The power of storytelling: treating the trauma of child soldiers

The power of storytelling: treating the trauma of child soldiers
29 June 2012

Children forced into combat often return years later with severe psychological trauma, struggling to reintegrate themselves into the families and communities from which they were taken.

In the first of its kind, a recent study into trauma-focused therapy for former child soldiers in Northern Uganda could provide one key to reducing the symptoms of PTSD and confronting the dual guilt of being both a survivor and perpetrator of war. In this community-based approach to recovery, the tools for rebuilding are placed firmly in the hands of communities.

About 80% of the former child soldiers treated with narrative exposure therapy, in which each young person works with a local lay therapist to create a detailed autobiography, showed significant improvements in the severity of their PTSD. This compared to improvements in PTSD for about half of the wait-listed control group, and half of the group treated with an academic catch-up program.

Children at war

Around 250,000 children younger than 18 years are still actively involved as child soldiers in 14 different countries and territories worldwide. During the two-decade-long civil war in Northern Uganda between the rebel group Lord’s Resistance Army (LRA) and government forces, the LRA commonly abducted children and forced them into service as combatants and sexual slaves.

For many child soldiers, forced conscription means the replacement of their everyday education with exposure to extreme violence, torture, forced participation in atrocities, sexual violence, and the loss of their loved ones. Many are left with physical, psychological, and behavioral problems, including nightmares, flashbacks, extreme fear, grief and guilt, depression, and suicidal ideation – further barriers to their successful rehabilitation and reintegration into community life.

Since 2008, the gradual calming of the Northern Ugandan conflict has seen a large influx of children, adolescents, and young adults returning after their rescue, flight, or release from forced conscription. Returning to the unstable conditions of displaced communities, these former child soldiers struggle to find their place within families and communities who are often distrustful of them and their violent past.

Tackling trauma

In a recent effort to address these issues, a team of psychologists led by Verena Ertl of Bielefeld University, Germany, aimed to identify appropriate interventions for former child soldiers. Using a community-based approach, they investigated the use of individual-based narrative exposure therapy in camps for internally displaced persons in Northern Uganda.

Individual-based narrative exposure therapy has been shown to be effective with individuals demonstrating high levels of PTSD. As a treatment, it is short-term and trauma-focused – developed for use in low-resource countries affected by crises and conflict.

In addition, narrative exposure therapy has been used effectively across a variety of cultures by community-based lay practitioners. Therapy involves the detailed documentation of patients’ lives and the reconstruction of fragmented memories of traumatic events.

The study

In a randomized controlled trial, 85 former child soldiers suffering with PTSD were identified in IDP camps using a population-based survey of more than 1100 randomly selected Northern Ugandans aged 12 to 25 years. The 85 participants were randomly assigned to one of three groups: a narrative exposure therapy group, an academic catch-up program with elements of supportive counseling, or a waiting-list group.

Symptoms of PTSD, depression, suicide risk, and stigmatization were measured before treatment and at 3 months, 6 months, and 12 months after the intervention.

The treatments took place within the communities, and consisted of eight 90- to 120-minute sessions delivered by intensively trained local lay therapists three times a week.

Encouraging results

Results of the study were positive, with participants in the narrative therapy group displaying greater reductions in PTSD symptom severity than those in either the catch-up education or wait-list groups. About 80% of the former child soldiers treated with narrative exposure therapy showed clinically significant improvements in the severity of their PTSD, compared to about half of the wait-listed control group, and half of the group treated with the academic catch-up program.

In addition, symptoms of functioning impairment – the inability to function in social, academic and occupational situations – were also greatly reduced in the trauma-focused group.

Greater reductions in feelings of guilt were found in the narrative exposure therapy and psychoeducation groups than in the wait-list group, although differences between the two treatment groups were not significant.

Despite the positive results for PTSD, symptoms relating to depression, suicidal ideation, and perceived stigmatization were not significantly different among the three groups.

An all-round solution?

Providing communities with the tools to treat and manage the trauma of former child soldiers is essential if such provisions are to be sustained over time. Additionally, treatment on a local level reduces cultural barriers between patient and practitioner, improving the chances of a trusting and effective therapeutic relationship with positive outcomes.

