Mental health counseling in Ukraine.

In the past two decades, some profound changes have occurred in the former Soviet Ukraine. These changes have significantly affected Ukrainian mental health counseling. This article provides a synopsis of the historical and social influences on Soviet and Ukrainian mental health services, transformations that are occurring within the mental health field of the present day Ukraine, and specific mental health issues faced by Ukrainian women and men. The conclusion shares potential implications of this information about Ukrainian mental health issues for U S. mental health counselors.

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The fall of the Soviet Union created a unique situation for people who have lived behind the Iron Curtain of the Cold War. The change in the political and economic systems of the newly formed independent states resulted in unprecedented changes in the lives of millions of people. These changes have been especially significant for the field of mental health counseling. This article provides an overview of the historical and social realities that have influenced Soviet and Ukrainian mental health counseling, changes that are occurring within the mental health field in present day Ukraine, mental health issues faced by its women and men, and the potential implications of this information for U.S. counselors.

HISTORY OF MENTAL HEALTH COUNSELING IN UKRAINE

Counseling and psychotherapy were not commonly available or sought after in Soviet Ukraine. During the Soviet era, information about mental health counseling concepts and practices was scarce. The work of famous scholars such as Pavlov and Vigotsky was known only for its connection to neuroscience and psychobiology, not for its applicability to counseling practice (Havenaar, Meijler-Iljina, van den Bout, & Melnikov, 1998).

Mental health practice, however, has a relatively long-standing tradition in the former Soviet Union. Prior to the Bolshevik Revolution of 1917, individual psychotherapy and, especially, psychoanalytically influenced counseling were highly developed in imperial Russia. Many of Freud's works were translated into Russian, and Freud himself paid great attention to Russia, which included Ukraine among its imperial colonies (Sosland, 1997). Starting in the 1930s, however, the work of Freud and other Western mental health scholars and practitioners was prohibited and considered reactionary (Havenaar et al., 1998). Books and articles on Western mental health practices were distributed only illegally, and foreign information about Western mental health ideas could only be learned through "black market" books.

During the Soviet era, individuals with mental illness were treated solely by psychiatrists within a medical setting. Mental illness was typically associated with prison-like mental institutions, where psychobiological treatments of political dissidence were common (Daw, 2002). The "paternalistic models of the State and of psychiatry" (Korinteli, 2003, p. 374) led many of the clients to see their counselors solely as figures of authority. Psychiatrists were not trusted with less clinically severe counseling help (Mokhovikov, 1994), and less severe difficulties, if treated, were addressed by medical professionals through a focus on psychosomatic concerns (Roth, 1994) as well as rational (e.g., convincing, explaining, distracting) and suggestive (e.g., hypnosis) techniques (Havenaar et al., 1998). Mental health counseling as a separate field was nearly nonexistent during the Soviet times.

Less frequently discussed in Western and scholarly literature are the indigenous or traditional forms of counseling, which have long been practiced by people of Ukraine. One of the common causes of poor mental health was believed to be a "bad or evil eye," a type of bad energy inflicted by others on a suffering individual. The treatment by medicine women and men could include listening to the person's concerns, asking for a detailed family and relationship history, scanning the person's body for bad energies, and giving advice on how to deal with particular difficulties. In addition, these indigenous healers were likely to suggest herbs, spiritual practices, and cognitive exercises, such as practicing positive affirmations or reciting a protective prayer or statement, in order to help their clients heal from a particular mental illness. During the Soviet era, seeking mental health help from these non-official and non-medically based healers was likely to be more appealing to individuals who were suspicious of the authority that psychiatrists represented. In addition, those who resided in rural rather than metropolitan areas were more likely to have access to traditional healers, rather than medical doctors. An alternative treatment based on beliefs in energies and spirituality, however, were severely restricted under the Soviet scientific atheism.

RECENT DEVELOPMENTS IN MENTAL HEALTH COUNSELING IN UKRAINE

After the fall of the Soviet Union in 1991, Ukraine and its people have experienced tremendous political, social, and economic transitions (Rubchak, 2000). These transitions have had an especially negative impact on the medical infrastructure, which prior to recent times was the primary setting for mental health services (Roth, 1994). Psychiatry, still viewed as a primary source for mental health management, has continued its focus on psychosomatic treatment of psychological difficulties; and the larger Ukrainian society has remained ambivalent toward the treatment of mental illness (Roth). For example, many people can recall the times when psychiatric counseling included forcible treatments through medications and hypnosis to control and change individuals' political views (Daw, 2002).

