The CRESS team in Northern Uganda
The CRESS team
In IDP and refugee settlements on the border between Uganda and Sudan, the UK-based charity, CRESS (Christian Relief and Education for South Sudanese) employs a team of nine trauma counsellors trained in CATT by ACT International. These counsellors work under the auspices of the Diocese of Liwolo exiled in Uganda, offering trauma therapy and emotional health guidance for a small remuneration of $15 a month. The most common causes of trauma they see are child neglect, rape and sexual abuse.
In two years of pandemic, between November 2019 and December 2021, these 9 counsellors saw 858 children, whose treatment is documented in case files. All of them had high CRIES-8 scores at the first assessment, indicating a diagnosis of PTSD. After treatment with CATT, a marked reduction in CRIES-8 scores was seen in all cases, to below the threshold for PTSD, indicating significant improvement or total removal of many of the main symptoms of PTSD such as re-experiencing and avoidance. The large drop in mean scores indicates that CATT is a successful and appropriate technique for treating PTSD in these communities, and that this group of CATT counsellors is very effective.
The CRESS CATT model is exceptional for Uganda in having a dedicated team of practitioners, who are themselves refugees with first-hand experience of trauma who live in the communities they serve. They are led by a co-ordinator who travels across the West Nile district, monitoring progress and have the additional support of Fiona Sheldon, a psychotherapist who advises CRESS on mental health issues. Details of cases are sent to CRESS headquarters on a regular basis, giving the age and gender of each child, number of CATT sessions and CRIES-8 scores before and after therapy.
Although 20 counsellors completed the initial CATT training programme in 2018, within a year almost half had dropped out and others followed, perhaps daunted by the demanding nature of the work in refugee camps where the level of need is high but basic resources are in short supply. The nine that now remain are highly motivated.
“We were experiencing a lot of challenges, especially in the refugee settlement, things were really terrible. We have to move a distance on foot to give the therapy. We have to do all that we can for these children. And at the end the parents ask, ‘Yes, you are doing a really amazing job, but now why can’t you fulfil the needs of these children?’ So it became a very hard question to answer. The only body that we can cry to was CRESS, there was no government support, nothing. … You find you start a therapy with a client, a single child who lost the parents, and often this is a child who is being mistreated at home. Child labour. And this is again a child who’s a school dropout. Now all these things are too complex. That means you have to carry a lot of serious therapy session for this child. And we have to move to where this child stays. We don’t have a specific place where we can work or provide the therapy, but rather we have to go out to them. Now, every time when it comes to the rain season, what can you do? You have to do the work. Actually the nine counsellors who have remained have really dedicated themselves to helping their people.”
“We work in tough times and tough situations. So, because of the love for the work and the love for the children, we have to accept and just continue doing the work to save the lives of the children so they can really cope positively and to build up the resilience of the children. That’s why I said, we go through tough times, tough situations, but we have to persevere. And our pleasure is seeing children coming up and coping positively. And that becomes our pride.”
In 2021 CRESS responded to requests for help by offering counsellors a monthly stipend of $15, paid every two months. The charity also provided gifts such as biscuits and pens for the children. To enable counsellors to cover the lengthy distances between settlements and remain in touch with children and their families, counsellors were equipped with bicycles and mobile phones. As a result, their motivation increased but so too did the number of referrals, bringing new pressures.
“They expect too much. They see we are angels to come to solve them. And of course the little that CRESS manages to afford has really had a remarkable effect on the ground. I can really appreciate that. The only thing now is to see how they can expand the help because the camps are too many. We cannot help everybody.”
The ACT International training programme for CATT emphasises the need for self-care to avoid compassion fatigue or burn-out. Supervision is also an element of good practice. This is often a problem for isolated practitioners working outside a hospital setting but the CRESS model fosters a sense of co-operation and mutual support.
“Of course, as a human being, you can be affected somehow psychological or emotionally on seeing somebody in that situation. However, because of the training given, after a while you can also come back to your senses and then you continue with the session with the child. There’s what we call ‘care for care givers’. So we have to consult each other where one is affected somehow and then we come together and then after the session, we debrief ourselves. So we can remind ourselves, we are the same people, all that has happened is normal and it cannot remain forever. So we continue the work.”
The volunteer counsellors face additional pressures because they need to supplement their income in other ways. The present co-ordinator is a church leader and his predecessor, Lulu Emmanuel, had to balance his CATT responsibilities with his job as a nurse and the need to grow food for his family. He would prefer his therapeutic role to be full-time.
“CATT is a full-time job. That is the reality with the experience that I have. Because you have to be full time work for the client that you are handling. It doesn’t need a work where you are part-time and so on. No. And giving full time for a job means there must be something that you can gain to support your family because it is going to take the whole of your time. I think if it can be done in that way, we would really achieve more successes. We would have handled very many cases, but now we have to divide our time. I was working with the clinic and at the same time I have to go and see my client, but where it can be made a full time job, I think we will achieve a remarkable effect.”
Children's testimony
Four children were interviewed for this research, together with a parent or carer. All had been treated for trauma by Sister Florence Achulo Osara, a lecturer in psychology at the University of Kisubi where she trains and supervises other CATT counsellors. Her clinical practice includes outreach work in the Kisubi district, where many children live on the street where they become drawn into child labour, gangs and drug or substance abuse. She also runs the Bishop Asili Counselling, Rehabilitation and Community Centre in Lira, an area of Northern Uganda which is still suffering from the legacy of war with the Lord's Resistence Army and where many children are trafficked into the sex trade or domestic servitude.
