“When the Safe Place Is Not Safe”: Therapists’ Perspectives on Implementing TF-CBT During the War in Ukraine

“When the Safe Place Is Not Safe”: Therapists’ Perspectives on Implementing TF-CBT During the War in Ukraine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “When the Safe Place Is Not Safe”: Therapists’ Perspectives on Implementing TF-CBT During the War in Ukraine Maike Garbade, Mariia Hrynova, Cedric Sachser, Elisa Pfeiffer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9569619/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background: 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. Method: 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. Results: 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. Conclusion: 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. Trauma Children PTSD Ukraine War TF-CBT ongoing war trauma-focused treatment Introduction Wars and conflicts pose a high risk to the mental health of affected populations worldwide (Carpiniello, 2023 ). The ongoing large-scale Russian invasion of Ukraine has deprived millions of children and adolescents not only of their safety but also of their psychological stability. The mental health burden among Ukrainian children and adolescents has already been documented in several studies with rates of post-traumatic stress symptoms (PTSS) between 12.6% to 70% (Goto et al., 2024 ; Martsenkovskyi et al., 2024 ; Pfeiffer et al., 2024 ) and 32% screened positive for moderate to severe depression, and 17.9% for moderate to severe anxiety (Goto et al., 2024 ). Therefore, providing effective mental health care support is of central importance in order to reduce the mental health burden of traumatized children and adolescents in Ukraine. Until March 2022, no trauma-focused evidence-based treatments for children and adolescents had been systematically implemented and evaluated in Ukraine (Goto et al., 2023 ; Hook et al., 2021 ). Therapists lacked of knowledge about existing treatments (Hook et al., 2021 ). An internationally recognized and evidence-based method for treating post-traumatic stress disorder (PTSD) in children and adolescents is “Trauma-Focused Cognitive Behavioral Therapy” (TF-CBT) (Cohen et al., 2016 ). TF-CBT has already been successfully applied and scientifically evaluated in many contexts and countries across the globe, including low- and middle-income countries or conflict-affected populations (Thielemann et al., 2022 ; Thomas et al., 2022 ). Particularly in work with conflict-affected populations, meta-analyses identified TF-CBT as the most effective treatment for complex trauma, demonstrating superior outcomes compared to other therapeutic approaches or larger evidence base (Lewey et al., 2018 ).Cohen et al.(2011) have proposed several strategies how to apply TF-CBT for youth who experience ongoing trauma, nevertheless, there is currently very limited empirical knowledge about whether and how TF-CBT can be applied under the conditions of an ongoing war. Therefore, the online-based training program “TF-CBT Ukraine” was developed and has been implemented in Ukraine since 2022 (Pfeiffer et al., 2023 ). The aim of the program was to train Ukrainian therapists in TF-CBT and thereby make TF-CBT available to potentially traumatized children and adolescents in Ukraine. In total, N = 138 therapists participated in the program and n = 62 were certified as TF-CBT therapists (Pfeiffer et al., 2025 ). The systematic evaluation of the training program demonstrated high participation rates, positive satisfaction ratings and positive outcomes at both the therapist and patient levels (Pfeiffer et al., 2025 ). So far, the implementation of TF-CBT in Ukraine has primarily been documented through quantitative data and qualitative findings remain limited. Nevertheless, the perspective of therapists is particularly important, as it can provide essential insights for the planning of future implementation programs, not only in Ukraine but also in other war and crisis regions worldwide. Qualitative investigations can contribute to a better understanding of how the war context affects both training and treatment processes. Hence, this study aims at examining the following research questions via a qualitative study design (focus groups): Which specific challenges in implementing TF-CBT do Ukrainian mental health care professionals encounter during the ongoing war? How do the therapists describe adapting TF-CBT to the specific contextual demands of the war setting? How do the therapists perceive the training program in supporting the implementation of TF-CBT under these circumstances? This study aims not only to make an important contribution to the understanding and further development of trauma-focused therapy measures in crisis regions, especially in Ukraine, but also to specifically give a voice to those who provide psychotherapeutic care and support to traumatized children and adolescents under war conditions. Methods This study is part of the project 'TF-CBT Ukraine' (Pfeiffer et al., 2023 ), in which 138 Ukrainian therapists participated in a large training program on TF-CBT between 2022 and 2024 ((Kostova et al., 2025 ; Pfeiffer et al., 2023 ; Pfeiffer et al., 2025 ; Pfeiffer et al., 2024 ). The project received ethical approval by Ulm University in Germany (Number: C1/Sta) and the Zhytomyr Ivan Franko State University (Number: 9–08072022) in Ukraine. Trauma-Focused Cognitive Behavioral Therapy The evidence-based trauma-focused treatment TF-CBT consists of nine components summarized by the acronym PRACTICE (Cohen et al., 2016 ). These include (1) psychoeducation and parenting skills (P), relaxation (R), affective modulation (A), cognitive coping (C), trauma narrative (T), in vivo exposure (I), conjoint parent–child sessions (C) and enhancing safety and development (E). The authors of the treatment approach recommend a minimum of eight sessions to ensure that all aspects of the manual are adequately addressed. The involvement of caregivers constitutes an essential component of TF-CBT; according to Cohen et al. ( 2016 ), caregivers should participate in all sessions. Each session lasts 90 minutes, with 45 minutes allocated respectively to the child/adolescent and the caregiver. Training-Program “TF-CBT Ukraine” Within the framework of the training program “TF-CBT Ukraine,” more than 130 Ukrainian therapists were trained in TF-CBT between 2022–2026. This online-based training program comprised the following mandatory components: (1) self-study of the TF-CBT manual and/or completion of the web-based training; (2) participation in a three-day online training; (3) participation in at least 10 monthly supervision sessions over the course of one year; and (4) provision of TF-CBT treatment to at least three children or adolescents from Ukraine. Upon successful completion of all training components, participants received their official TF-CBT therapist certification. In addition, optional workshops were offered on the following topics: traumatic grief, trauma assessment, related measurements in the field of trauma treatment, caregiver involvement, strategies for implementing TF-CBT during ongoing trauma exposure, sexual development and sexually problematic behavior in children and adolescents, treatment of depression in the context of trauma, and suicidality. Furthermore, all therapists had the opportunity to participate in the PRACTICE Skills Course aimed at enhancing their personal and professional well-being (Pollio et al., 2025 ). All program components were delivered by certified international TF-CBT trainers or, in the case of the optional workshops, by international experts. Since August 2022, all training content has been simultaneously translated into Ukrainian. In addition, a wide range of therapeutic materials were translated and made available to participants. For a more detailed description of the Training program, please see Pfeiffer et al. ( 2023 ). Recruitment and participants In March 2023, a total of N = 28 Ukrainian therapists who were enrolled in the project “TF-CBT Ukraine” were invited via email by the study team to participate in a focus group to share their experiences in implementing TF-CBT with Ukrainian children and adolescents. This invitation was sent exclusively to therapists who had previously provided TF-CBT treatment to children during the project and were recommended by the respective trainers and supervisors. Trainers were asked to identify potential participants who had demonstrated consistent engagement and active involvement in the project's activities. Of those invited, n = 13 (46%) therapists agreed to participate. All participants provided informed consent for study participation, video recording, and the anonymized analysis of the focus group data. Of the therapists who registered, a total of n = 7 (100% female) ultimately participated in the focus groups. Of those, six were Psychologists and one Psychiatrist. At the start of the training program, they were located in 7 different cities in Ukraine (Kyiv, Dnipro, Mokolaiv, Zaporizhzhia, Lutsk, Lwiw and Schytomyr). Data collection In alignment with the research questions, a semi-structured interview guide comprising open-ended questions was developed (see ESM1). The formulation of the questions was informed by findings from the above presented previous research findings and the authors’ expertise in the project management of the "TF-CBT Ukraine" project (Pfeiffer et al., 2023 ). In this context, not only were the authors’ experiences gained through direct project work with the participants taken into account, but also the written and oral feedback from participants of “TF-CBT Ukraine,” as well as the input provided by the international trainers. To ensure cultural appropriateness, the interview guide was reviewed by MH, a Ukrainian psychologist residing in Germany and a member of the research team. While four focus groups were initially planned, only three were conducted due to organizational constraints. However, prior research suggests that two to three focus groups are typically sufficient to identify approximately 80% of relevant themes (Guest et al., 2017 ). Therefore, the number of focus groups conducted is considered adequate for addressing the present research questions. All three focus groups took place in April 2023. In Focus group 1, only one therapist participated, in Focus group 2 and 3 there were 3 therapists participating in each group. Each focus group was conducted online and facilitated in Ukrainian by MH, an Ukrainian female psychologist and researcher, who was also in training of TF-CBT. All sessions were video recorded. Each focus group lasted up to 130 minutes ( M = 111 minutes, SD = 30,92; Range 75–130 minutes). Only the moderator and the participants were present during the focus groups. At the beginning of each session, the moderator and participants introduced themselves. The moderator then provided an overview of the focus group structure before initiating the discussion with the first question. Throughout the session, the moderator actively encouraged participation from all group members to ensure a balanced and inclusive discussion. Data analysis The data were transcribed and anonymized by MH, a Ukrainian native speaker and translated into English by professional Ukrainian interpreters who are familiar with TF-CBT. The data was analyzed according to Kuckartz and Rädiker ( 2022 ) by two authors (MG and a research assistant (VP)), one of whom (MG) holds a master degree in intercultural psychology and migration studies and the research assistant is currently finishing her master studies in clinical psychology. After an initial familiarization with the content of the transcripts, the coding process combined inductive and deductive approaches, supplemented by analytical memos to discuss unclear expressions. Based on the interview guideline, MG developed a preliminary codebook from all three focus groups, which was refined through ongoing analysis with input from VP, reaching consensus on code after review. Discrepancies in coding were discussed and resolved through consensus within the research team. In cases of divergent interpretations, the respective passages were re-examined in their original context until agreement was reached. Negative or deviant cases were systematically identified and analyzed in order to refine the coding framework and to ensure that the final code list adequately captured variations and contradictions within the data. The resulting defined code list was analyzed using MAXQDA 24. Codes that were mentioned only once were grouped under the code “other”. Results 1. Experience in implementing TF-CBT in Ukraine None of the therapists had to actively recruit patients themselves. Instead, existing networks were utilized, such as contacts with local social services, other therapists, or institutions like Non-Governmental Organisations, juvenile criminal police, or churches, which referred patients to the therapists. Nevertheless, the participating therapists mentioned that there is a substantial unmet need for therapy among children and adolescents from Ukraine, many of whom have not yet received treatment. Some therapists previously had little experience in conducting psychotherapy with children and adolescents, as they had primarily worked with adult clients. Since working with children requires a different approach than with adults, various adjustments were made, such as allowing children to bring toys or pets to therapy sessions, incorporating movement breaks during sessions, or using creative methods like drawing instead of relying solely on verbal narration of experiences. ID 1.1. stated: “ During our sessions, I also allow children to get up and move. I say, ‘It’s been fifteen minutes now. Let's jump around.’ They love it. Body activation is a must for children. And then, “Can I show you a break dance?” – “Okay”. Why not give a child two minutes? (Position 1.117)“. All therapists reported subjective improvements in patients' symptoms, which became particularly evident through feedback from parents to therapists. Improvements in sleep, renewed participation in daily activities such as attendance at school or participation in hobbies, shared meals with the family, and increased social contact were frequently mentioned indicators of symptom improvement: “Back to this traumatized boy, we are already reaching the end of our therapy, and his mother wrote a very nice message to me last week saying that her child had been suffering for a year, and now he could finally sleep. This is the first month that he has been sleeping through the night. Before that he had disturbing dreams and couldn't fall asleep.” (ID 2.1, Position 2.163). However, therapist ID 1.1 also reported that there were some of her patients whose symptoms became more severe following exposure than they had been before (Position 1.252). TF-CBT was conducted both in-person (7/7 therapists) and online (6/7 therapists), depending on the professional circumstances of the therapists and the geographical locations of the patients. Therapists clearly expressed a preference for in-person sessions, as they allowed for a more accurate response to patients' physical reactions and were not affected by poor internet connectivity, which could otherwise disrupt the flow of a therapy session. Nevertheless, therapists also acknowledged the benefits of online therapy, as it enabled access to patients located in other countries or regions remote areas. As one therapist put it, “ it's better to do it [online] than not to do it (ID 3.2, Pos. 3.196)”. Furthermore, the children were according to the therapists already familiar with the online format due to the COVID-19 pandemic, which facilitated the online TF-CBT implementation. From the therapists’ perspective, however, ID 1.1 clearly articulated a desire to learn more about how specific situations, such as working with parents or with sexually abused children, can be implemented effectively and safely in an online setting, since she was lacking knowledge in this regard (Position 1.92). Having a clear structure for the therapy sessions through the manualized intervention was perceived as very helpful. ID 2.1 describes it as follows: „The first thing that I really like and use with my patients is that there is a therapy plan that I follow, there are clearly structured sessions. I know exactly what I am doing. I can explain everything to my clients, whether they are teenagers or children. And they also understand what is happening to their brain, what is happening to their behavior, what thoughts they have, why these thoughts affect their functioning, how they affect their quality of life.” (Position 2.161) She also reports that patients had specifically chosen her as their therapist because they greatly valued the structured and clearly defined procedures of TF-CBT and, in particular, after having already tried other therapeutic approaches, patients had intentionally chosen this treatment method (Position 2.110). Therapists reported experiencing various emotional and physical reactions during or after the implementation of TF-CBT. These included exhaustion, anger and aggression, as well as intense bodily sensations such as nausea. At the same time, they also described positive emotions, such as joy at being able to help patients process their experiences, and happiness when patients left a session or completed the therapy showing positive changes. To cope with the wide range of often intense emotions, the therapists report using various self-care strategies. Despite their heavy workloads, they state that they do not work on Sundays (even though Sunday is considered a regular workday in some of the countries where the therapists currently reside). In addition, they emphasize the importance of getting sufficient sleep, engaging in physical activity, and ensuring that coffee and food are always readily available. They have also developed highly individualized self-care routines, such as listening to classical music while cooking or cleaning to unwind or engaging in hobbies such as puzzling or sewing. Moreover, exchange with colleagues, such as through supervision within the TF-CBT Ukraine project, was described as beneficial for their own well-being. Participant ID 3.2 describes using stabilization techniques such as breathing exercises or the visualization of a safe place and underscores their importance: “When we want to take care of our health, we make appointments with doctors. It's the same with self-care. There must be a sort of self-care schedule (Position 2.370)”. Participant ID 3.1 reports similar experiences and adds that her knowledge of Cognitive Behavioral Therapy (CBT) skills has a positive effect on her overall well-being: “I can even see how my work, my work in CBT, significantly affects the quality of my life. I mean, you use the same techniques for yourself, and you have a completely different attitude to thoughts, and it's much less exhausting, much easier when you have a good connection with them. So that's also how I deal with it. (Position 3.295)”. Nonetheless, participant ID 2.3 also notes that under current circumstances, self-care is particularly challenging. She states: “ In terms of self-care, nowadays there is a little less sunshine, you know. Somehow the weather is not very conducive to overall wellness. But there are stabilization techniques, I agree (Position 2.368) ”. 1.1. Challenges in treatment Despite the positive feedback regarding the feasibility and effectiveness, participants reported various challenges in implementing TF-CBT with Ukrainian children and adolescents. The challenges mentioned included various difficulties arising from the ongoing war and its effect on both child, parent and therapist. 1.1.1. Ongoing war and the lack of a safe environment The most frequently mentioned challenge in implementing TF-CBT in the Ukrainian context was the ongoing war, which often meant that a safe environment, could not be guaranteed. “ Another important thing that we need to keep in mind is that the war is ongoing. I mean, we process a traumatic experience and then it recurs. […] They know based on the sound what [missiles] it is. And then they slip back into that reaction, even though we have processed the previous event. The war is not over. Doing exposure in the midst of the war is a new experience (Position 1.130-131).” The ongoing war situation is described by ID 3.3 as a highly emotional burden. She recounts the story of a “[…] girl from Mariupol, they stayed in that bunker and then they found out about the death of their loved ones (Position 3.68). " This reality confronted therapists with entirely new challenges, which they also discussed during supervision sessions as part of the accompanying training program. For example, participating therapists reported that during air raid sirens or bomb alarms, clients would panic, crouching on the floor or hiding. In light of the continuous shelling of Ukrainian territories, such intense reactions to the ongoing war represent one of the greatest obstacles to effective therapy, as “ the child’s psych doesn’t have enough time to fully […] recover ” (ID 1.1., Position 1.134). Therapists reported that they were “ dealing with children who are constantly under stress, just like their parents. Well, maybe there are no bombs flying around, but other cues and triggers arise ” (ID 2.2.; Position 2. 175). Moreover, several therapists emphasized that the therapeutic goals of parents or children often did not focus on the trauma itself, but rather on issues such as the treatment of other mental health difficulties such as enuresis or school-related difficulties. In the context of the ongoing war of aggression against Ukraine, “traumatization seems to have taken a back seat. […] It has become part and parcel of their everyday life, this war and the fact that people are dying, this whole situation” (ID 2.3, Position 2.145). 1.1.2. Technical difficulties Another war-related challenge lies in technical difficulties. As ID 1.1 reported one client had to leave [name of Ukrainian city removed due to the anonymization] due to the war and moved to a location with very poor internet connection. As a result, it was logistically impossible to continue therapy. Therapists also reported technical issues such as unstable internet connections due to the power outages: “ You couldn’t do full-fledged exposure because the connection could be interrupted any minute ” (ID 1.1, Position 1.136). However, the extent to which this challenge was perceived varied depending on the infrastructure of the respective workplace. For instance, ID 2.1 explained that her workplace was part of the critical infrastructure: “ Therefore, I was lucky to have uninterrupted power supply in my office. Only once, there was one single time when they turned it off. So, I could have my counselling sessions at work, no problem. Yeah? That's a big advantage for me (Position 2.261).” 1.1.3. Working with caregivers A commonly reported challenge raised by participants in the focus groups was working with caregivers. For example, participants reported that, due to the war, many parents are themselves traumatized or otherwise psychologically burdened. They are often constantly following the news and, because of their own poor mental health, may negatively impact their children's well-being. “ Challenges also arise when a child is triggered by their parents. I mean that the parents are in such a bad mental state that the child absorbs their emotions after a session and sinks back into a hole. Circumstances like that. And I can't always talk parents into joining the therapy. In the end, it’s up to them. (ID 1.1., Position 1.130)” Caregivers were described as being so preoccupied with their own problems and challenges that, on the one hand, children often assumed the role of the supportive figure within the family dynamic. As a result, caregivers frequently failed to recognize that their children were also struggling. ID 2.2. reported: “A lot of children helped their own parents. They were stronger during those bombings. Children helped their parents, supported them. And the first thing parents said was, “No, she is fine. She supported me. She said everything would be fine.” Children often initiated the family’s departure from the occupied territories. The parent-child dynamics got skewed. (ID 2.2., Position 2.312-313)” On the other hand, despite receiving psychoeducation and dedicated caregiver sessions as part of the TF-CBT protocol, many caregivers did not fulfill their role in the implementation of TF-CBT and did not apply the parenting skills. ID 3.1 explains this by pointing to a lack of awareness of psychotherapy in Ukraine. “Parents are more used to just taking pills” (Position 3.229) . This observation was shared by other therapists, who reported that support offers were often not accepted, and that parents in particular were highly skeptical about psychotherapy. Traumatic experiences and the resulting psychological burden were perceived as a current norm in Ukraine, which led to a lack of awareness among parents and children/adolescents that therapy could be helpful in their situation. 1.1.4. Challenges due to cultural aspects Apart from the previously described, potentially cultural challenges in working with Ukrainian parents, no further specific cultural challenges were reported. ID 1.1. stated: “[...] no differences in cultural factors or any other national factors. I didn't see that in our program. It was all about ‘here's a problem, this child has this problem, and this is what we do’. That was the scheme. [...] And it worked. [...] There was nothing about certain things working only for people of specific religions or something like that” (Position 1.243–246). 1.2. Adaptations for the Ukrainian context Given the multitude of challenges therapists encountered in delivering TF-CBT to Ukrainian children and adolescents, it is not surprising that certain adaptations were made to ensure successful implementation. However, these were not modifications to the TF-CBT manual itself, but rather adjustments or additional techniques made in response to the challenges described above. The TF-CBT manual was largely adhered to. For example ID 3.1. reported : “it all depends on the case, […] sometimes you stay for several sessions working on one component (Position 3.160). The only deviations reported by some therapists concerned a more intensive and prolonged focus on psychoeducation, therapeutic relationship and stabilization, as well as an extension of the overall number of sessions, since in some cases it took longer for clients to feel ready to share their traumatic experiences. In addition, therapy had to be slightly adapted for each individual client. As ID 2.3 reported, for example, breathing techniques did not help all clients, nor did muscle relaxation exercises. It was a “ kind of search within the proposed algorithm ” (Position 2.239) to find the appropriate methods and techniques for each client. “ Some things work well with children, while others don't” (Position 2.240). Culturally-based adaptations were reported only by ID 1.1: “I switch to Russian only if a client is from the Luhansk or Donetsk region, where Russian is their everyday language. As you might know, we do therapy in the language the person thinks in ” (Position 1.14). 1.2.1. Working with caregivers Despite the frequently discussed challenges in working with caregivers, none of the participants reported specific adaptations in how collaboration with caregivers was conducted. In cases where caregivers exhibited noticeable psychological distress, they were, at best, referred to psychologists themselves. 1.2.2. Ongoing war and the lack of a safe environment Due to the ongoing war situation, certain adaptations were necessary to provide both therapists and clients with a greater sense of safety during therapy sessions. For instance, ID 3.2 reported that in the initial sessions, she supplemented the TF-CBT manual by also inquiring about war-related fears, such as fear of explosions or sirens. If significant fear was present, the focus of her therapy would shift toward stabilization, calming, relaxation, and the question: “ How likely is it that you will be okay here? ” In doing so, she aimed to “ give them the opportunity to feel relaxed; only then would I address the traumatic effect, the traumatic event ” (Transcript 3 (Engl): 208). Since a safe place could not be assumed during the ongoing war situation, therapists reported various adaptations and alternative methods in place of the TF-CBT “safe place” technique. These ranged from imagination exercises exploring what the client’s safe place would look like and which objects and people would be present, to questions such as “ How do you want us to win? ” (Position 2.191), and even “ What happens next? What are we going to do when we win?” (Position 2.311). 1.2.3. Technical difficulties One therapist, ID 1.1, reported specifically how she proactively addressed the emotional uncertainty caused by power outages during therapy sessions: “A t the beginning of each session I discuss it with both adults and children, ‘If the Internet goes down, we call back as soon as the power and the Internet come back on, no matter what. Or we text each other if the session is over timewise.’ Because there were situations when I had Internet outages even though I was in another country. […] It reduces their anxiety as they might be thinking, ‘Maybe I've been abandoned’. I had one client like that. He told me, ‘I thought you disconnected halfway through my story because you couldn't take it.’ […] now I always discuss it in advance, ‘If I disappear, it’s not because you told me something wrong […]’ Sort of power supply psychoeducation. (Position 1.136-140) 2. Feedback Training Program Participants reported being generally very satisfied with the training program “TF-CBT Ukraine” (Pfeiffer et al., 2023; Pfeiffer et al., 2025). One participant stated: „The training itself was highly professional. This is something that we lack in Ukraine. Now I have a much better understanding of how to work with children and adolescents with trauma. (ID 2.1, Position 2.111)“. They said that being part of the training program made them feel more confident, especially when working with children. Participating therapists particularly appreciated the clear structure of the training, the communication between organizers, trainers, and participants, and regarded every component of the training program as supportive for successfully learning the therapeutic method. As one participant put it: “I spend a lot of time learning, but this is probably my first project where there is so much support and guidance. Yes, there are letters. I call them happiness [that’s what I call them]. You know, every time you get one, it's some kind of news that you're waiting for, a reminder that you have a supervision in two days, or a reminder that they are planning to develop roadmaps, and they want to involve you in the process (ID 2.1. Position 2.109)”. Participant ID 3.2 emphasized the importance of personal contact as follows: „So, actually, the project is valuable not only because it provides knowledge, but also because it provides personal support to us (Position 3.52)”. While participants noted that the training involved a high volume of theoretical content at the beginning, they reported becoming increasingly familiar with both the content and the structure over time. Several participants stated that the early and transparent communication of schedules was particularly helpful, as it allowed them to plan accordingly. Interviewee 2.1 reports that without simultaneous interpretation she would not have been able to participate in the program, as her English proficiency was insufficient. As soon as participation in Ukrainian became possible, she registered immediately (Position 2.50). The only critical remark regarding the overall training program came from ID 1.1, who commented on the online format: “I'm just used to this format. Of course, it would be great if