and to identify benefits, specific challenges and necessary adaptations.

In April 2023, three focus groups were conducted with a total of seven Ukrainian therapists who were part of the "TF-CBT Ukraine" project. The focus groups were transcribed, translated into English, and analyzed using qualitative content analysis with MAXQDA.

All participants had already initiated or successfully completed TF-CBT treatments and reported positive therapeutic experiences underscoring the acceptability and perceived benefit of the intervention under highly adverse conditions. At the same time, a range of challenges was identified, including an unstable security situation, unreliable internet connections, frequent relocation of clients, and difficulties in working with parents. Therapists discuss possible reasons for this, like the parents' own psychological burden or the limited mental health literacy within the general population. Therapists described specific adaptations in their therapeutic practice to address these challenges, including adjustments to pacing, and enhanced efforts in psychoeducation and stabilization.

The findings indicate therapists perceive TF-CBT as generally feasible under conditions of war, highlighting its robustness as an evidence-based intervention in humanitarian settings. However, the results also emphasize the necessity of context-specific adaptations to address ongoing instability, structural barriers, and sociocultural factors. Beyond the Ukrainian context, these findings provide valuable implications for the implementation and scaling of trauma-focused interventions in other war- and crisis-affected regions. They further underscore the importance of sustained training, supervision, and support for therapists to ensure treatment fidelity, as well as the need to integrate mental health literacy initiatives at the community level to maximize both effectiveness and long-term sustainability.