Introduction
Child and adolescent mental health services in Uganda have vastly improved
over the last decade and ACT International has played a part in this
change, training more than 160 health and social care professionals to
deliver a child-centred treatment for trauma - Child Accelerated Trauma
Technique (CATT). There are now CATT counsellors in every region of the
country helping trafficked children, children suffering from domestic
violence and abuse and those who've fled conflict in neighbouring
countries.
The aim of this report is to assess the impact of ACT International's work
in Uganda, focussing on the clinical benefits of CATT in treating symptoms
of PTSD and the challenges of implementing CATT on the ground.
An overview of child and adolescent mental health services in Uganda
Over half of Uganda's population are under 15 years old and many have been
subjected to traumatic events leading to a high rate of mental health
disorders. The country's history of prolonged armed conflicts such as the
war involving the Lord's Resistance Army, has left a legacy of children
who grew up in a brutalised environment without their parents and who face
discrimination and social stigma. Uganda's open-door policy has swelled
the number of orphans bringing almost one and a half million refugees from
countries like Sudan, Rwanda, Burundi, Ethiopia, Somalia and the
Democratic Republic of Congo. According to the Ugandan Government, the
burden of mental and neurological disorders has been increased "by the
effects of war, exposure to violence including defilement, poverty,
physical, emotional and sexual abuse, commercial sex and sex for survival,
addiction to substances such as alcohol and cannabis, infection or being
affected by HIV/AIDS and other disease like malaria resulting in
psychological and/or intellectual handicap, bereavement and separation."
Depression among secondary school students and anxiety disorders,
particularly among girls, are high.
“Child abuse is so common… We are raised by parents who are punitive and
they think it's a normal thing to beat a child. And then Uganda being a
chaotic country sometimes, most especially around election periods, people
being whisked away, tortured, children exposed to so much in the
neighbourhood. And then the domestic violence and then the accidents as
well...So there are so many traumatic instances here. Then we have another
problem of refugees.”
—James Nyereko, Principal Clinical Psychologist, Butabika National
Referral Hospital.
When ACT International (then Luna Children's Charity) began to work in
Uganda in 2011, child and adolescent mental health services were
inaccessible to most Ugandans and there was only one psychiatrist
specialising in child and adolescent mental health. From 2012, ACT
International worked as a partner of East London NHS Foundation Trust on
its mental health link with Butabika National Referral Hospital in
Kampala, training the country's first children's mental health
specialists. Dr Godfrey Zaari Rukundo, one of the first to be trained in
CATT, was among those who persuaded the Ministry of Health to support the
two-year children's mental health diploma course, accredited by Mbarara
University of Science and Technology where he is Head of the Department of
Psychiatry. CATT was an important element of the course within the module
on childhood trauma.
“With an adult you could easily do something. You could easily ask them to
say what happened, and maybe you have a conversation but, because children
were not able to express themselves most of the time following trauma, it
was quite challenging to handle children who were traumatised. We just
ended up giving them medication without knowing what we are treating. So
when CATT came, it was very helpful because at least it can be used with a
range of children, whether they were able to communicate, whether they are
willing to talk about their trauma or not, at least as long as they're
able to understand the instructions, you could do it.”
—Dr Godfrey Zaari Rukundo, Head of Psychiatry at Mbarara Regional
Referral Hospital and Senior Lecturer at Mbarara University of Science
and Technology.
Although CATT training is specifically designed to help children suffering
from PTSD, a social impact assessment carried out in 2016 showed that it
increased counsellors' psycho-social knowledge, improved their
understanding of children's rights and promoted child-centred practice.
Since then, more than 160 CATT counsellors have been trained, and 14 have
themselves become trainers, spreading practice across the country.
In 2017, the Ugandan Ministry of Health set out ambitious policy
guidelines for child and adolescent mental health;but the recent pandemic
offers a stark reminder that there is still much to be done. School
closures, social distancing, curfews, and lockdown led to an upsurge in
domestic violence, child abuse, teenage pregnancies and suicide yet, far
from throwing more resources into mental health, administrators did the
opposite. In most of the country's regional referral hospitals, wards for
psychiatric patients were turned into COVID wards, and psychiatric
patients could not access services.
“They quickly thought that the mental health units should be the places
for COVID treatment. So most regional referral hospitals actually sent out
our patients and replaced them with COVID patients. They thought that they
are not as important as maybe surgical patients. They couldn't think of
others, maybe even of ophthalmology, but they thought of psychiatry.”
