The Ministry of Social Affairs announced the PFA training courses on its Facebook page last Wednesday, inviting anyone who works together with war refugees, including as volunteers, to sign up; one one-day course each will be held in Tartu on Tuesday, May 10 and in Tallinn on Wednesday, May 11.

"Psychological first aid is an evidence-informed approach used to help those who have experienced traumatic events — including disasters and war — following these events," Sarapik, a specialist at the Mental Health Department of the Ministry of Social Affairs, told ERR News.

According to the WHO, PFA involves "humane, supportive and practical assistance for people who are distressed, in ways that respect their dignity, culture and abilities." The organization's 82-page field workers' guide to PFA is available online in a total of 36 languages, including Estonian, and "reflects emerging science and international consensus regarding how to support people in the immediate aftermath of extremely stressful events."

While the ministry does not have exact info regarding all mental health-related training, guidelines or resources that have been offered to date in Estonia, they are aware that the Women's Voluntary Defense Organization (Naiskodukaitse, NKK), the women's arm of the volunteer Estonian Defense League, has facilitated in-person PFA training more recently, and that the Social Insurance Board (SKA) also created an online course based on the WHO's resources.

"What makes this week's training provided by the WHO different from the online course is that these in-person courses are highly interactive, with constant participation, the opportunity to actually practice PFA via role playing during the training itself, and with immediate feedback from the trainer; this makes the training stronger as a whole," Sarapik explained.

"Perhaps more importantly, though, this week's training is specific to the humanitarian crisis in connection with the war in Ukraine," she continued. "While the basic principles of PFA remain the same, PFA training can be tailored to the intended audience and situation, whether for natural disasters, war, or smaller traumatic events that may occur on a more everyday basis, such as car crashes. What we need right now, however, is evidence-informed training with a humanitarian, war trauma focus."

The training received at this week's two one-day courses will ultimately reach beyond just the in-person attendees as well.

"As one goal for the Ministry of Social Affairs' Mental Health Department is capacity building, this training is 'train-the-trainer,' meaning that for those who participate in training — and who want — will, with future support, be able to train people within their respective organizations in turn," she said. "That is the intention of this — to ultimately reach as many people as possible throughout Estonia."

NGOs surprised by Estonia's refugee numbers

According to the public mental health expert, cooperation with international NGOs such as the WHO is imperative during humanitarian crises.

"For those countries bordering Ukraine, such as Poland, Slovakia and Moldova, the WHO is on the ground, meaning they have people located in those countries helping, providing PFA, organizing mental health and psychosocial support (MHPSS) as well as working on capacity building," she explained.

As Estonia does not share a border with Ukraine, several NGOs were still unaware in early March that Estonia was already receiving large numbers of war refugees from Ukraine until she reached out at an MHPSS Reference Group meeting of the Inter-Agency Standing Committee, a forum of the UN and non-UN humanitarian partners aimed at strengthening humanitarian assistance.

The response was immediate, including from Fahmy Hanna and Melita Murko from WHO Headquarters and the WHO Regional Office for Europe.

"Since then, we have had a great working relationship," she said. "They immediately did a webinar regarding humanitarian crises, the slides for which can be found on the Ministry of Social Affairs' page of resources regarding refugee mental health; we have kept in touch regarding mental health and psychosocial support; and now they provided the opportunity for Peter Hughes, a psychiatrist from the U.K. and longtime WHO partner, to come to Estonia and provide two in-person PFA training courses, one of which will be attended by Murko as well."

While the aforementioned ministry page bringing together resources and guidelines for providing mental health support to refugees is still not available in English, several of the resources linked there nonetheless are, including Hanna's slide deck from his March webinar, IASC and WHO's overview of resources for the humanitarian response in Ukraine and nearby countries, and a multi-agency MHPSS guide for refugees, asylum-seekers and migrants in Europe.

'Building back better'

Estonia has not had any firsthand experience with such a large-scale humanitarian crisis since World War II, when its own people were the refugees fleeing the country, said Sarapik, herself the grandchild of four such refugees to end up in the U.S.

"When I worked with refugees in Estonia in 2017-2018, there were about 300 refugees total living here," she recalled. "Now there are more than 36,000, and that number is still growing. Just as in the countries bordering Ukraine, we are working hard to build capacity for this work. The WHO calls it 'building back better,' and even has a technical document for it: 'Building Back Better: Sustainable mental healthcare after emergencies.' What this means is that as we are having to quickly learn and grow, in the future our mental healthcare will be even stronger than before."

According to the public mental health expert, the original intended audience for this training was people from every sector or organization that comes into contact with refugees within the first month of their arrival in Estonia.

"This included the Police and Border Guard Board (PPA), paramedics, the Rescue Board, emergency departments and hospitals, anyone working at Estonia's refugee reception centers and housing centers, as well as people in communities who may have initial contact with refugees, such as social workers and teachers," she said, noting that not all arriving war refugees go into state housing, and thus end up in direct contact with community members right away.

The ministry is aware that some members of the NKK have received in-person PFA training, and that psychosocial crisis support volunteers of SKA's Ohvriabi, the board's victim support arm, have also received online training. It also now has a database of its own for those who will be receiving training this week, and intends to keep in touch with participants so that the ministry can continue to track how much, how quickly and in what areas of Estonia their PFA skills are spreading.

Volunteers, Facebook groups providing crucial support

According to Sarapik, volunteers have played a huge rule in supporting incoming refugees in Estonia — at different places and in different ways.

"SKA has their own volunteers, and there are also volunteers at different NGOs and, as seen on Facebook, many are totally grassroots," she highlighted, acknowledging the efforts of regular residents of Estonia as seen in popular Facebook groups such as the quadrilingual "Friends of Ukraine in Estonia" ("Ukraina sõbrad Eestis"), which has more than 31,000 members.

"Regardless of what organization, name or title someone has, if they are working with refugees within the first month that a refugee is here, ideally, they should receive full PFA training," the expert emphasized. "It is even more critical for those working with refugees within the first days to week following their arrival."

If Estonia were right on the border with Ukraine, like Poland, Slovakia or Moldova, the WHO and other NGOs would be here on the ground providing psychological first aid as well as training people in how to provide PFA and/or train others in it, she continued, noting that they have been doing just that within Ukraine as well.

"Estonia may be further away from the border, and so it may take a few more days for refugees to arrive here from Ukraine, but it is still incredibly important," Sarapik said. "That's why we're making it happen, and that's why the WHO is coming here."

As of Monday, May 9, Estonia has received a total of 36,870 war refugees from Ukraine since February 27, according to PPA figures published Tuesday (link in Estonian). This total does not reflect those refugees considered to be in transit.

The ministry's PFA training this week will be conducted by British psychiatrist Peter Hughes, a longtime partner of the WHO; live interpretation into Estonian will be provided.

By Monday afternoon, a total of 70 people had registered for the PFA course in Tartu on Tuesday and 90 people for the course in Tallinn on Wednesday. According to a ministry spokesperson, they are no longer accepting further registrations for either day.

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