“When you help a child, you have empowered the whole community. When you help, the mother, you have empowered the whole community. So these children are future generations who are going to be effective children in the community. ... We empower them so that they’re able to make meaning in life. They are those who have lost meaning in life and they don’t see any hope. And then we also help them to understand life and know that they can still change. That’s not the end of things. Something good can come out of the worst. We help them to have positive thinking about their life because once they have a positive thinking about their life, everything about them is going to be positive.”
The children spoke openly about the abuse they had suffered and about their new lives and hopes for the future. Thirteen-year-old Okhot* ran away from his violent father and was working on a construction site when Sister Florence took him in, placed him with a foster mother and starting CATT sessions. The same foster mother was looking after a small girl called Atim who had been physically abused by her stepmother, forced to do menial tasks and referred to as a dog. In Lira, Sister Florence rescued some girls who were about to be trafficked to Kenya and brought them to the Bishop Asili Centre. Among them was Omollo, who had difficulty sleeping and was always crying and running around so the others thought she was mad. When Sister Florence gained her trust, she discovered that the child lived in extreme poverty and was traumatised after being abducted and taken into slave labour when she was only seven years old. Her disabled mother had been reduced to begging and neighbours had set fire to their home.
Following CATT protocol, Sister Florence ensured that the children felt secure and that their basic needs were met before taking them through the phase of re-processing memory. As a respected member of a religious community, she has several networks to draw on and can therefore offer children opportunities they previously did not have, which undoubtedly contributes to successful outcomes. In every case, after CATT their PTSD symptoms had been significantly reduced and they were able to function more or less normally and continue their studies. As part of the research, the children were shown a series of emoji faces charting a range of emotions from sad to happy. They made a clear distinction between their feelings before and after therapy, pointing to 0 or 2 at the bottom of the scale when describing the past, and 10 - the smiling face - for now. Their carers confirmed the change in their mood and ability to cope with relationships and schooling.
“I had flashbacks. I had dreams of bad things. I see as if the stepfather is coming to beat me, he comes with that aggressiveness wanting to beat me, so I could not have sleep because of those dreams. Now I feel free. I don’t have the pressure of looking for money for school fees because I am already at school. I feel proud.”
“Now it is promising because at least now we can sit round a table like this and we chat, we laugh, we pray together.”
“I went to the centre and I told Sister Florence my problem and she counselled me. … It has calmed me and released the sadness I was having and out of the counselling is what I am now, since I am improving and getting better.”
“She was this kind of child who was too polite, too fearful, you know, too secretive, like somebody who had been tortured a lot. She was a kind of girl who seemed to be neglected, who was denied very many things. She had lost her childhood. That is the way I can phrase it. After the six months of sister Florence all that did change.”
The fourth child interviewed was Tomas who had been referred to Sister Florence for counselling in January 2022. He had been subjected to a vicious attack by his paternal grandmother, who threw liquid over his face which caused it to swell and left him unable to see. Although doctors had restored his sight, the mental scars remained.
“Two months down the road Tomas developed fear and nightmares. He saw his grandmother running after him and he started avoiding old people, even his maternal grandmother. He could scream whenever he saw any woman who is elderly and would be very aggressive, antisocial, isolate himself and even wet his bed. He stopped going to school and was not functioning.”
Tomas was living with his mother and maternal grandmother. His father was frequently violent and had thrown them out of the family home. His mother explained that the paternal grandmother was jealous of the fact that she had given birth to a son who might inherit his father's land. She had threatened to kill Tomas and had tried poisoning him before the attack.
Sister Florence gained Tomas's trust by showing care, engaging him in activities like exercise and dancing and playing music until he relaxed and felt safe. An assessment of his basic needs showed that he did not have enough food, clothes or bedding and lacked privacy at home, so she brought him and his mother to the Bishop Asili centre. Following the CATT protocol, she explained the causes of his changed behaviour and how she could help him and together they set out some goals, such as being able to sleep soundly and interact with relatives and eventually return to school. She identified social workers and members of the community who could provide further support.
In the narrative phase of CATT, the child compiled a list of characters in his story and created them from bits and pieces provided by Sister Florence. He chose a safe place for the start of the narrative, and another for the end. In moving the characters through the story, she noticed several moments, or hotspots, when he became agitated or stuttered. She would then hurry him along so he did not become re-traumatised. Each time he completed the narrative, she would ask him to re tell it backwards, a process which requires reprocessing memories. In the next phase of treatment, he was asked to choose and make an imaginary character who could change the course of the story. Picking two pipe cleaners, he fashioned a pair of glasses which could protect his eyes and help him see.
Before CATT, Tom's CRIES-8 score of trauma symptoms was 32. Afterwards, it had fallen to 10 and more recently it is zero. He is now back in school and, like many young boys, his passion is football.
“The boy was going to have mental problems so Sister Florence called him and talked to him. And later on, she introduced him to games like football and many others like skipping. And he became used to the sister and the sister befriended him. They were now great friends. And that is how the boy changed.”
“I was getting a lot of pain before I went to Florence. It stopped me from playing. I was fearing that the elder people like the grandmother would put more poison on me. So when I saw elderly people, I ran away and i didn’t stop.”
Asked what he felt before CATT and shown the emoji chart of emotions, Tomas pointed to 0 - the saddest. When asked how he feels now, he pointed to 10, the smiliest face. Then he ran off to play hopscotch with his friends.
*All the children’s names have been changed.