—Dr Godfrey Zaari Rukundo
In most cases, the service is now back to a pre-pandemic norm but there
are still major gaps which reduce a child or young person's chances of
recovery. Child and adolescent services (CAMHS) are not integrated into
primary health care, hospitals and clinics remain underfunded and
understaffed, and mental health remains low on a list of priorities
competing for limited funds with more obvious killer diseases such as
malaria and HIV/AIDS. An additional problem is the lack of public
awareness and the stigma attached to mental ill health. If parents do seek
help, it tends to be traditional healers to whom they turn.
Methodology
In May 2022, Uganda's first two-day conference for CATT counsellors took
place at Butabika National Referral Hospital. Of the 38 practitioners who
attended, 26 (seven women and 19 men) filled in a questionnaire about
their practice, representing almost half the country's practising CATT
counsellors. They were first trained in CATT between 2012 and 2022.
Respondents were asked to describe their professional role or job title.
They fall broadly into two categories: 15 are specialists who have a
degree level qualification which entitles them to work as clinical
psychologists, psychiatric clinical officers (PCOs), psychosocial
counsellors and psychiatric nurses. There are 11 non-specialists who work
with children, for instance as general nurses or therapists, social
workers and teachers.
| Job title |
Number |
Proportion |
| Non-specialist |
11 |
42% |
| Nurse |
4 |
15% |
| Child development worker |
1 |
4% |
| Nursing officer |
1 |
4% |
| Occupational therapist |
1 |
4% |
| Psychosocial counsellor |
1 |
4% |
| Social worker |
1 |
4% |
| Teacher |
1 |
4% |
| Therapist |
1 |
4% |
| Specialist |
15 |
58% |
| PCO |
4 |
15% |
| PCO (CAMHS) |
2 |
8% |
| Clinical psychologist |
2 |
8% |
| Psychiatric nurse |
2 |
8% |
| CPO (CAMHS) |
1 |
4% |
| Principal clinical psychologist |
1 |
4% |
| Principal PCO |
1 |
4% |
| Principal PCO (CAMHS) |
1 |
4% |
| Psychologist |
1 |
4% |
| Total |
26 |
100% |
Respondents were first trained in CATT between 2012 and 2021 and now work
in a variety of settings. 62% work in regional referral hospitals, others
work for humanitarian organisations in refugee camps, schools, or centres
for disadvantaged children. Most practise CATT as part of their official
duties while others have chosen to do so on a voluntary basis.
Fourteen counsellors, including two who were not among the respondents,
were subsequently interviewed. The researcher was also given access to
case records from counsellors working for CRESS UK on the South Sudanese
border. She interviewed four children in Kisubi and Lira who have been
treated with CATT for post-traumatic stress disorder (PTSD) as well as
their counsellor and carers. This report summarises the findings of that
research. Authored by a trustee of ACT International, it cannot be
regarded as an independent survey but is presented in the hope that,
together with partner organisations, ACT International can draw on the
Ugandan experience to evaluate and improve our training and the practice
of CATT worldwide.
Children's Accelerated Trauma Technique
CATT enables children to reprocess traumatic memories through imaginative
play, combining play and arts therapy with trauma focussed cognitive
behavioural therapy (CBT) and children's rights principles. There are 12
stages which include finding a safe and comfortable setting for the child,
carrying out an assessment of basic needs and working with the child to
set measurable and realistic goals. Symptoms of PTSD are measured before
and after therapy.
In the memory processing phase of CATT, children are asked to compile a
list of characters involved in the traumatic events and to choose a safe
place for the beginning and end of the narrative. They then create those
characters out of available materials and use them to enact the story.
After reaching the end, they are asked to re-tell the story backwards, a
process which uses working memory. The therapist asks them to repeat this
forward and backward narrative until the emotional response is reduced or
eliminated.
This is followed by a second phase of treatment in which the child tells a
new story which re-frames the experience and provides it with a new, more
positive meaning which is empowering and more easily recalled.
Rate of referrals
For qualified psychologists working in a medical setting, CATT is one of
many treatments they may offer to children and adolescents in their care
whereas, for non-specialists in the community, it may be the only
psychological therapy they ever use. Asked how many children were referred
to them in a typical year, answers vary widely from zero to 62, with half
of all respondents (50%) estimating five or fewer referrals in a year.