it were in person, if we lived in peacetime, if we had a full day of training with coffee breaks and informal discussions.” (Position 1.63-66). However, she went on to note: “ This format works pretty well for me.” (Position 1.67). Nevertheless, especially at the beginning of the training program, there was a large amount of theoretical input, according to ID 1.1 (Position 1.71). The participating therapists found it very difficult to name a highlight of the training program, since “ I really like the way the program is structured and divided in general, and without any part of the program it would be much more difficult .” (ID 3.2, Position 3.108). Later she adds: “It's hard to say, because the whole program was the icing on the cake for me, to be honest. To single it out right away. Well, it's hard for me to say offhand what the highlight was.” (Position 3.275). However, the supervisions, the voluntary additional workshops, and the provided materials were considered particularly helpful for the learning process. Regarding the supervisions, ID 3.2 reports: “The highlight […] I guess it's still supervisions, perhaps. Because I think I have a lot of experience […] of programs that we went through, were trained in. But there were no such long-term year-long supervisions, where you knew that you were allowed to practice clinically and would be supported in this way. […] And you are provided with such support. There used to be intervision groups, there were singular supervisions, but the fact that you are guaranteed to get a year's worth of time and you take cases and you know for sure that you will receive support, I think this is the biggest highlight of this program.” (Position 3.275–277) Another key aspect was the additional optional workshops introduced during the course of the project. These addressed supplementary topics relevant to the treatment of traumatized Ukrainian children and adolescents, which were not part of the core TF-CBT training curriculum. As ID 3.2 describes: “Theoretically, it is possible to do without those additional seminars that were announced as additional seminars. But this is such a helpful part. I am very happy that it was there too.” (Position 3.108) For example, one optional workshop was on the topic on traumatic grief. ID 3.1 remembered: “There was a seminar on grief that was very helpful to me. […] topic is an integral part of working with trauma during the war. […]. That is, it became understandable how to clearly recognize this complicated grieving, yes, so the trainers gave very good answers.” (Position 3.88) These optional workshops were offered to all project participants, but they were also recorded and made available afterwards, enabling asynchronous learning as well. ID 1.1 reports: “and the recordings that I am very grateful for. Because you can’t always listen with concentration, or you can be distracted by something else […], so I listen again. I'm very grateful for that.” (Position 1.54) In addition to the individual components of the training program, the materials provided were also considered very helpful: “But we are so well provided with methodological material […], everything is uploaded, from workbooks to materials needed for psychoeducation. At each stage, we have a set of materials that we can use. they are divided into folders. Programs that are recommended to us, like a mobile application, in order to implement certain stages of the protocol. It is very convenient in this context.” (ID 3.X, Position 3.82) The TF-CBT-specific workbooks in particular were especially helpful in following the therapy protocol (Position 3.83). 2.1. Suggestions for Improvement In order to better tailor training programs to the needs of Ukrainian therapists, suggestions for improvement were collected. Most notably, these included requests for more frequent supervision sessions (twice per month) and more regular additional workshops (at least once a month). ID 2.X explains it as follows: “ The more knowledge you have, the better you understand, the fewer mistakes you make then, right? Well, this is my thing. The more knowledge, the better for me (Position 2.99).” Specifically, there was a desire for optional workshops on the topics of “sexual abuse against children,” particularly in times of war, and “complex trauma”. Discussion This study presents, for the first time, qualitative data of therapists on the implementation of TF-CBT in an ongoing war context. Overall, despite existing challenges, the implementation of TF-CBT in Ukraine can be considered both feasible and beneficial. The high demand for trauma-focused interventions for Ukrainian children and adolescents previously reported in earlier studies (Pfeiffer et al., 2024 ) was once again confirmed by the ease with which participating therapists were able to recruit patients. Furthermore, the findings indicate that TF-CBT is effective as a therapeutic approach even under the exceptional and challenging conditions of an ongoing war, which is in line with the quantitative patient results (Pfeiffer et al., 2025 ). Particularly noteworthy is that a high degree of treatment fidelity was reported even under highly stressful circumstances affecting not only the children and their parents but also the therapists themselves (Freedman & Tuval Mashiach, 2018 ; Taubman – Ben-Ari et al., 2025 ). This finding not only confirms the cross-cultural applicability of TF-CBT, as previously demonstrated in Thielemann et al. ( 2022 ), but also adds qualitative evidence to the quantitative shown evidence of the feasibility of TF-CBT in a context of an ongoing war (Pfeiffer et al., 2025 ). Therefore, the findings highlight the considerable potential for the use of TF-CBT in crisis and conflict regions worldwide. Similar to the findings reported by Murray et al. ( 2013 ) in the contextual description, therapists implemented the core elements of TF-CBT. However, certain adaptations were made to implementation techniques in response to the war situation. Despite the absence of a safe environment, previously considered a prerequisite for conducting PTSD-Treatment (Schäfer et al., 2019 ), our findings indicate that TF-CBT can be successfully applied even in situations of ongoing war. Despite the generally positive findings regarding implementation of TF-CBT during an ongoing war, it is essential that existing training and therapy programs be adapted to the specific conditions of an ongoing war in order to ensure long-term implementation. The present study clearly highlights the challenges therapists face when providing trauma-focused therapies during a persistent threat situation. Both adaptations and creativity on the part of therapists, openness on the part of patients and their caregivers, as well as adjustments by trainers and supervisors are required to ensure alignment between specific needs and available services. In the present project, for example, the introduction of simultaneous translation proved to be a particularly successful measure. It might not only substantially increased the utilization of the program but might also have improved the overall quality of the training. By providing translation, language barriers were reduced, which significantly enhanced communication between trainers and supervisors and the therapists. This measure likely contributed to the high level of treatment fidelity reported (Pfeiffer et al., 2025 ). In addition, the present project was able to respond to emerging topics and the therapists’ needs by offering additional optional workshops. Continuous contact between the project team and the participants allowed for timely responses to these needs, which proved to be essential for the overall success of the program. Continuous adaptation and expansion of training opportunities can enable TF-CBT to be successfully learned and implemented even under particularly challenging circumstances. Therefore, it is essential to respond to the specific local conditions and requirements in order to create training opportunities that are as accessible as possible. As some therapists reported own psychological distress after TF-CBT sessions it seems crucial to offer ongoing case consultation and supervision, thereby also focusing on the mental wellbeing of the therapists by programs such as the PRACTICE skills course (Pollio et al., 2025 ). Working with caregivers remains a major challenge. Therapists in this study did not report specific adaptations that had already been implemented to improve the inclusion of caregivers in TF-CBT treatment. This may be attributable to several factors. On the one hand, it is conceivable that parents themselves are heavily burdened by the war situation (Karatzias et al., 2023 ). On the other hand, there might be a lack of mental health literacy within the general population in Ukraine (Quirke et al., 2021 ). It is therefore highly necessary to increase societal awareness of the relevance of mental disorders and of the effectiveness of evidence-based therapeutic methods, alongside or at least as an alternative to psychopharmacological treatment. Psychoeducational campaigns (e.g. Gorbunova & Klymchuk, 2025 ) and other measures aimed at reducing stigma toward mental illness (e.g. Ekblad et al., 2024 ) should therefore be increasingly implemented in order to improve collaboration between therapists and the family system. Limitations The findings of the present study should be interpreted in light of several limitations. A substantial sample bias cannot be ruled out. Participants in the study were particularly active therapists involved in the “TF-CBT Ukraine” project, who had distinguished themselves through regular and highly engaged participation in supervision sessions. This sampling strategy was chosen in the hope of achieving the highest possible participation rate in the focus groups in order to facilitate in-depth and meaningful discussions. In addition, the symptom improvements reported in this study are based solely on therapists’ subjective reports. However, these findings are consistent with the objective measures previously demonstrated in the evaluation study of the “TF-CBT Ukraine” project (Pfeiffer et al., 2025 ). Implications The present study clearly demonstrates that TF-CBT can be implemented successfully in an ongoing war context with only minor adaptations. TF-CBT should therefore be further disseminated in other conflict- and crisis regions. Political stakeholders need to place greater emphasis on the relevance of such measures and provide, among other forms of support, adequate financial resources in order to sustainably improve the mental health of children and adolescents worldwide. At the same time, accompanying research remains necessary, as context-specific adaptations to training programs may be required. Online formats introduce new challenges but also create many new opportunities to further advance the global dissemination of trauma-focused therapeutic methods. In regions with little evidence-based treatments implemented so far, they might represent an important solution. Therefore, scientific evaluations of digital training concepts are crucial. Self-care among therapists working in these highly demanding circumstances is of particular importance. This is not only reported by the participating therapists in this study but is also reflected in the broader scientific discussion on secondary traumatization and the overall professional quality of life of therapists (Canfield, 2005 ). At the beginning of the war of aggression, the Ukrainian therapists in this project demonstrated remarkable resilience (Kostova et al., 2025 ). However, this resilience must be continuously maintained and stabilized through ongoing self-care activities. Programs such as a PRACTICE skill course for therapists (Pollio et al., 2025 ) should therefore be implemented broadly for therapists working in crisis and conflict regions so that they can learn strategies for effective self-care. Only therapists who themselves maintain good psychological well-being possess sufficient mental capacity to support and improve the mental health of traumatized children and adolescents. The “TF-CBT Ukraine” project once again illustrates how cooperation between international experts and local partners can lead to the development of sustainable structures within the respective regions. As a result of the project, a follow-up initiative has now emerged directly within Ukraine, in which participants from the original “TF-CBT Ukraine” project, now being internationally certified TF-CBT trainers, are training additional Ukrainian therapists in TF-CBT. However, a participatory approach is needed not only in practical implementation but also in research in order to adapt programs appropriately to the context-specific realities faced by therapists, children, and adolescents in affected regions. Furthermore, it is essential to give a voice to those implementing these methods under challenging conditions through increased qualitative research. This study represents one of the first qualitative investigations focusing on therapists’ perspectives in wartime settings. In the future, children, adolescents, and parents should also be included in qualitative studies so that their perspectives can be more strongly represented in research and experiences related to trauma therapy and war can be better understood. Conclusion This study is encouraging not only in light of the now more than four-year-long war of aggression by Russia against Ukraine, but also clearly demonstrates the possibility of providing evidence-based trauma therapy at an early stage in other conflict and war regions, rather than waiting for the often unpredictable end of a conflict. Such an approach could contribute to reducing the currently very high rates of PTSD in populations living in war and crisis regions (Ahmed et al., 2024 ) at an early stage and, ideally, help prevent complex and chronic trajectories (Roberts et al., 2019 ). Abbreviations CBT Cognitive Behavioral Therapy TF-CBT Trauma-Focused Cognitive Behavioral Therapy PTSS post-traumatic stress symptoms PTSD post-traumatic stress disorder Declarations Ethics approval and consent to participate This project received ethical approval by the Ulm University (Number: CI/Sta) in Germany and the Zhytomyr Ivan Franko University (Number: 9-09072022) in Ukraine. All participants were informed about the study protocol and gave their written consent prior study inclusion. Consent for publication The consent for publication was obtained from all therapists included in this study. The individual information was handled anonymously. Availability of data and materials The anonymized dataset used for this study is available from the corresponding author upon reasonable request. The used semi-structured interview guideline can be found in the supplementary material of this publication. Competing interest The authors have no conflict of interest/ competing interest to disclose. Financial Support This work was supported by the Swiss Cooperation Office, Porticus Foundation, and the Medical University of South Carolina, College of Medicine Drexel University. Authors’ contributions All authors made the conceptualization of the focus group. EP and CS obtained funding and provided supervision. MH conducted and transcribed the focus groups. MG analysed the data, drafted the initial manuscript. All authors critically reviewed the manuscript. All authors approved the final version of the manuscript. Acknowledgements We would like to thank all involved collaboration partners, who supported the TF-CBT Ukraine project. A special thanks goes to our translators Oksana Mykytka and Olia Thyshkovets. Most importantly though, we would like to thank all Ukrainian therapists and patients who participated in this project. References Ahmed, S. H., Zakai, A., Zahid, M., Jawad, M. Y., Fu, R., & Chaiton, M. (2024). Prevalence of post-traumatic stress disorder and depressive symptoms among civilians residing in armed conflict-affected regions: A systematic review and meta-analysis. General Psychiatry , 