However, since the mid-1990s, interest in mental health counseling has been booming (Havenaar et al., 1998). Universities and colleges are increasingly offering training in mental health counseling in addition to traditional scientific psychobiology. Interest in behavior and cognitive modification therapies has decreased and new schools that emphasize psychoanalytic, Jungian, transpersonal, Gestalt, humanistic, body-focused, art, and music therapies have been highly successful (Havenaar et al.; Sosland, 1997). Havenaar and his colleagues suggested that such interest in nondirective, insight-oriented counseling methods reflects the societal movement away from what are perceived as authoritarian therapeutic traditions associated with the Soviet era.

In addition, many of the nondirective approaches are based on Western theories, which appeal to both lay and professional individuals of Ukraine because of the general Westernization influences (Havenaar et al., 1998). In metropolitan areas, an interest in counseling has been on the rise in part due to the influx of Western values through Western media. For example, magazines such as the Ladies Home Journal are now printed in Ukrainian and Russian languages with contents similar to their Western parent magazines (e.g., advice on how to chose a therapist, mental health advice, sex advice, diet advice). Mental health counseling often is presented as a new status practice: Individuals who are wealthy and properly Westernized could avail themselves of new counseling services at a growing number of counseling centers.

One of the other more uniquely Ukrainian responses to the past authoritarian models of dealing with mental health difficulties is the growing number of nongovernmental organizations that address specific mental health needs. Such issues as domestic violence, trafficking of women, and rights of individuals with severe mental illnesses are addressed by centers and organizations through individual and group counseling and active hot lines. Horne (1999) described the development of domestic violence response centers in Russia, and many such organizations are opening their doors to serve the needs of people in Ukraine.

Individuals also continue to seek mental health services from more traditional indigenous healers. Their presence has become more visible through a growing media attention to their practices. For example, most daily Ukrainian papers include sections on traditional healing methods that can help individuals deal with issues such as anxiety, depression, substance abuse, and relational concerns (e.g., divorce, family conflict, intergenerational misunderstanding).

Although it is rapidly emerging, mental health counseling in Ukraine continues to face a number of profound challenges. Training in mental health counseling is unregulated and widely varied. A person can claim to be a counselor after a several-months course in psychology as well as after a long educational process through training at universities or institutes (Daw, 2002). Programs in mental health counseling have no accreditation process, and there are no ethical statutes or regulations that govern the work of those who practice counseling. Because of this lack of standards, abuses can easily occur, and there is no mechanism for educating professionals or addressing sanctions against counselors' nonprofessional or harmful behavior. Anecdotal evidence indicates that dual and sexual relationships between therapists and their clients are not uncommon and, at times, are encouraged by the counselors themselves. Lastly, counseling help often is available only to those who can afford high fees because Ukraine, with its history of socialized free medicine, does not have a system of third-party payments for health or mental health (Daw).

MENTAL HEALTH ISSUES FACED BY UKRAINIANS

Despite the limitations of the current mental health counseling system and continued distrust of mental health counseling by the Ukrainian people, mental health counseling can provide many Ukrainians with much needed help for difficulties, which have been amplified by profound events in the recent history of Ukraine. The World Health Organization (WHO, 2004a) indicates that in 1999, Ukraine was one of the worst-placed European countries in terms of overall mortality and a negative trend in population growth. Among the world's nations, Ukraine has had a prevalence rate of mental health disorders much higher than other countries and as high as the United States, which is considered to have the highest mental illness prevalence rates in the world (WHO, 2004b). However, unlike the United States or other Western countries, Ukraine does not have an economic or social infrastructure to adequately address its people's mental health needs (WHO, 2003). For example, as highlighted earlier, Ukraine does not have a state-wide legal and medical mental health agenda that systematically deals with mental health treatment and training concerns (WHO, 2001).