However, the successful reintegration of former child soldiers is complex, and requires changes in the community as well as individual therapy. For long-term gains to be realized, reduced social stigma and improved opportunities for work and education are needed alongside individual treatment for psychological symptoms.

In the case of this study, what the authors call the “unusual” rate of recovery even in the waiting-list group may be the result of broader political changes, since “the trial took place when Northern Uganda started its transition from the conflict era to the post-conflict era.” Many participants reported that the less frequent sounds of fighting in the night and fewer soldiers in the streets helped to reduce their PTSD symptoms.

The results of this study are, however, very promising. With 80% of narrative exposure therapy patients achieving clinical improvement, and with an average symptom reduction of over 50%, there is a strong case for further implementation and longer-term evaluation.

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Reference:
Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011). Community-implemented trauma therapy for former child soldiers in Northern Uganda: A randomized controlled trial. Journal of the American Medical Association, 306(5), 503-512.

Explainers

Narrative exposure therapy (NET)

Short-term treatment for traumatic stress and post-traumatic stress disorder, specifically designed for use in crisis regions where longer-term treatment is not possible. Therapy involves the joint creation of the patient’s personal history, involving specific memories related to trauma. The aim is for patients to explore their traumatic memories within the safety of therapy and to reduce the impact of those experiences on their everyday life.

Narrative exposure therapy is appropriate for use with both children and adults, with three to six sessions providing considerable relief. It can be delivered by either trained clinicians or lay practitioners.

post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is an emotional illness that develops as a result of a terrifying, life-threatening, or otherwise highly unsafe experience. Sufferers re-experience the traumatic event or events in some way, tend to avoid places, people, or other things that remind them of the event (avoidance), and are exquisitely sensitive to normal life experiences (hyper arousal).
See: http://www.medicinenet.com/posttraumatic_stress_disorder/article.htm

Lay Health Worker

Lay health worker is a member of the community who has received some training to promote health or to carry out some healthcare services, but is not a healthcare professional. The duties of a lay health worker may include giving help and advice about issues such as child health, child illnesses, and medicine taking.

randomized controlled trials

Sometimes referred to as experimental evaluations, randomized controlled trials or RCTs randomly allocate potential beneficiaries of an intervention to a program or treatment group (who receive the intervention) or a control group (who do not). Outcomes for the two groups are then compared.

They are most often used to test medicines or medical procedures, but they are becoming more common in social interventions, particularly in relation to early years programs and education interventions in the US.

RCTs are considered the most reliable way of testing the effect of an intervention on outcomes for the potential beneficiary. Since the subjects of a trial are allocated at random to program and control groups, both are statistically equivalent and comparisons of outcome will reflect the effect of the intervention and not the characteristic of the groups.

Most importantly, RCTs eliminate selection effects. For example, if entry to the program tested was not random, the outcome might be the result of one group wanting the intervention more than another.

RCTs are strong at estimating the size of the difference in predefined outcomes between program and control groups. It is possible, therefore, to estimate how much change is the result of the intervention.

Other evaluation designs, including quasi-experimental designs that include a control group can detect associations between an intervention and an outcome but they cannot rule out the possibility that the association was caused by a third factor linked to both.

Clinician-Administered PTSD Scale (CAPS)

The CAPS is a tool for assessing post-traumatic stress disorder, and is one of the most widely used and regarded of its kind. Through the process of a structured interview, trained practitioners can are able to obtain a clinical diagnosis as well as a score of symptom severity. It takes between 30-60 minutes to complete and is available in a number of languages.

Mini International Neuropsychiatric Interview (M.I.N.I.)

A brief structured diagnostic interview for major psychiatric disorders developed by psychiatrists and clinicians in the United States and Europe. It takes an average of 15 minutes to complete. Both clinicians and trained lay workers can use the M.I.N.I. as an assessment tool.

Psychoeducation

Education offered to individuals suffering from mental health problems, or those caring for someone with mental health problems. The aim is to provide information and a better understanding of either a specific or broad range of psychological problems.

Suicidal ideation

A medical term referring to thoughts about suicide. This can vary from fleeting thoughts and fantasies to detailed plans for suicide.

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