37 (3), e101438. https://doi.org/10.1136/gpsych-2023-101438 Canfield, J. (2005). Secondary Traumatization, Burnout, and Vicarious Traumatization. Smith College Studies in Social Work , 75 (2), 81–101. https://doi.org/10.1300/J497v75n02_06 Carpiniello, B. (2023). The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones. International Journal of Environmental Research and Public Health , 20 (4). https://doi.org/10.3390/ijerph20042840 Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2016). Trauma-focused CBT for children and adolescents : treatment applications / edited by Judith A. Cohen, Anthony P. Mannarino, Esther Deblinger (Paperback edition). Guilford Press. Cohen, J. A., Mannarino, A. P., & Murray, L. K. (2011). Trauma-focused CBT for youth who experience ongoing traumas. Child Abuse & Neglect , 35 (8), 637–646. https://doi.org/10.1016/j.chiabu.2011.05.002 Ekblad, S., Gramatik, O., & Suprun, Y. (2024). Increasing perceived health and mental health literacy among separated refugee Ukrainian families with urgent needs occasioned by invasion-a group intervention study with participatory methodology in Sweden. Frontiers in Public Health , 12 , 1356605. https://doi.org/10.3389/fpubh.2024.1356605 Freedman, S. A., & Tuval Mashiach, R. (2018). Shared trauma reality in war: Mental health therapists' experience. PloS One , 13 (2), e0191949. https://doi.org/10.1371/journal.pone.0191949 Gorbunova, V., & Klymchuk, V [Vitalii] (2025). Universal mental health training: Policy proposal for national rollout of the new scalable intervention in Ukraine. Open Research Europe , 5 , 119. https://doi.org/10.12688/openreseurope.20116.2 Goto, R., Pinchuk, I., Kolodezhny, O., Pimenova, N., Kano, Y., & Skokauskas, N. (2024). Mental Health of Adolescents Exposed to the War in Ukraine. JAMA Pediatrics , 178 (5), 480. https://doi.org/10.1001/jamapediatrics.2024.0295 Goto, R., Pinchuk, I., Kolodezhny, O., Pimenova, N., & Skokauskas, N. (2023). Mental health services in Ukraine during the early phases of the 2022 Russian invasion. The British Journal of Psychiatry : The Journal of Mental Science , 222 (2), 82–87. https://doi.org/10.1192/bjp.2022.170 Guest, G., Namey, E., & McKenna, K. (2017). How Many Focus Groups Are Enough? Building an Evidence Base for Nonprobability Sample Sizes. Field Methods , 29 (1), 3–22. https://doi.org/10.1177/1525822X16639015 Hook, K., Kozishkurt, J., Kovalchuk, O., Goncharenko, E., Kodovbetskyi, V., Opanasenko, M., Kopytko, A., Girnyk, A., Kliuzko, K., Drainoni, M.‑L., & Bogdanov, S. (2021). Evaluating context and interest in training in evidence-based mental health care: A qualitative investigation among healthcare providers in Kyiv, Ukraine. BMC Research Notes , 14 (1), 373. https://doi.org/10.1186/s13104-021-05786-3 Karatzias, T., Shevlin, M., Ben-Ezra, M., McElroy, E., Redican, E., Vang, M. L., Cloitre, M., Ho, G. W. K., Lorberg, B., Martsenkovskyi, D., & Hyland, P. (2023). War exposure, posttraumatic stress disorder, and complex posttraumatic stress disorder among parents living in Ukraine during the Russian war. Acta Psychiatrica Scandinavica , 147 (3), 276–285. https://doi.org/10.1111/acps.13529 Kostova, Z., Pfeiffer, E., & Garbade, M. (2025). “What doesn’t kill you makes you stronger”—Professional quality of life in Ukrainian mental health care professionals during the ongoing war. Traumatology. Advance online publication. https://doi.org/10.1037/trm0000562 Kuckartz, U., & Rädiker, S. (2022). Qualitative Inhaltsanalyse. Methoden, Praxis, Computerunterstützung: Grundlagentexte Methoden (5. Auflage). Grundlagentexte Methoden . Beltz Juventa. http://www.content-select.com/index.php?id=bib_view&ean=9783779955337 Lewey, J. H., Smith, C. L., Burcham, B., Saunders, N. L., Elfallal, D., & O'Toole, S. K. (2018). Comparing the Effectiveness of EMDR and TF-CBT for Children and Adolescents: A Meta-Analysis. Journal of Child & Adolescent Trauma , 11 (4), 457–472. https://doi.org/10.1007/s40653-018-0212-1 Martsenkovskyi, D., Karatzias, T., Hyland, P., Shevlin, M., Ben-Ezra, M., McElroy, E., Redican, E., Vang, M. L., Cloitre, M., Ho, G. W. K., Lorberg, B., & Martsenkovsky, I. (2024). Parent-reported posttraumatic stress reactions in children and adolescents: Findings from the mental health of parents and children in Ukraine study. Psychological Trauma: Theory, Research, Practice, and Policy , 16 (8), 1269–1275. https://doi.org/10.1037/tra0001583 Murray, L. K., Dorsey, S., Skavenski, S., Kasoma, M., Imasiku, M., Bolton, P., Bass, J., & Cohen, J. A. (2013). Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: The use of TF-CBT in Zambia. International Journal of Mental Health Systems , 7 (1), 24. https://doi.org/10.1186/1752-4458-7-24 Pfeiffer, E., Beer, R., Birgersson, A., Cabrera, N., Cohen, J. A., Deblinger, E., Garbade, M., Kirsch, V., Kostova, Z., Larsson, M., Mannarino, A., Moffitt, G., Onsjö, M., Ostensjo, T., Sachser, C., Vikgren, A., Weyler Mueller, H., & Klymchuk, V [Vitaii] (2023). Implementation of an evidence-based trauma-focused treatment for traumatised children and their families during the war in Ukraine: A project description. European Journal of Psychotraumatology , 14 (2), 2207422. https://doi.org/10.1080/20008066.2023.2207422 Pfeiffer, E., Garbade, M., Beer, R., Birgersson, A., Cabrera, N., Cohen, J. A., Deblinger, E., Gjini, R., Kirsch, V., Kostova, Z., Larsson, M., Mannarino, A., Moffitt, G., Onsjö, M., Ostensjo, T., Vikgren, A., Weyler, H., Klymchuk, V [Vitalii], & Sachser, C. (2025). Evaluation of the feasibility and effectiveness of trauma-focused cognitive behavioural therapy for children and youth in Ukraine during the war. European Psychiatry : The Journal of the Association of European Psychiatrists , 68 (1), e96. https://doi.org/10.1192/j.eurpsy.2025.10032 Pfeiffer, E., Garbade, M., & Sachser, C. (2024). Traumatic events and posttraumatic stress symptoms in a treatment-seeking sample of Ukrainian children during the war. Child and Adolescent Psychiatry and Mental Health , 18 (1), 25. https://doi.org/10.1186/s13034-024-00715-1 Pollio, E., Deblinger, E., Cooper, B., Garbade, M., Harrison, J. P., & Pfeiffer, E. (2025). Engaging Ukrainian TF-CBT therapists in a PRACTICE skills course to support their wellbeing. European Journal of Psychotraumatology , 16 (1), 2476898. https://doi.org/10.1080/20008066.2025.2476898 Quirke, E., Klymchuk, V [Vitalii], Suvalo, O., Bakolis, I., & Thornicroft, G. (2021). Mental health stigma in Ukraine: Cross-sectional survey. Global Mental Health (Cambridge, England) , 8 , e11. https://doi.org/10.1017/gmh.2021.9 Roberts, N. P., Kitchiner, N. J., Kenardy, J., Lewis, C. E., & Bisson, J. I. (2019). Early psychological intervention following recent trauma: A systematic review and meta-analysis. European Journal of Psychotraumatology , 10 (1), 1695486. https://doi.org/10.1080/20008198.2019.1695486 Schäfer, I., Gast, U., Hoffmann, A., Knaevelsrud, C., Lampe, A., Liebermann, P., Lotzin, A., Maerker, A., Rosner, R., & Wöller, W. (2019). Posttraumatische Belastungsstörung: S3 Leitlinie der Deutschsprachigen Gesellschaft für Psychotraumatologie (DeGPT) . https://register.awmf.org/assets/guidelines/155-001l_S3_Posttraumatische_Belastungsstoerung_2020-02_1.pdf Taubman – Ben‐Ari, O., Erel‐Brodsky, H., & Ben‐Kimhy, R. (2025). Therapists in Wartime: Holding Others' Trauma While Contending With Your Own. Journal of Clinical Psychology , 81 (3), 119–132. https://doi.org/10.1002/jclp.23751 Thielemann, J. F. B., Kasparik, B., König, J., Unterhitzenberger, J., & Rosner, R. (2022). A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents. Child Abuse & Neglect , 134 , 105899. https://doi.org/10.1016/j.chiabu.2022.105899 Thomas, F. C., Puente-Duran, S., Mutschler, C., & Monson, C. M. (2022). Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review. Child and Adolescent Mental Health , 27 (2), 146–160. https://doi.org/10.1111/camh.12435 Additional Declarations No competing interests reported. Supplementary Files ESMFocusgroupsTFCBT.pdf Supplementary Information ESM1 semi-structured interview guide for the focus groups Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviewers agreed at journal 04 May, 2026 Reviewers invited by journal 04 May, 2026 Editor assigned by journal 04 May, 2026 Submission checks completed at journal 02 May, 2026 First submitted to journal 29 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9569619","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634440650,"identity":"c8006618-9303-4314-8130-e644d0b54696","order_by":0,"name":"Maike Garbade","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYBACgwOMzRCWBAhVgFgJzECCGacWS1QtZ0AUAS32B2CSIC2MbURoMTt+uNngA0OtvPns5oc3Ps6rqzM4nsBszMNgLYdTy5nE5sQZDMcN59w5Zmw5c9thCYMzD5iTeRjSjXFqOZDYfJiH4RjjDIkEM2nebQckDG4kMANFDic24NBicP5h8+E/DMfsZ0ikf5P+O6cOrqUep5Ybic3JDAw1iTMkcsykGRuYwVqADjucgMthBjceNhv2GBxIniFzptiy59hhyZlngCJzDNINcTss/bHEj4o62xnS7Rtv/Kip4+c7nnxY4k2FtTwuW6AaDyPzGIHmG+DXAAR1BFWMglEwCkbBCAYAK8Vbu3KKeoAAAAAASUVORK5CYII=","orcid":"","institution":"Catholic University of Eichstätt-Ingolstadt","correspondingAuthor":true,"prefix":"","firstName":"Maike","middleName":"","lastName":"Garbade","suffix":""},{"id":634440651,"identity":"ff0f1eb0-9c62-445a-a4e9-ba5cb04f9c80","order_by":1,"name":"Mariia Hrynova","email":"","orcid":"","institution":"University of Ulm","correspondingAuthor":false,"prefix":"","firstName":"Mariia","middleName":"","lastName":"Hrynova","suffix":""},{"id":634440652,"identity":"020450ad-0927-4b08-9171-34018942a80e","order_by":2,"name":"Cedric Sachser","email":"","orcid":"","institution":"University of Bamberg","correspondingAuthor":false,"prefix":"","firstName":"Cedric","middleName":"","lastName":"Sachser","suffix":""},{"id":634440653,"identity":"7cdc279f-270e-4bee-a32e-f6104049cca3","order_by":3,"name":"Elisa Pfeiffer","email":"","orcid":"","institution":"Catholic University of Eichstätt-Ingolstadt","correspondingAuthor":false,"prefix":"","firstName":"Elisa","middleName":"","lastName":"Pfeiffer","suffix":""}],"badges":[],"createdAt":"2026-04-29 20:08:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9569619/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9569619/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109204672,"identity":"6cc96fde-b8e1-4291-a69f-2e2d9485651e","added_by":"auto","created_at":"2026-05-13 15:01:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":260505,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9569619/v1/5b6978bf-86fb-46be-9b3a-aba5352e36bf.pdf"},{"id":109118035,"identity":"500ec922-cc4f-4d54-9d1c-44e0151ba930","added_by":"auto","created_at":"2026-05-12 16:48:16","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":248539,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eESM1 semi-structured interview guide for the focus groups\u003c/p\u003e","description":"","filename":"ESMFocusgroupsTFCBT.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9569619/v1/771cbb9d8e8bf4a42e3d2d76.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“When the Safe Place Is Not Safe”: Therapists’ Perspectives on Implementing TF-CBT During the War in Ukraine","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWars and conflicts pose a high risk to the mental health of affected populations worldwide (Carpiniello, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The ongoing large-scale Russian invasion of Ukraine has deprived millions of children and adolescents not only of their safety but also of their psychological stability. The mental health burden among Ukrainian children and adolescents has already been documented in several studies with rates of post-traumatic stress symptoms (PTSS) between 12.6% to 70% (Goto et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Martsenkovskyi et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Pfeiffer et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and 32% screened positive for moderate to severe depression, and 17.9% for moderate to severe anxiety (Goto et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Therefore, providing effective mental health care support is of central importance in order to reduce the mental health burden of traumatized children and adolescents in Ukraine.\u003c/p\u003e \u003cp\u003eUntil March 2022, no trauma-focused evidence-based treatments for children and adolescents had been systematically implemented and evaluated in Ukraine (Goto et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hook et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Therapists lacked of knowledge about existing treatments (Hook et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). An internationally recognized and evidence-based method for treating post-traumatic stress disorder (PTSD) in children and adolescents is \u0026ldquo;Trauma-Focused Cognitive Behavioral Therapy\u0026rdquo; (TF-CBT) (Cohen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). TF-CBT has already been successfully applied and scientifically evaluated in many contexts and countries across the globe, including low- and middle-income countries or conflict-affected populations (Thielemann et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Thomas et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Particularly in work with conflict-affected populations, meta-analyses identified TF-CBT as the most effective treatment for complex trauma, demonstrating superior outcomes compared to other therapeutic approaches or larger evidence base (Lewey et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).Cohen et al.(2011) have proposed several strategies how to apply TF-CBT for youth who experience ongoing trauma, nevertheless, there is currently very limited empirical knowledge about whether and how TF-CBT can be applied under the conditions of an ongoing war. Therefore, the online-based training program \u003cem\u003e\u0026ldquo;TF-CBT Ukraine\u0026rdquo;\u003c/em\u003e was developed and has been implemented in Ukraine since 2022 (Pfeiffer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The aim of the program was to train Ukrainian therapists in TF-CBT and thereby make TF-CBT available to potentially traumatized children and adolescents in Ukraine. In total, \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;138 therapists participated in the program and \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;62 were certified as TF-CBT therapists (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The systematic evaluation of the training program demonstrated high participation rates, positive satisfaction ratings and positive outcomes at both the therapist and patient levels (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). So far, the implementation of TF-CBT in Ukraine has primarily been documented through quantitative data and qualitative findings remain limited. Nevertheless, the perspective of therapists is particularly important, as it can provide essential insights for the planning of future implementation programs, not only in Ukraine but also in other war and crisis regions worldwide. Qualitative investigations can contribute to a better understanding of how the war context affects both training and treatment processes. Hence, this study aims at examining the following research questions via a qualitative study design (focus groups):\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhich specific challenges in implementing TF-CBT do Ukrainian mental health care professionals encounter during the ongoing war?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do the therapists describe adapting TF-CBT to the specific contextual demands of the war setting?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow do the therapists perceive the training program in supporting the implementation of TF-CBT under these circumstances?