Contributing to the high mortality and prevalence rate of mental illness are the increased AIDS cases associated with drug addictions, the suicide rates, and the instances of cancer due to the Chernobyl disaster (WHO, 2004a). Ukraine has the highest HIV/AIDS rate of the European countries, with 13% of its population infected with the virus (UNICEF, 2003). Suicide rates in Ukraine and neighboring Russia have consistently been the highest in the world and have especially increased among working-age men (Pridemore, 2003). Between 1988 and 1997, the years of intense political and social transitions, the suicide rates increased by 57% (Kryzhanovskaya, 1999). Suicide rates in various Ukrainian regions have been particularly associated with indexes of social disintegration (e.g., high divorce rates) (Kondrichin & Lester, 2002). The nuclear disaster in Chernobyl in 1986 also left a profound impact on the Ukrainian people. The strongest effect of its aftermath is found among children and adolescents, who are at high risk for developing cancer of the thyroid (Christiansen, 2002). Christiansen reported that severe depression and high suicidal rates among the adolescents were associated with this sharp increase in cancer instances.

Among other areas that demand the attention of mental health professionals are high divorce rates, which often are complicated by the fact that divorced couples cannot afford to move out; alcoholism and drug addictions, instances of which have doubled since the early 1990s; and unemployment and poverty (Cockerham, 2000; Daw, 2002; Pridemore, 2002). These difficulties have been particularly profound for Ukrainian women (Noonan, 1996; Rubchak, 2000). Recent figures suggest that 75% of the vast unemployed population of Ukraine are women (Pavlychko, 1997). A study by Kauppinen-Toropainen and Gruber (1993) showed that during the breakup of the Soviet Union, working women experienced an increase in women-unfriendly experiences and had high work stress and low job satisfaction.

This aggressive remasculinization of former Soviet republics, such as Ukraine and Russia, has resulted in the rise of difficulties that are unique to women and that have tremendous impact on their mental health. Among these difficulties are the increased rates of depression and suicide (Mokhovikov, 1994) and a growing prevalence of domestic violence against women (Home, 1999; Pridemore, 2002). Gondolf and Shestakov (1997) compared rates in Russia, Ukraine's closest neighbor, and the United States and found that Russian women were two and a half times more likely to be killed by their spouses than were their U.S. counterparts. Ukrainian women, who have been exposed to Western media standards of beauty, also have become at higher risk of developing disordered body image and eating behaviors (Bilukha & Utermohlen, 2002). In addition, Ukraine has now exceeded other countries in the world in the number of women who are trafficked, legally (e.g., mail order brides) and illegally, to countries around the world, and particularly to Western countries (Scholes, 1999).

The mental health needs of Ukrainian women and men are significant. Therefore, the growing mental health counseling field as well as the revival of more traditional methods of mental health healing are a welcoming trend for the Ukrainian people and the state. I believe that in spite of the difficulties faced by Ukrainians, they remain hopeful and willing to make a difference in their own and others' lives as evidenced by the increasing number of mental health training opportunities and service organizations.

CONCLUSION

Ukraine has experienced a tremendous number of difficult social and political transitions. Mental health counseling can be one of the key ways to help Ukrainian people address the profound impact of these transitions on their personal lives. Western models of counseling, especially those that focus on nondirective and creative approaches, have been welcomed by many enthusiastic mental health practitioners in Ukraine. U.S. and Western mental health counseling also can serve as a model to the growing Ukrainian field of counseling in the area of establishing standards for education and ethical/professional behavior.

On the other side, U.S. mental health counselors who are learning about the Ukrainian mental health issues can gain a greater understanding of some of the global developments in their field. This understanding can aid them, for example, in working with an increasing number of immigrants from Ukraine and the former Soviet Union in the United States. In addition, it can enrich mental health counselors' grasp of the interactions of the sociopolitical and personal spheres of human lives and their impact on the mental health of clients. Also, political and cultural transitions in the United States itself (e.g., terrorist acts or military operations) can produce changes in the mental health and well-being of the U.S. people as has been experienced by Ukrainians.

Lastly, traditional methods, which are more common in non-Western countries such as Ukraine, warrant greater exploration among the Western mental health counselors, especially in their work with the growing diverse population of the United States. These alternative methods may include utilization of spiritual, herbal, and folk wisdom methods rather than solely relying on medical models. Thus, the fall of the Iron Curtain can provide both American and Ukrainian professionals with a chance to learn and to exchange ideas about ways to serve the mental health needs of people who live in far-apart places of the world.

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Oksana Yakushko, Ph.D, is an assistant professor at the University of Nebraska-Lincoln. E-mail: [e-mail]