• By Dartington SRU
  • Posted on Friday 29th June, 2012

The power of storytelling: treating the trauma of child soldiers

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 warAround 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 traumaIn 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 studyIn 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 resultsResults 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. **********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.

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