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis study aims not only to make an important contribution to the understanding and further development of trauma-focused therapy measures in crisis regions, especially in Ukraine, but also to specifically give a voice to those who provide psychotherapeutic care and support to traumatized children and adolescents under war conditions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study is part of the project 'TF-CBT Ukraine' (Pfeiffer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), in which 138 Ukrainian therapists participated in a large training program on TF-CBT between 2022 and 2024 ((Kostova et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Pfeiffer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Pfeiffer et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The project received ethical approval by Ulm University in Germany (Number: C1/Sta) and the Zhytomyr Ivan Franko State University (Number: 9\u0026ndash;08072022) in Ukraine.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTrauma-Focused Cognitive Behavioral Therapy\u003c/h2\u003e \u003cp\u003eThe evidence-based trauma-focused treatment TF-CBT consists of nine components summarized by the acronym PRACTICE (Cohen et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). These include (1) psychoeducation and parenting skills (P), relaxation (R), affective modulation (A), cognitive coping (C), trauma narrative (T), in vivo exposure (I), conjoint parent\u0026ndash;child sessions (C) and enhancing safety and development (E). The authors of the treatment approach recommend a minimum of eight sessions to ensure that all aspects of the manual are adequately addressed. The involvement of caregivers constitutes an essential component of TF-CBT; according to Cohen et al. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), caregivers should participate in all sessions. Each session lasts 90 minutes, with 45 minutes allocated respectively to the child/adolescent and the caregiver.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTraining-Program “TF-CBT Ukraine”\u003c/h3\u003e\n\u003cp\u003eWithin the framework of the training program \u0026ldquo;TF-CBT Ukraine,\u0026rdquo; more than 130 Ukrainian therapists were trained in TF-CBT between 2022\u0026ndash;2026. This online-based training program comprised the following mandatory components: (1) self-study of the TF-CBT manual and/or completion of the web-based training; (2) participation in a three-day online training; (3) participation in at least 10 monthly supervision sessions over the course of one year; and (4) provision of TF-CBT treatment to at least three children or adolescents from Ukraine. Upon successful completion of all training components, participants received their official TF-CBT therapist certification.\u003c/p\u003e \u003cp\u003eIn addition, optional workshops were offered on the following topics: traumatic grief, trauma assessment, related measurements in the field of trauma treatment, caregiver involvement, strategies for implementing TF-CBT during ongoing trauma exposure, sexual development and sexually problematic behavior in children and adolescents, treatment of depression in the context of trauma, and suicidality. Furthermore, all therapists had the opportunity to participate in the PRACTICE Skills Course aimed at enhancing their personal and professional well-being (Pollio et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll program components were delivered by certified international TF-CBT trainers or, in the case of the optional workshops, by international experts. Since August 2022, all training content has been simultaneously translated into Ukrainian. In addition, a wide range of therapeutic materials were translated and made available to participants. For a more detailed description of the Training program, please see Pfeiffer et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eRecruitment and participants\u003c/h3\u003e\n\u003cp\u003eIn March 2023, a total of \u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;28 Ukrainian therapists who were enrolled in the project \u0026ldquo;TF-CBT Ukraine\u0026rdquo; were invited via email by the study team to participate in a focus group to share their experiences in implementing TF-CBT with Ukrainian children and adolescents. This invitation was sent exclusively to therapists who had previously provided TF-CBT treatment to children during the project and were recommended by the respective trainers and supervisors. Trainers were asked to identify potential participants who had demonstrated consistent engagement and active involvement in the project's activities. Of those invited, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;13 (46%) therapists agreed to participate. All participants provided informed consent for study participation, video recording, and the anonymized analysis of the focus group data. Of the therapists who registered, a total of \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7 (100% female) ultimately participated in the focus groups. Of those, six were Psychologists and one Psychiatrist. At the start of the training program, they were located in 7 different cities in Ukraine (Kyiv, Dnipro, Mokolaiv, Zaporizhzhia, Lutsk, Lwiw and Schytomyr).\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eIn alignment with the research questions, a semi-structured interview guide comprising open-ended questions was developed (see ESM1). The formulation of the questions was informed by findings from the above presented previous research findings and the authors\u0026rsquo; expertise in the project management of the \"TF-CBT Ukraine\" project (Pfeiffer et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In this context, not only were the authors\u0026rsquo; experiences gained through direct project work with the participants taken into account, but also the written and oral feedback from participants of \u0026ldquo;TF-CBT Ukraine,\u0026rdquo; as well as the input provided by the international trainers. To ensure cultural appropriateness, the interview guide was reviewed by MH, a Ukrainian psychologist residing in Germany and a member of the research team.\u003c/p\u003e \u003cp\u003eWhile four focus groups were initially planned, only three were conducted due to organizational constraints. However, prior research suggests that two to three focus groups are typically sufficient to identify approximately 80% of relevant themes (Guest et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Therefore, the number of focus groups conducted is considered adequate for addressing the present research questions. All three focus groups took place in April 2023. In Focus group 1, only one therapist participated, in Focus group 2 and 3 there were 3 therapists participating in each group. Each focus group was conducted online and facilitated in Ukrainian by MH, an Ukrainian female psychologist and researcher, who was also in training of TF-CBT. All sessions were video recorded. Each focus group lasted up to 130 minutes (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;111 minutes, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;30,92; Range 75\u0026ndash;130 minutes). Only the moderator and the participants were present during the focus groups.\u003c/p\u003e \u003cp\u003eAt the beginning of each session, the moderator and participants introduced themselves. The moderator then provided an overview of the focus group structure before initiating the discussion with the first question. Throughout the session, the moderator actively encouraged participation from all group members to ensure a balanced and inclusive discussion.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data were transcribed and anonymized by MH, a Ukrainian native speaker and translated into English by professional Ukrainian interpreters who are familiar with TF-CBT. The data was analyzed according to Kuckartz and R\u0026auml;diker (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) by two authors (MG and a research assistant (VP)), one of whom (MG) holds a master degree in intercultural psychology and migration studies and the research assistant is currently finishing her master studies in clinical psychology. After an initial familiarization with the content of the transcripts, the coding process combined inductive and deductive approaches, supplemented by analytical memos to discuss unclear expressions. Based on the interview guideline, MG developed a preliminary codebook from all three focus groups, which was refined through ongoing analysis with input from VP, reaching consensus on code after review. Discrepancies in coding were discussed and resolved through consensus within the research team. In cases of divergent interpretations, the respective passages were re-examined in their original context until agreement was reached. Negative or deviant cases were systematically identified and analyzed in order to refine the coding framework and to ensure that the final code list adequately captured variations and contradictions within the data. The resulting defined code list was analyzed using MAXQDA 24. Codes that were mentioned only once were grouped under the code \u0026ldquo;other\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.\u0026nbsp; \u0026nbsp;Experience in implementing TF-CBT in Ukraine\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the therapists had to actively recruit patients themselves. Instead, existing networks were utilized, such as contacts with local social services, other therapists, or institutions like Non-Governmental Organisations, juvenile criminal police, or churches, which referred patients to the therapists. Nevertheless, the participating therapists mentioned that there is a substantial unmet need for therapy among children and adolescents from Ukraine, many of whom have not yet received treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome therapists previously had little experience in conducting psychotherapy with children and adolescents, as they had primarily worked with adult clients. Since working with children requires a different approach than with adults, various adjustments were made, such as allowing children to bring toys or pets to therapy sessions, incorporating movement breaks during sessions, or using creative methods like drawing instead of relying solely on verbal narration of experiences. ID 1.1. stated: \u003cem\u003e“\u003c/em\u003e\u003cem\u003eDuring our sessions, I also allow children to get up and move. I say, ‘It’s been fifteen minutes now. Let's jump around.’ They love it. Body activation is a must for children. And then, “Can I show you a break dance?” – “Okay”. Why not give a child two minutes? (Position 1.117)“.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll therapists reported subjective improvements in patients' symptoms, which became particularly evident through feedback from parents to therapists. Improvements in sleep, renewed participation in daily activities such as attendance at school or participation in hobbies, shared meals with the family, and increased social contact were frequently mentioned indicators of symptom improvement:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Back to this traumatized boy, we are already reaching the end of our therapy, and his mother wrote a very nice message to me last week saying that her child had been suffering for a year, and now he could finally sleep. This is the first month that he has been sleeping through the night. Before that he had disturbing dreams and couldn't fall asleep.” (ID 2.1, Position 2.163).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, therapist ID 1.1 also reported that there were some of her patients whose symptoms became more severe following exposure than they had been before (Position 1.252).\u003c/p\u003e\n\u003cp\u003eTF-CBT was conducted both in-person (7/7 therapists) and online (6/7 therapists), depending on the professional circumstances of the therapists and the geographical locations of the patients. Therapists clearly expressed a preference for in-person sessions, as they allowed for a more accurate response to patients' physical reactions and were not affected by poor internet connectivity, which could otherwise disrupt the flow of a therapy session. Nevertheless, therapists also acknowledged the benefits of online therapy, as it enabled access to patients located in other countries or regions remote areas. As one therapist put it, “\u003cem\u003eit's better to do it [online] than not to do it\u003c/em\u003e (ID 3.2, Pos. 3.196)”. Furthermore, the children were according to the therapists already familiar with the online format due to the COVID-19 pandemic, which facilitated the online TF-CBT implementation. From the therapists’ perspective, however, ID 1.1 clearly articulated a desire to learn more about how specific situations, such as working with parents or with sexually abused children, can be implemented effectively and safely in an online setting, since she was lacking knowledge in this regard (Position 1.92).\u003c/p\u003e\n\u003cp\u003eHaving a clear structure for the therapy sessions through the manualized intervention was perceived as very helpful. ID 2.1 describes it as follows:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e„The first thing that I really like and use with my patients is that there is a therapy plan that I follow, there are clearly structured sessions. I know exactly what I am doing. I can explain everything to my clients, whether they are teenagers or children. And they also understand what is happening to their brain, what is happening to their behavior, what thoughts they have, why these thoughts affect their functioning, how they affect their quality of life.”\u0026nbsp;\u003c/em\u003e(Position 2.161)\u003c/p\u003e\n\u003cp\u003eShe also reports that patients had specifically chosen her as their therapist because they greatly valued the structured and clearly defined procedures of TF-CBT and, in particular, after having already tried other therapeutic approaches, patients had intentionally chosen this treatment method (Position 2.110).\u003c/p\u003e\n\u003cp\u003eTherapists reported experiencing various emotional and physical reactions during or after the implementation of TF-CBT. These included exhaustion, anger and aggression, as well as intense bodily sensations such as nausea. At the same time, they also described positive emotions, such as joy at being able to help patients process their experiences, and happiness when patients left a session or completed the therapy showing positive changes. To cope with the wide range of often intense emotions, the therapists report using various self-care strategies. Despite their heavy workloads, they state that they do not work on Sundays (even though Sunday is considered a regular workday in some of the countries where the therapists currently reside). In addition, they emphasize the importance of getting sufficient sleep, engaging in physical activity, and ensuring that coffee and food are always readily available. They have also developed highly individualized self-care routines, such as listening to classical music while cooking or cleaning to unwind or engaging in hobbies such as puzzling or sewing. Moreover, exchange with colleagues, such as through supervision within the TF-CBT Ukraine project, was described as beneficial for their own well-being. Participant ID 3.2 describes using stabilization techniques such as breathing exercises or the visualization of a safe place and underscores their importance:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“When we want to take care of our health, we make appointments with doctors. It's the same with self-care. There must be a sort of self-care schedule (Position 2.370)”.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipant ID 3.1 reports similar experiences and adds that her knowledge of Cognitive Behavioral Therapy (CBT) skills has a positive effect on her overall well-being:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I can even see how my work, my work in CBT, significantly affects the quality of my life. I mean, you use the same techniques for yourself, and you have a completely different attitude to thoughts, and it's much less exhausting, much easier when you have a good connection with them. So that's also how I deal with it. (Position 3.295)”.