Implications from Research with Refugees, Genocide Survivors and School-Based Approaches

Because little empirical work exists for the group of former combatants in post-conflict regions, it is of interest to examine the experiences of other groups of war-affected individuals, beyond ex-combatants. The following sections will briefly summarize some key experiences and main insights.

4.1.1 Refugees and IDPs

This group often faces similar challenges as former combatants when it comes to returning and reintegrating into home or host communities. Similarly, forced migrants are often extremely burdened by psychological stress (Karunakara, et al., 2004; Onyut, et al., 2005). In a series of studies in Ugandan refugee camps, at first with refugees from Sudan, later with refugees from Rwanda and Somalia, our group implemented treatment programs that aimed at reduction of symptoms of the trauma spectrum (specifically PTSD and depression) and improvement of every day functioning. All programs included a screening tool, in order to identify individuals who fulfilled the DSM-IV diagnosis of PTSD. In a randomized, controlled trial with Sudanese refugees, clinical experts delivered three sessions of a narrative trauma-focused therapy (Narrative Exposure Therapy [NET] see below) or supportive counseling, such as is employed in many post-conflict zones (Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004). In a one-year

81 follow up, almost all participants were traced and re-interviewed. The PTSD-symptom severity of the NET-group clearly improved, in comparison to the group that received supportive counseling. And most importantly, significantly more subjects from the NET group had left the refugee camp and had either gone back to their home communities, where they were able to grow food or where they found a job in local trading centers and thus did not depend on food aid any more.

In a treatment project with refugees from Rwanda and Somalia, all of whom had DSM-IV PTSD diagnoses, local staff was recruited from amongst the refugee communities and trained to deliver trauma-focused therapies (Neuner, et al., 2008). After one year, the two active treatment conditions, NET and Trauma Counseling, achieved a clear symptom reduction compared to a monitoring control group; furthermore, participants of the NET-group showed an astonishing improvement of their physical health compared to the other groups.

4.1.2 Survivors of the Rwandan Genocide

Subsequently, our colleagues conducted two randomized controlled trials with orphans, who survived the Rwandan genocide and who fulfilled the DSM-IV PTSD diagnosis (Schaal & Elbert, 2006; Schaal, Elbert, & Neuner, 2009). The first study showed that NET, in contrast to Interpersonal Therapy, restored functioning and reduced the PTSD-rate by 80%. Both treatments improved depressive symptom-load in genocide orphans. In a second controlled, dissemination trial, local psychologists were trained to deliver the therapy; they also managed to achieve clear symptom improvement, reducing the PTSD rate by about 60%. The Rwandan psychologists were also instructed to be trainers of NET. The second generation of local therapists delivered treatment to widows of the genocide and have achieved an equally clear symptom-reduction compared to a control group (Jacob, in prep.).

4.1.3 School Children in Sri Lanka

Several studies report on effective school-based, mental-health programs for traumatized children, which rely on trained teachers (Berger & Gelkopf, 2009; Cox, et al., 2007; Dybdahl, 2001; Layne, Pynoos, & Saltzman, 2001; Layne, et al., 2008; Tol, et al., 2008; Yule, 2000, 2002) or

82 involve mothers (Dybdahl, 2001). During the past decades, children in North-Eastern Sri Lanka were exposed to war between government troops and the Liberation Tigers of Tamil Eelam (LTTE), as well as to the tsunami, which killed tens of thousands of people and destroyed hundreds of villages in Sri Lanka alone. Our group has worked in Sri Lanka since 2002. During the 2002 - 2006 ceasefire, we found a high PTSD prevalence and related functional impairment among pupils (Neuner, Schauer, Catani, Ruf, & Elbert, 2006). Additionally, domestic violence and physical abuse in families, who were exposed to war and natural disasters, emerged as a wide-spread problem, which further increased the psychological stress of children (Catani, Jacob, et al., 2008; Jacob, 2007; Neuner & Elbert, 2007). As part of an evaluation of the implementation of a large school-based, psychological cascade-service structure, two controlled treatment dissemination trials with traumatized children (who had a DSM-IV diagnosis of PTSD, depression, and/or suicidality) were implemented. KIDNET (i.e., Narrative Exposure Therapy for Children) and an active meditation-relaxation program were found to be effective in reducing the symptom-load in all three categories in a 1-year follow-up (Neuner, et al., 2006; E. Schauer, 2008; M. Schauer, et al., 2007). Therapies were delivered by highly trained teachers (master counselors), who were supported through a close supervision and referral structure. In every school, at least one of the teachers was further trained to recognize trauma symptoms and to carry out first-level social counseling and family support. These ‘Befrienders’ were regularly supervised by the master counselors, who took supervision responsibility for several schools.

Master counselors, in turn, were closely coordinated by a team of psychologists and psychiatrists from mental-health service institutions in Jaffna, Northern Sri Lanka. This structure allowed skill-capacity enhancement, such as trauma and depression treatment, grief counseling, family-based social interventions, as well as awareness-raising campaigns on domestic violence and drug abuse.

Successful interventions, like the above, lead us to assume that: (a) trauma-focused short-term psychotherapy can be successfully delivered in resource-poor conflict zones, (b) local staff (medical and non-medical) can be trained to deliver such treatment, and (c) sustainable (one-year follow-up) symptom reduction can be achieved with individuals suffering from trauma-spectrum disorders, who remain living in unsafe and difficult conditions. The improvement of every-day functioning at all levels is an especially significant finding, which strongly suggests that engaging in trauma-therapy work with populations in post-conflict settings is effective.

83 4.2 Traditional Rituals and Healing Methods

In many countries, psychological suffering is explained and treated in traditional categories with close connection to local culture, ethnic groups, and traditional religions (Harlacher, Okot, Obonyo, Balthazard, & Atkinson, 2006). Often, these rituals seem to have important functions, such as facilitating the reception of ex-combatants in their communities (Annan, et al., 2006), helping to shift the collective role from a combatant to a civilian, and assisting a coming to terms with the past. Gear (2002) explains that if individuals have participated in traditional rituals to be equipped with special combat powers, then it is important for them to be cleansed of these powers once the conflict is over. He quotes an ex-combatant, who explains: “I have to undergo the same rituals to get rid of it because if I don't do that, I will always be gun crazy.”

Numerous reports of healing and the subjectively reported helpfulness of traditional rituals for the emotional adjustment of the individual should not lead to the conclusion that there is solid (i.e., more than anecdotal) evidence that these procedures have any lasting effects. Nevertheless, some psychologists and psychiatrists recommend including traditional rituals or cooperating with traditional healers in psychosocial projects (see Engdahl, et al., 2003; Stark, 2006). What has been established in the scientific literature is that traditional rituals cannot be considered sufficient treatment, especially for those individuals with severe mental disorders (Annan, et al., 2006;

Somasundaram, van de Put, Eisenbruch, & de Jong, 1999).

4.3 Evidence-Based Treatment Approaches