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The Experiences of Survivors and Trauma Counselling Service Providers in Northern Uganda and Rwanda: Implications for Mental Health Policy and Legislation

Funder

British Academy
Leverhulme Small Research Grants

Total value of project

£9,970

Project team

Dr Helen Liebling, Laura Davidson, Gladys Canogura, Geoffrey Ochola

Partners

Kitgum Women’s Peace Initiative, Global Women’s Peace Initiative (formerly Isis-WICCE, Uganda)

Duration of project

01/04/2013 - 31/01/2014

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Project overview

Previous research in northern Uganda found high levels of trauma-related difficulties amongst the conflict-affected population. There is international evidence that psychological therapy can reduce depression, as one of the psychological effects of trauma, but very limited literature regarding the experiences of trauma counselling in Sub-Saharan Africa.

The current British Academy and Leverhulme-funded research investigated the experiences of service users and providers of trauma services in Kitgum and Gulu, northern Uganda. It also examined their implications for mental health policy and legislation. A decision was made to utilise qualitative methodology to highlight the in-depth experiences of participants.

The researchers carried out interviews with 10 women and 10 men survivors attending trauma services in Kitgum and Gulu. The researchers also interviewed 15 key informants in Kitgum, Gulu and Kampala including trauma counselling service providers, ministers, cultural leaders and mental health professionals. The authors report the findings of the research based on thematic analysis of the interviews. Themes included the experiences of survivors, bearing witness and instilling hope, constraints to service provision, stigma and abuse, holistic approach, service providers doing their best, specialist populations, limited understanding, training and skills development, gaps in service provision and mental health policy and legislation. The interviews resulted in a clear indication that counselling and medication was valued by service users, and that service providers felt the treatments that were provided improved depression, and increased empowerment and engagement in social activities.

However, the authors argue that there was a limit to the benefits that could be achieved without using the holistic approach that the survivors requested. Thus, in cases of trauma arising from conflict, there is a clear need for the state to ensure reparation and/or justice for the atrocities witnessed by and perpetrated against survivors. This might include the provision of compensation, which would help to meet social needs and reduce feelings of shame and anger.

Project objectives

Specific objectives are to:

  1. assess service provision and the experiences of those accessing specialist psychological trauma services;
  2. examine gaps in current service provision; and
  3. evaluate the implications for mental health, educational policies and legislation.
  • Contribution to discipline
    1. The occurrence of a wide variety of psychological symptoms in conflict populations is widely documented by available research. However, research from different conflict-affected countries consistently demonstrates the value of both physical and psychological support in minimising the effects of war-related traumas (Murthy & Lakshminarayana, 2006). Survivors and service providers in the current study repeatedly blamed land disputes, stigma and harassment by communities, as well as a lack of basic resources, for the continued traumatic impact of their experiences and block to their recovery and resilience.
    2. Survivors expressed the desire for a holistic approach to meet their needs, as has been previously recommended by earlier research (Liebling et al., 2012). This included regular provision of medication, trauma counselling, vocational opportunities and financial support; especially the provision of school fees for their children. In terms of the approach to therapy and counselling, our research found survivors greatly valued person-centred approaches that also assisted them to build their own resilience.
    3. Those we spoke to also valued the opportunity to participate in group therapy, which has also found to be an effective approach within resource-constrained settings in Africa. However, the importance of choice of individual and/or group counselling approach for survivors was found to be imperative, along with the gender of the therapist.
    4. The holistic approach our study recommends also recognises the cultural and social realities of survivors continuing to struggle in their daily lives, and seeks to support and build resilience in individuals within their communities. Miller and Rasmussen (2010) recommend building a bridge between more clinically focused and psychosocially-oriented approaches for survivors of conflict-related violence. The current authors argue that there is a limit to the progress survivors can make through counselling and medication alone in the absence of meaningful justice for the atrocities they have experienced. Although there has been a peace and development programme for northern Uganda, this does not appear to have given sufficient attention to justice processes for the survivors. This issue has been discussed more fully in the key investigator's previous research (see Liebling & Baker, 2010). Where there is evidence of abuse, a formal acknowledgement that survivors were wronged should be given by the government. In addition, medical treatment could be funded. Schooling for children born from rape and if necessary, the resettlement of such families to a safe area should also be facilitated. Our research concludes that survivors perceived a benefit from having a listening ear and someone to confide in, and find this leads to greater reported empowerment and lifting of depression.
    5. However, the importance of continued reconciliation processes in order to transform society following conflict is also important here. Indeed, Rimé et al. (1992) found that describing experiences to others can transform its representation so that it takes a less emotive form. Rimé's research argues that this also assists survivors to gain a better sense of coherence, and social support and coping are also invaluable where a person's basic security is undermined. As found in the current study, shame and stigma the survivors we spoke to experienced, had a profound effect on their lives, and sensitive approaches to dealing with these issues are imperative. As Ahmed and Braithwaite (2006) also argue, social relationships and shame management are central to the processes of restorative justice.
    Societal impact
    1. The research was disseminated in the Ugandan National Parliament and the research recommendations acted on.
    2. The holistic model recommended was further improved by the trauma centres in Northern Uganda and the model disseminated at international conferences.
    3. The project recommendations were also utilised by service providers of trauma services for conflict survivors including better structures for supervision and support of staff and care and treatment of survivors.
    4. Dissemination of research findings led to positive changes for the support and protection of trauma survivors within the revised mental health legislation in Uganda.
  • 1. The primary product were international journal articles and book chapters:

    Journal articles

    Liebling H., et al. (2016) The Experiences of Survivors and Trauma Counselling Service Providers in northern Uganda: Implications for Mental Health Policy and Legislation. International Journal of Law and Psychiatry, 49, 84-92.

    Liebling, H., et al. (2014). ‘Improvements to National Health Policy: Mental Health, Mental Health Bill, Legislation and Justice’. African Journal of Traumatic Stress, 3 (2), 55-64

    Book chapters

    Liebling, H. (2018) Service Responses for Survivors of Conflict and Post-Conflict Sexual and Gender-Based Violence and Torture in the Great Lakes Region. Colleen O'Manique & Pieter Fourie (Eds.) Global Health and Security: Critical Feminist Perspectives. Routledge.

    Liebling, H. (2015) 'Conflict and Post-Conflict Sexual Violence in Africa: Case Studies of Liberia, northern Uganda and eastern Democratic Republic of Congo'. A.R. Ackerman. & R. Furman. (Eds). Sexual Crimes: Transnational Problems and Global Perspectives. New York, NY: Columbia University Press.

    2. A policy-relevant summary was disseminated to practitioners and mental health, education and legal policy makers in Uganda and Rwanda, London (DFID), Isis-Women’s International Cross -Cultural Exchange, Uganda and the Sexual Violence Research Initiative, SVRI (Johannesburg).

    3. The research findings were presented at the Sexual Violence Research Initiative Forum 2013 international conference. The executive summary report will be made available on African Studies, Politics and International Studies, Coventry University, Makerere University, Institute of Mental Health, Mental Health Research UK, Isis-WICCE and SVRI websites.

    4. The research was circulated to service users and service providers of specialist trauma services in northern Uganda and Rwanda, as well as those involved in mental health policy and legislation in East Africa in order to influence future mental health service provision and policy.

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