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNonetheless, participant ID 2.3 also notes that under current circumstances, self-care is particularly challenging. She states:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eIn terms of self-care, nowadays there is a little less sunshine, you know. Somehow the weather is not very conducive to overall wellness. But there are stabilization techniques, I agree (Position 2.368)\u003c/em\u003e”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.1. \u003cstrong\u003eChallenges in treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the positive feedback regarding the feasibility and effectiveness, participants reported various challenges in implementing TF-CBT with Ukrainian children and adolescents. The challenges mentioned included various difficulties arising from the ongoing war and its effect on both child, parent and therapist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Ongoing war and the lack of a safe environment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe most frequently mentioned challenge in implementing TF-CBT in the Ukrainian context was the ongoing war, which often meant that a safe environment, could not be guaranteed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eAnother important thing that we need to keep in mind is that the war is ongoing. I mean, we process a traumatic experience and then it recurs. […] They know based on the sound what [missiles] it is. And then they slip back into that reaction, even though we have processed the previous event. The war is not over. Doing exposure in the midst of the war is a new experience (Position 1.130-131).”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ongoing war situation is described by ID 3.3 as a highly emotional burden. She recounts the story of a “[…] \u003cem\u003egirl from Mariupol, they stayed in that bunker and then they found out about the death of their loved ones (Position 3.68).\u003c/em\u003e\" This reality confronted therapists with entirely new challenges, which they also discussed during supervision sessions as part of the accompanying training program. For example, participating therapists reported that during air raid sirens or bomb alarms, clients would panic, crouching on the floor or hiding. In light of the continuous shelling of Ukrainian territories, such intense reactions to the ongoing war represent one of the greatest obstacles to effective therapy, as “\u003cem\u003ethe child’s psych doesn’t have enough time to fully […] recover\u003c/em\u003e” (ID 1.1., Position 1.134). Therapists reported that they were “\u003cem\u003edealing with children who are constantly under stress, just like their parents. Well, maybe there are no bombs flying around, but other cues and triggers arise\u003c/em\u003e” (ID 2.2.; Position 2. 175).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, several therapists emphasized that the therapeutic goals of parents or children often did not focus on the trauma itself, but rather on issues such as the treatment of other mental health difficulties such as enuresis or school-related difficulties. In the context of the ongoing war of aggression against Ukraine, \u003cem\u003e“traumatization seems to have taken a back seat. […] It has become part and parcel of their everyday life, this war and the fact that people are dying, this whole situation”\u0026nbsp;\u003c/em\u003e(ID 2.3, Position 2.145).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Technical difficulties\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother war-related challenge lies in technical difficulties. As ID 1.1 reported one client had to leave \u003cem\u003e[name of Ukrainian city removed due to the anonymization]\u0026nbsp;\u003c/em\u003edue to the war and moved to a location with very poor internet connection. As a result, it was logistically impossible to continue therapy. Therapists also reported technical issues such as unstable internet connections due to the power outages: “\u003cem\u003eYou couldn’t do full-fledged exposure because the connection could be interrupted any minute\u003c/em\u003e” (ID 1.1, Position 1.136). However, the extent to which this challenge was perceived varied depending on the infrastructure of the respective workplace. For instance, ID 2.1 explained that her workplace was part of the critical infrastructure: “\u003cem\u003eTherefore, I was lucky to have uninterrupted power supply in my office. Only once, there was one single time when they turned it off. So, I could have my counselling sessions at work, no problem. Yeah? That's a big advantage for me\u003c/em\u003e (Position 2.261).”\u003c/p\u003e\n\u003cp\u003e1.1.3. \u003cem\u003eWorking with caregivers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA commonly reported challenge raised by participants in the focus groups was working with caregivers. For example, participants reported that, due to the war, many parents are themselves traumatized or otherwise psychologically burdened. They are often constantly following the news and, because of their own poor mental health, may negatively impact their children's well-being.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e“\u003cem\u003eChallenges also arise when a child is triggered by their parents. I mean that the parents are in such a bad mental state that the child absorbs their emotions after a session and sinks back into a hole. Circumstances like that. And I can't always talk parents into joining the therapy. In the end, it’s up to them. (ID 1.1., Position 1.130)”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCaregivers were described as being so preoccupied with their own problems and challenges that, on the one hand, children often assumed the role of the supportive figure within the family dynamic. As a result, caregivers frequently failed to recognize that their children were also struggling. ID 2.2. reported:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A lot of children helped their own parents. They were stronger during those bombings. Children helped their parents, supported them. And the first thing parents said was, “No, she is fine. She supported me. She said everything would be fine.” Children often initiated the family’s departure from the occupied territories. The parent-child dynamics got skewed. (ID 2.2., Position 2.312-313)”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, despite receiving psychoeducation and dedicated caregiver sessions as part of the TF-CBT protocol, many caregivers did not fulfill their role in the implementation of TF-CBT and did not apply the parenting skills. ID 3.1 explains this by pointing to a lack of awareness of psychotherapy in Ukraine. \u003cem\u003e“Parents are more used to just taking pills” (Position 3.229)\u003c/em\u003e. This observation was shared by other therapists, who reported that support offers were often not accepted, and that parents in particular were highly skeptical about psychotherapy. Traumatic experiences and the resulting psychological burden were perceived as a current norm in Ukraine, which led to a lack of awareness among parents and children/adolescents that therapy could be helpful in their situation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.4.\u0026nbsp; \u0026nbsp;\u0026nbsp;Challenges due to cultural aspects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eApart from the previously described, potentially cultural challenges in working with Ukrainian parents, no further specific cultural challenges were reported. ID 1.1. stated: “[...] \u003cem\u003eno differences in cultural factors or any other national factors. I didn't see that in our program. It was all about ‘here's a problem, this child has this problem, and this is what we do’. That was the scheme. [...] And it worked. [...] There was nothing about certain things working only for people of specific religions or something like that”\u003c/em\u003e (Position 1.243–246).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2. \u003cstrong\u003eAdaptations for the Ukrainian context\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eGiven the multitude of challenges therapists encountered in delivering TF-CBT to Ukrainian children and adolescents, it is not surprising that certain adaptations were made to ensure successful implementation. However, these were not modifications to the TF-CBT manual itself, but rather adjustments or additional techniques made in response to the challenges described above. The TF-CBT manual was largely adhered to. For example ID 3.1. reported\u003cem\u003e: “it all depends on the case, […] sometimes you stay for several sessions working on one component\u003c/em\u003e (Position 3.160). The only deviations reported by some therapists concerned a more intensive and prolonged focus on psychoeducation, therapeutic relationship and stabilization, as well as an extension of the overall number of sessions, since in some cases it took longer for clients to feel ready to share their traumatic experiences. \u0026nbsp;In addition, therapy had to be slightly adapted for each individual client. As ID 2.3 reported, for example, breathing techniques did not help all clients, nor did muscle relaxation exercises. It was a “\u003cem\u003ekind of search within the proposed algorithm\u003c/em\u003e” (Position 2.239) to find the appropriate methods and techniques for each client. “\u003cem\u003eSome things work well with children, while others don't”\u003c/em\u003e (Position 2.240).\u003c/p\u003e\n\u003cp\u003eCulturally-based adaptations were reported only by ID 1.1: \u003cem\u003e“I switch to Russian only if a client is from the Luhansk or Donetsk region, where Russian is their everyday language. As you might know, we do therapy in the language the person thinks in\u003c/em\u003e” (Position 1.14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Working with caregivers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDespite the frequently discussed challenges in working with caregivers, none of the participants reported specific adaptations in how collaboration with caregivers was conducted. In cases where caregivers exhibited noticeable psychological distress, they were, at best, referred to psychologists themselves.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Ongoing war and the lack of a safe environment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDue to the ongoing war situation, certain adaptations were necessary to provide both therapists and clients with a greater sense of safety during therapy sessions. For instance, ID 3.2 reported that in the initial sessions, she supplemented the TF-CBT manual by also inquiring about war-related fears, such as fear of explosions or sirens. If significant fear was present, the focus of her therapy would shift toward stabilization, calming, relaxation, and the question: “\u003cem\u003eHow likely is it that you will be okay here?\u003c/em\u003e” In doing so, she aimed to “\u003cem\u003egive them the opportunity to feel relaxed; only then would I address the traumatic effect, the traumatic event\u003c/em\u003e” (Transcript 3 (Engl): 208).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSince a safe place could not be assumed during the ongoing war situation, therapists reported various adaptations and alternative methods in place of the TF-CBT “safe place” technique. These ranged from imagination exercises exploring what the client’s safe place would look like and which objects and people would be present, to questions such as “\u003cem\u003eHow do you want us to win?\u003c/em\u003e” (Position 2.191), and even “\u003cem\u003eWhat happens next? What are we going to do when we win?”\u003c/em\u003e (Position 2.311).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.3.\u0026nbsp; \u0026nbsp;\u0026nbsp;Technical difficulties\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOne therapist, ID 1.1, reported specifically how she proactively addressed the emotional uncertainty caused by power outages during therapy sessions:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A\u003c/em\u003e\u003cem\u003et the beginning of each session I discuss it with both adults and children, ‘If the Internet goes down, we call back as soon as the power and the Internet come back on, no matter what. Or we text each other if the session is over timewise.’ Because there were situations when I had Internet outages even though I was in another country. […] It reduces their anxiety as they might be thinking, ‘Maybe I've been abandoned’. I had one client like that. He told me, ‘I thought you disconnected halfway through my story because you couldn't take it.’ […] now I always discuss it in advance, ‘If I disappear, it’s not because you told me something wrong […]’ Sort of power supply psychoeducation. (Position 1.136-140)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.\u0026nbsp; \u0026nbsp;Feedback Training Program\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported being generally very satisfied with the training program “TF-CBT Ukraine” (Pfeiffer et al., 2023; Pfeiffer et al., 2025). One participant stated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e„The training itself was highly professional. This is something that we lack in Ukraine. Now I have a much better understanding of how to work with children and adolescents with trauma.\u003c/em\u003e\u0026nbsp; (ID 2.1, Position 2.111)“.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThey said that being part of the training program made them feel more confident, especially when working with children. Participating therapists particularly appreciated the clear structure of the training, the communication between organizers, trainers, and participants, and regarded every component of the training program as supportive for successfully learning the therapeutic method. As one participant put it:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I spend a lot of time learning, but this is probably my first project where there is so much support and guidance. Yes, there are letters. I call them happiness [that’s what I call them]. You know, every time you get one, it's some kind of news that you're waiting for, a reminder that you have a supervision in two days, or a reminder that they are planning to develop roadmaps, and they want to involve you in the process (ID 2.1. Position 2.109)”.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipant ID 3.2 emphasized the importance of personal contact as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e„So, actually, the project is valuable not only because it provides knowledge, but also because it provides personal support to us (Position 3.52)”.\u003c/em\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhile participants noted that the training involved a high volume of theoretical content at the beginning, they reported becoming increasingly familiar with both the content and the structure over time. Several participants stated that the early and transparent communication of schedules was particularly helpful, as it allowed them to plan accordingly.\u003c/p\u003e\n\u003cp\u003eInterviewee 2.1 reports that without simultaneous interpretation she would not have been able to participate in the program, as her English proficiency was insufficient. As soon as participation in Ukrainian became possible, she registered immediately (Position 2.50).\u003c/p\u003e\n\u003cp\u003eThe only critical remark regarding the overall training program came from ID 1.1, who commented on the online format:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I'm just used to this format. Of course, it would be great if it were in person, if we lived in peacetime, if we had a full day of training with coffee breaks and informal discussions.” (Position 1.63-66).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, she went on to note: “\u003cem\u003eThis format works pretty well for me.” (Position 1.67).\u003c/em\u003e Nevertheless, especially at the beginning of the training program, there was a large amount of theoretical input, according to ID 1.1 (Position 1.71). The participating therapists found it very difficult to name a highlight of the training program, since “\u003cem\u003eI really like the way the program is structured and divided in general, and without any part of the program it would be much more difficult\u003c/em\u003e.” (ID 3.2, Position 3.108). Later she adds: \u003cem\u003e“It's hard to say, because the whole program was the icing on the cake for me, to be honest. To single it out right away. Well, it's hard for me to say offhand what the highlight was.”\u0026nbsp;\u003c/em\u003e(Position 3.275). However, the supervisions, the voluntary additional workshops, and the provided materials were considered particularly helpful for the learning process. Regarding the supervisions, ID 3.2 reports:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The highlight […] I guess it's still supervisions, perhaps. Because I think I have a lot of experience […] of programs that we went through, were trained in. But there were no such long-term year-long supervisions, where you knew that you were allowed to practice clinically and would be supported in this way. […] And you are provided with such support. There used to be intervision groups, there were singular supervisions, but the fact that you are guaranteed to get a year's worth of time and you take cases and you know for sure that you will receive support, I think this is the biggest highlight of this program.”\u003c/em\u003e (Position 3.275–277)\u003c/p\u003e\n\u003cp\u003eAnother key aspect was the additional optional workshops introduced during the course of the project. These addressed supplementary topics relevant to the treatment of traumatized Ukrainian children and adolescents, which were not part of the core TF-CBT training curriculum. As ID 3.2 describes:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Theoretically, it is possible to do without those additional seminars that were announced as additional seminars. But this is such a helpful part. I am very happy that it was there too.” (Position 3.108)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor example, one optional workshop was on the topic on traumatic grief. ID 3.1 remembered:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“There was a seminar on grief that was very helpful to me. […] topic is an integral part of working with trauma during the war. […]. That is, it became understandable how to clearly recognize this complicated grieving, yes, so the trainers gave very good answers.” (Position 3.88)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThese optional workshops were offered to all project participants, but they were also recorded and made available afterwards, enabling asynchronous learning as well. ID 1.1 reports:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“and the recordings that I am very grateful for. Because you can’t always listen with concentration, or you can be distracted by something else […], so I listen again. I'm very grateful for that.”\u0026nbsp;\u003c/em\u003e(Position 1.54)\u003c/p\u003e\n\u003cp\u003eIn addition to the individual components of the training program, the materials provided were also considered very helpful:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“But we are so well provided with methodological material […], everything is uploaded, from workbooks to materials needed for psychoeducation. At each stage, we have a set of materials that we can use. they are divided into folders. Programs that are recommended to us, like a mobile application, in order to implement certain stages of the protocol. It is very convenient in this context.”\u003c/em\u003e (ID 3.X, Position 3.82)\u003c/p\u003e\n\u003cp\u003eThe TF-CBT-specific workbooks in particular were especially helpful in following the therapy protocol (Position 3.83).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e2.1. Suggestions for Improvement\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn order to better tailor training programs to the needs of Ukrainian therapists, suggestions for improvement were collected. Most notably, these included requests for more frequent supervision sessions (twice per month) and more regular additional workshops (at least once a month). ID 2.X explains it as follows: “\u003cem\u003eThe more knowledge you have, the better you understand, the fewer mistakes you make then, right? Well, this is my thing. The more knowledge, the better for me\u0026nbsp;\u003c/em\u003e(Position 2.99).” Specifically, there was a desire for optional workshops on the topics of “sexual abuse against children,” particularly in times of war, and “complex trauma”.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study presents, for the first time, qualitative data of therapists on the implementation of TF-CBT in an ongoing war context. Overall, despite existing challenges, the implementation of TF-CBT in Ukraine can be considered both feasible and beneficial. The high demand for trauma-focused interventions for Ukrainian children and adolescents previously reported in earlier studies (Pfeiffer et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) was once again confirmed by the ease with which participating therapists were able to recruit patients. Furthermore, the findings indicate that TF-CBT is effective as a therapeutic approach even under the exceptional and challenging conditions of an ongoing war, which is in line with the quantitative patient results (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Particularly noteworthy is that a high degree of treatment fidelity was reported even under highly stressful circumstances affecting not only the children and their parents but also the therapists themselves (Freedman \u0026amp; Tuval Mashiach, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Taubman \u0026ndash; Ben-Ari et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This finding not only confirms the cross-cultural applicability of TF-CBT, as previously demonstrated in Thielemann et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), but also adds qualitative evidence to the quantitative shown evidence of the feasibility of TF-CBT in a context of an ongoing war (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Therefore, the findings highlight the considerable potential for the use of TF-CBT in crisis and conflict regions worldwide. Similar to the findings reported by Murray et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2013\u003c/span\u003e) in the contextual description, therapists implemented the core elements of TF-CBT. However, certain adaptations were made to implementation techniques in response to the war situation. Despite the absence of a safe environment, previously considered a prerequisite for conducting PTSD-Treatment (Sch\u0026auml;fer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), our findings indicate that TF-CBT can be successfully applied even in situations of ongoing war.\u003c/p\u003e \u003cp\u003eDespite the generally positive findings regarding implementation of TF-CBT during an ongoing war, it is essential that existing training and therapy programs be adapted to the specific conditions of an ongoing war in order to ensure long-term implementation. The present study clearly highlights the challenges therapists face when providing trauma-focused therapies during a persistent threat situation. Both adaptations and creativity on the part of therapists, openness on the part of patients and their caregivers, as well as adjustments by trainers and supervisors are required to ensure alignment between specific needs and available services. In the present project, for example, the introduction of simultaneous translation proved to be a particularly successful measure. It might not only substantially increased the utilization of the program but might also have improved the overall quality of the training. By providing translation, language barriers were reduced, which significantly enhanced communication between trainers and supervisors and the therapists. This measure likely contributed to the high level of treatment fidelity reported (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In addition, the present project was able to respond to emerging topics and the therapists\u0026rsquo; needs by offering additional optional workshops. Continuous contact between the project team and the participants allowed for timely responses to these needs, which proved to be essential for the overall success of the program. Continuous adaptation and expansion of training opportunities can enable TF-CBT to be successfully learned and implemented even under particularly challenging circumstances. Therefore, it is essential to respond to the specific local conditions and requirements in order to create training opportunities that are as accessible as possible. As some therapists reported own psychological distress after TF-CBT sessions it seems crucial to offer ongoing case consultation and supervision, thereby also focusing on the mental wellbeing of the therapists by programs such as the PRACTICE skills course (Pollio et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWorking with caregivers remains a major challenge. Therapists in this study did not report specific adaptations that had already been implemented to improve the inclusion of caregivers in TF-CBT treatment. This may be attributable to several factors. On the one hand, it is conceivable that parents themselves are heavily burdened by the war situation (Karatzias et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). On the other hand, there might be a lack of mental health literacy within the general population in Ukraine (Quirke et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It is therefore highly necessary to increase societal awareness of the relevance of mental disorders and of the effectiveness of evidence-based therapeutic methods, alongside or at least as an alternative to psychopharmacological treatment. Psychoeducational campaigns (e.g. Gorbunova \u0026amp; Klymchuk, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) and other measures aimed at reducing stigma toward mental illness (e.g. Ekblad et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) should therefore be increasingly implemented in order to improve collaboration between therapists and the family system.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThe findings of the present study should be interpreted in light of several limitations. A substantial sample bias cannot be ruled out. Participants in the study were particularly active therapists involved in the \u0026ldquo;TF-CBT Ukraine\u0026rdquo; project, who had distinguished themselves through regular and highly engaged participation in supervision sessions. This sampling strategy was chosen in the hope of achieving the highest possible participation rate in the focus groups in order to facilitate in-depth and meaningful discussions. In addition, the symptom improvements reported in this study are based solely on therapists\u0026rsquo; subjective reports. However, these findings are consistent with the objective measures previously demonstrated in the evaluation study of the \u0026ldquo;TF-CBT Ukraine\u0026rdquo; project (Pfeiffer et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThe present study clearly demonstrates that TF-CBT can be implemented successfully in an ongoing war context with only minor adaptations. TF-CBT should therefore be further disseminated in other conflict- and crisis regions. Political stakeholders need to place greater emphasis on the relevance of such measures and provide, among other forms of support, adequate financial resources in order to sustainably improve the mental health of children and adolescents worldwide. At the same time, accompanying research remains necessary, as context-specific adaptations to training programs may be required.\u003c/p\u003e \u003cp\u003eOnline formats introduce new challenges but also create many new opportunities to further advance the global dissemination of trauma-focused therapeutic methods. In regions with little evidence-based treatments implemented so far, they might represent an important solution. Therefore, scientific evaluations of digital training concepts are crucial.\u003c/p\u003e \u003cp\u003eSelf-care among therapists working in these highly demanding circumstances is of particular importance. This is not only reported by the participating therapists in this study but is also reflected in the broader scientific discussion on secondary traumatization and the overall professional quality of life of therapists (Canfield, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). At the beginning of the war of aggression, the Ukrainian therapists in this project demonstrated remarkable resilience (Kostova et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, this resilience must be continuously maintained and stabilized through ongoing self-care activities. Programs such as a PRACTICE skill course for therapists (Pollio et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) should therefore be implemented broadly for therapists working in crisis and conflict regions so that they can learn strategies for effective self-care. Only therapists who themselves maintain good psychological well-being possess sufficient mental capacity to support and improve the mental health of traumatized children and adolescents.\u003c/p\u003e \u003cp\u003eThe \u0026ldquo;TF-CBT Ukraine\u0026rdquo; project once again illustrates how cooperation between international experts and local partners can lead to the development of sustainable structures within the respective regions. As a result of the project, a follow-up initiative has now emerged directly within Ukraine, in which participants from the original \u0026ldquo;TF-CBT Ukraine\u0026rdquo; project, now being internationally certified TF-CBT trainers, are training additional Ukrainian therapists in TF-CBT. However, a participatory approach is needed not only in practical implementation but also in research in order to adapt programs appropriately to the context-specific realities faced by therapists, children, and adolescents in affected regions. Furthermore, it is essential to give a voice to those implementing these methods under challenging conditions through increased qualitative research. This study represents one of the first qualitative investigations focusing on therapists\u0026rsquo; perspectives in wartime settings. In the future, children, adolescents, and parents should also be included in qualitative studies so that their perspectives can be more strongly represented in research and experiences related to trauma therapy and war can be better understood.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study is encouraging not only in light of the now more than four-year-long war of aggression by Russia against Ukraine, but also clearly demonstrates the possibility of providing evidence-based trauma therapy at an early stage in other conflict and war regions, rather than waiting for the often unpredictable end of a conflict. Such an approach could contribute to reducing the currently very high rates of PTSD in populations living in war and crisis regions (Ahmed et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) at an early stage and, ideally, help prevent complex and chronic trajectories (Roberts et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCBT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Cognitive Behavioral Therapy\u003c/p\u003e\n\u003cp\u003eTF-CBT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Trauma-Focused Cognitive Behavioral Therapy\u003c/p\u003e\n\u003cp\u003ePTSS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;post-traumatic stress symptoms\u003c/p\u003e\n\u003cp\u003ePTSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; post-traumatic stress disorder\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project received ethical approval by the Ulm University (Number: CI/Sta) in Germany and the Zhytomyr Ivan Franko University (Number: 9-09072022) in Ukraine. All participants were informed about the study protocol and gave their written consent prior study inclusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe consent for publication was obtained from all therapists included in this study. The individual information was handled anonymously.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe anonymized dataset used for this study is available from the corresponding author upon reasonable request. The used semi-structured interview guideline can be found in the supplementary material of this publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflict of interest/ competing interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancial Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Swiss Cooperation Office, Porticus Foundation, and the Medical University of South Carolina, College of Medicine Drexel University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors made the conceptualization of the focus group. EP and CS obtained funding and provided supervision. MH conducted and transcribed the focus groups. MG analysed the data, drafted the initial manuscript. All authors critically reviewed the manuscript. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all involved collaboration partners, who supported the TF-CBT Ukraine project. A special thanks goes to our translators Oksana Mykytka and Olia Thyshkovets. Most importantly though, we would like to thank all Ukrainian therapists and patients who participated in this project.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAhmed, S. H., Zakai, A., Zahid, M., Jawad, M. Y., Fu, R., \u0026amp; Chaiton, M. (2024). Prevalence of post-traumatic stress disorder and depressive symptoms among civilians residing in armed conflict-affected regions: A systematic review and meta-analysis. \u003cem\u003eGeneral Psychiatry\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(3), e101438. https://doi.org/10.1136/gpsych-2023-101438\u003c/li\u003e\n\u003cli\u003eCanfield, J. (2005). Secondary Traumatization, Burnout, and Vicarious Traumatization. \u003cem\u003eSmith College Studies in Social Work\u003c/em\u003e, \u003cem\u003e75\u003c/em\u003e(2), 81\u0026ndash;101. https://doi.org/10.1300/J497v75n02_06\u003c/li\u003e\n\u003cli\u003eCarpiniello, B. (2023). The Mental Health Costs of Armed Conflicts-A Review of Systematic Reviews Conducted on Refugees, Asylum-Seekers and People Living in War Zones. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(4). https://doi.org/10.3390/ijerph20042840\u003c/li\u003e\n\u003cli\u003eCohen, J. A., Mannarino, A. P., \u0026amp; Deblinger, E. (2016). \u003cem\u003eTrauma-focused CBT for children and adolescents : treatment applications / edited by Judith A. Cohen, Anthony P. Mannarino, Esther Deblinger\u003c/em\u003e (Paperback edition). Guilford Press. \u003c/li\u003e\n\u003cli\u003eCohen, J. A., Mannarino, A. P., \u0026amp; Murray, L. K. (2011). Trauma-focused CBT for youth who experience ongoing traumas. \u003cem\u003eChild Abuse \u0026amp; Neglect\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(8), 637\u0026ndash;646. https://doi.org/10.1016/j.chiabu.2011.05.002\u003c/li\u003e\n\u003cli\u003eEkblad, S., Gramatik, O., \u0026amp; Suprun, Y. (2024). Increasing perceived health and mental health literacy among separated refugee Ukrainian families with urgent needs occasioned by invasion-a group intervention study with participatory methodology in Sweden. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e, 1356605. https://doi.org/10.3389/fpubh.2024.1356605\u003c/li\u003e\n\u003cli\u003eFreedman, S. A., \u0026amp; Tuval Mashiach, R. (2018). Shared trauma reality in war: Mental health therapists\u0026apos; experience. \u003cem\u003ePloS One\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(2), e0191949. https://doi.org/10.1371/journal.pone.0191949\u003c/li\u003e\n\u003cli\u003eGorbunova, V., \u0026amp; Klymchuk, V [Vitalii] (2025). Universal mental health training: Policy proposal for national rollout of the new scalable intervention in Ukraine. \u003cem\u003eOpen Research Europe\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e, 119. https://doi.org/10.12688/openreseurope.20116.2\u003c/li\u003e\n\u003cli\u003eGoto, R., Pinchuk, I., Kolodezhny, O., Pimenova, N., Kano, Y., \u0026amp; Skokauskas, N. (2024). Mental Health of Adolescents Exposed to the War in Ukraine. \u003cem\u003eJAMA Pediatrics\u003c/em\u003e, \u003cem\u003e178\u003c/em\u003e(5), 480. https://doi.org/10.1001/jamapediatrics.2024.0295\u003c/li\u003e\n\u003cli\u003eGoto, R., Pinchuk, I., Kolodezhny, O., Pimenova, N., \u0026amp; Skokauskas, N. (2023). Mental health services in Ukraine during the early phases of the 2022 Russian invasion. \u003cem\u003eThe British Journal of Psychiatry : The Journal of Mental Science\u003c/em\u003e, \u003cem\u003e222\u003c/em\u003e(2), 82\u0026ndash;87. https://doi.org/10.1192/bjp.2022.170\u003c/li\u003e\n\u003cli\u003eGuest, G., Namey, E., \u0026amp; McKenna, K. (2017). How Many Focus Groups Are Enough? Building an Evidence Base for Nonprobability Sample Sizes. \u003cem\u003eField Methods\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(1), 3\u0026ndash;22. https://doi.org/10.1177/1525822X16639015\u003c/li\u003e\n\u003cli\u003eHook, K., Kozishkurt, J., Kovalchuk, O., Goncharenko, E., Kodovbetskyi, V., Opanasenko, M., Kopytko, A., Girnyk, A., Kliuzko, K., Drainoni, M.‑L., \u0026amp; Bogdanov, S. (2021). Evaluating context and interest in training in evidence-based mental health care: A qualitative investigation among healthcare providers in Kyiv, Ukraine. \u003cem\u003eBMC Research Notes\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 373. https://doi.org/10.1186/s13104-021-05786-3\u003c/li\u003e\n\u003cli\u003eKaratzias, T., Shevlin, M., Ben-Ezra, M., McElroy, E., Redican, E., Vang, M. L., Cloitre, M., Ho, G. W. K., Lorberg, B., Martsenkovskyi, D., \u0026amp; Hyland, P. (2023). War exposure, posttraumatic stress disorder, and complex posttraumatic stress disorder among parents living in Ukraine during the Russian war. \u003cem\u003eActa Psychiatrica Scandinavica\u003c/em\u003e, \u003cem\u003e147\u003c/em\u003e(3), 276\u0026ndash;285. https://doi.org/10.1111/acps.13529\u003c/li\u003e\n\u003cli\u003eKostova, Z., Pfeiffer, E., \u0026amp; Garbade, M. (2025). \u0026ldquo;What doesn\u0026rsquo;t kill you makes you stronger\u0026rdquo;\u0026mdash;Professional quality of life in Ukrainian mental health care professionals during the ongoing war. \u003cem\u003eTraumatology. \u003c/em\u003eAdvance online publication. https://doi.org/10.1037/trm0000562\u003c/li\u003e\n\u003cli\u003eKuckartz, U., \u0026amp; R\u0026auml;diker, S. (2022). \u003cem\u003eQualitative Inhaltsanalyse. Methoden, Praxis, Computerunterst\u0026uuml;tzung: Grundlagentexte Methoden \u003c/em\u003e(5. Auflage). \u003cem\u003eGrundlagentexte Methoden\u003c/em\u003e. Beltz Juventa. http://www.content-select.com/index.php?id=bib_view\u0026amp;ean=9783779955337 \u003c/li\u003e\n\u003cli\u003eLewey, J. H., Smith, C. L., Burcham, B., Saunders, N. L., Elfallal, D., \u0026amp; O\u0026apos;Toole, S. K. (2018). Comparing the Effectiveness of EMDR and TF-CBT for Children and Adolescents: A Meta-Analysis. \u003cem\u003eJournal of Child \u0026amp; Adolescent Trauma\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(4), 457\u0026ndash;472. https://doi.org/10.1007/s40653-018-0212-1\u003c/li\u003e\n\u003cli\u003eMartsenkovskyi, D., Karatzias, T., Hyland, P., Shevlin, M., Ben-Ezra, M., McElroy, E., Redican, E., Vang, M. L., Cloitre, M., Ho, G. W. K., Lorberg, B., \u0026amp; Martsenkovsky, I. (2024). Parent-reported posttraumatic stress reactions in children and adolescents: Findings from the mental health of parents and children in Ukraine study. \u003cem\u003ePsychological Trauma: Theory, Research, Practice, and Policy\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(8), 1269\u0026ndash;1275. https://doi.org/10.1037/tra0001583\u003c/li\u003e\n\u003cli\u003eMurray, L. K., Dorsey, S., Skavenski, S., Kasoma, M., Imasiku, M., Bolton, P., Bass, J., \u0026amp; Cohen, J. A. (2013). Identification, modification, and implementation of an evidence-based psychotherapy for children in a low-income country: The use of TF-CBT in Zambia. \u003cem\u003eInternational Journal of Mental Health Systems\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(1), 24. https://doi.org/10.1186/1752-4458-7-24\u003c/li\u003e\n\u003cli\u003ePfeiffer, E., Beer, R., Birgersson, A., Cabrera, N., Cohen, J. A., Deblinger, E., Garbade, M., Kirsch, V., Kostova, Z., Larsson, M., Mannarino, A., Moffitt, G., Onsj\u0026ouml;, M., Ostensjo, T., Sachser, C., Vikgren, A., Weyler Mueller, H., \u0026amp; Klymchuk, V [Vitaii] (2023). Implementation of an evidence-based trauma-focused treatment for traumatised children and their families during the war in Ukraine: A project description. \u003cem\u003eEuropean Journal of Psychotraumatology\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(2), 2207422. https://doi.org/10.1080/20008066.2023.2207422\u003c/li\u003e\n\u003cli\u003ePfeiffer, E., Garbade, M., Beer, R., Birgersson, A., Cabrera, N., Cohen, J. A., Deblinger, E., Gjini, R., Kirsch, V., Kostova, Z., Larsson, M., Mannarino, A., Moffitt, G., Onsj\u0026ouml;, M., Ostensjo, T., Vikgren, A., Weyler, H., Klymchuk, V [Vitalii], \u0026amp; Sachser, C. (2025). Evaluation of the feasibility and effectiveness of trauma-focused cognitive behavioural therapy for children and youth in Ukraine during the war. \u003cem\u003eEuropean Psychiatry : The Journal of the Association of European Psychiatrists\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(1), e96. https://doi.org/10.1192/j.eurpsy.2025.10032\u003c/li\u003e\n\u003cli\u003ePfeiffer, E., Garbade, M., \u0026amp; Sachser, C. (2024). Traumatic events and posttraumatic stress symptoms in a treatment-seeking sample of Ukrainian children during the war. \u003cem\u003eChild and Adolescent Psychiatry and Mental Health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(1), 25. https://doi.org/10.1186/s13034-024-00715-1\u003c/li\u003e\n\u003cli\u003ePollio, E., Deblinger, E., Cooper, B., Garbade, M., Harrison, J. P., \u0026amp; Pfeiffer, E. (2025). Engaging Ukrainian TF-CBT therapists in a PRACTICE skills course to support their wellbeing. \u003cem\u003eEuropean Journal of Psychotraumatology\u003c/em\u003e, \u003cem\u003e16\u003c/em\u003e(1), 2476898. https://doi.org/10.1080/20008066.2025.2476898\u003c/li\u003e\n\u003cli\u003eQuirke, E., Klymchuk, V [Vitalii], Suvalo, O., Bakolis, I., \u0026amp; Thornicroft, G. (2021). Mental health stigma in Ukraine: Cross-sectional survey. \u003cem\u003eGlobal Mental Health (Cambridge, England)\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e, e11. https://doi.org/10.1017/gmh.2021.9\u003c/li\u003e\n\u003cli\u003eRoberts, N. P., Kitchiner, N. J., Kenardy, J., Lewis, C. E., \u0026amp; Bisson, J. I. (2019). Early psychological intervention following recent trauma: A systematic review and meta-analysis. \u003cem\u003eEuropean Journal of Psychotraumatology\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(1), 1695486. https://doi.org/10.1080/20008198.2019.1695486\u003c/li\u003e\n\u003cli\u003eSch\u0026auml;fer, I., Gast, U., Hoffmann, A., Knaevelsrud, C., Lampe, A., Liebermann, P., Lotzin, A., Maerker, A., Rosner, R., \u0026amp; W\u0026ouml;ller, W. (2019). \u003cem\u003ePosttraumatische Belastungsst\u0026ouml;rung: S3 Leitlinie der Deutschsprachigen Gesellschaft f\u0026uuml;r Psychotraumatologie (DeGPT)\u003c/em\u003e. https://register.awmf.org/assets/guidelines/155-001l_S3_Posttraumatische_Belastungsstoerung_2020-02_1.pdf \u003c/li\u003e\n\u003cli\u003eTaubman \u0026ndash; Ben‐Ari, O., Erel‐Brodsky, H., \u0026amp; Ben‐Kimhy, R. (2025). Therapists in Wartime: Holding Others\u0026apos; Trauma While Contending With Your Own. \u003cem\u003eJournal of Clinical Psychology\u003c/em\u003e, \u003cem\u003e81\u003c/em\u003e(3), 119\u0026ndash;132. https://doi.org/10.1002/jclp.23751\u003c/li\u003e\n\u003cli\u003eThielemann, J. F. B., Kasparik, B., K\u0026ouml;nig, J., Unterhitzenberger, J., \u0026amp; Rosner, R. (2022). A systematic review and meta-analysis of trauma-focused cognitive behavioral therapy for children and adolescents. \u003cem\u003eChild Abuse \u0026amp; Neglect\u003c/em\u003e, \u003cem\u003e134\u003c/em\u003e, 105899. https://doi.org/10.1016/j.chiabu.2022.105899\u003c/li\u003e\n\u003cli\u003eThomas, F. C., Puente-Duran, S., Mutschler, C., \u0026amp; Monson, C. M. (2022). Trauma-focused cognitive behavioral therapy for children and youth in low and middle-income countries: A systematic review. \u003cem\u003eChild and Adolescent Mental Health\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(2), 146\u0026ndash;160. https://doi.org/10.1111/camh.12435\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trauma, Children, PTSD, Ukraine, War, TF-CBT, ongoing war, trauma-focused treatment","lastPublishedDoi":"10.21203/rs.3.rs-9569619/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9569619/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eSince 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.\u003c/p\u003e\u003ch2\u003eMethod:\u003c/h2\u003e \u003cp\u003eIn April 2023, three focus groups were conducted with a total of seven Ukrainian therapists who were part of the \u0026ldquo;TF-CBT Ukraine\u0026rdquo; project. The focus groups were transcribed, translated into English, and analyzed using qualitative content analysis with MAXQDA.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eAll 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\u0026rsquo; 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.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eThe 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.\u003c/p\u003e","manuscriptTitle":"“When the Safe Place Is Not Safe”: Therapists’ Perspectives on Implementing TF-CBT During the War in Ukraine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-12 16:48:12","doi":"10.21203/rs.3.rs-9569619/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-17T01:08:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140517182158115085497979019887189367486","date":"2026-05-05T01:17:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-05-04T17:32:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-04T08:51:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-02T05:36:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child and Adolescent Psychiatry and Mental Health","date":"2026-04-29T19:57:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"child-and-adolescent-psychiatry-and-mental-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"caph","sideBox":"Learn more about [Child and Adolescent Psychiatry and Mental Health](http://capmh.biomedcentral.com)","snPcode":"13034","submissionUrl":"https://submission.nature.com/new-submission/13034/3","title":"Child and Adolescent Psychiatry and Mental Health","twitterHandle":"@IACAPAP","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f78d68b-0bbb-4470-9665-75f36c0a397f","owner":[],"postedDate":"May 12th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-17T01:08:12+00:00","index":9,"fulltext":""},{"type":"reviewerAgreed","content":"140517182158115085497979019887189367486","date":"2026-05-05T01:17:11+00:00","index":8,"fulltext":""},{"type":"reviewersInvited","content":"2","date":"2026-05-04T17:32:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-04T08:51:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-02T05:36:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child and Adolescent Psychiatry and Mental Health","date":"2026-04-29T19:57:02+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T16:48:12+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-12 16:48:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9569619","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9569619","identity":"rs-9569619","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}