Those who provided higher numbers may have been answering in terms of the
numbers referred to their place of work. The age range of young people
referred was between 5 and 22 years old with girls and young women
representing a slightly higher proportion than males.
|
In a typical year how many children were referred to you for CATT
counselling?
|
Number referred |
Proportion |
| 0 to 5 |
13 |
50% |
| 6 to 10 |
2 |
8% |
| 11 to 15 |
4 |
15% |
| 16 to 20 |
1 |
4% |
| 21 to 25 |
1 |
4% |
| 26 to 30 |
1 |
4% |
| 30+ |
4 |
15% |
When interviewed, some counsellors working in refugee camps reported being
overwhelmed by the number of children suffering from PTSD.
“Refugee camps like Oruchinga in south western, Uganda, are overwhelmed by
the numbers from DRC, because there is fighting. And now there are many
buses, many lorries transporting people to the camp and CATT counsellors
are overwhelmed by their numbers and they need to provide the basics. For
example, right now when the refugees arrive, they are interested in the
basic needs, like food, like shelter, like medical care. And therefore
that is their attention. And maybe with time, they start screening for
children who need CATT, but it would've taken some time and suffering
doesn't wait. Meanwhile, they'll be suffering.”—Elias Byaruhanga, CATT co-ordinator in Uganda
“The organisation did not have a proper understanding about mental health,
but me being a technical person in that line, I tried to guide in a way of
helping. So I was the psychosocial officer working with other four
assistants, but we were not enough. We were overwhelmed with the work that
we were doing”
—Jimmy N
While some were unable to deal with the number of cases presented, others
wished more children were brought to them for treatment. One reason for a
comparatively low rate of referrals was stigma or a lack of a public
awareness about mental illness and available treatments. Counsellors
reported that symptoms in children tended to be misinterpreted as bad
behaviour punishable by beating and those parents who sought help often
turned to traditional healers or expected to be given medicine with quick
results rather than a more time-consuming course of therapy. As one
respondent put it, "Some family members do not believe talking is
treating".
“It is true that parents may not easily refer the child to a psychiatrist
or a psychologist because they may not know that this is something that
requires a hospital. In fact, in our African setting, we have been abused
a lot. And we think that like beating the children is what will shape,
sharpen them. So most of the children are beaten by the time they come to
hospital, they have been beaten and brutalised by everybody. The big
brother beats, the mother beats, the father beats the teachers beat... So,
many times it's difficult to know that the child has a problem.”
—Dr Godfrey Zaari Rukundo
“Some causes of trauma come with shame, feelings of guilt, people don't
want to bring it out ... If a girl child has been sexually defiled,
they'll take this child for medical examination. And, if they have a tear,
they will treat that. If they have an STD, they will treat that. And it
ends there. Not knowing that there is something which is still not known,
which has not come out clearly. So I can't really say that there are no
cases; the cases could be there, but they're silent in the community.”
—Martha
Symptoms of PTSD
Asked what symptoms of PTSD their clients presented, the most frequently
mentioned in the questionnaire was "avoidance" (used 16 times across 26
questionnaires), meaning that children avoided places and people that
brought back memories of the traumatic event. Other words that cropped up
often were "nightmares" (10) and "flashbacks" (11) and disturbed "sleep"
(10). Counsellors also described hyper arousal, negative moods,
aggression, a fear of being alone, startled reactions to stimuli, a loss
of interest in things they once loved and excessive worries.
Measuring the effectiveness of CATT
Respondents reported having between four and 11 sessions with a child to
complete CATT, with the average being 6.8.
|
What is the average number of sessions you have with a child to
complete CATT?
|
Number of responses |
Proportion |
| 4 |
4 |
16% |
| 5 |
3 |
12% |
| 6 |
5 |
20% |
| 7 |
3 |
12% |
| 8 |
4 |
16% |
| 9 |
4 |
16% |
| 10 |
1 |
4% |
| 11 |
1 |
4% |
| Total |
25 |
|
As a measure of CATT's effectiveness, counsellors use the Children's
Revised Impact of Event Scale, CRIES-8, devised by the Children and War
Foundation to screen children at risk of PTSD. Records of cases kept by
the CRESS team of nine volunteer counsellors working with refugees from
South Sudan show a remarkably high success rate with reduced symptoms of
PTSD in 858 cases between November 2019 and December 2021.
Similarly, eight case histories recorded by Sister Florence Achulo-Osara,
director of the Bishop Asili Counselling, Rehabilitation and Community
Centre in Lira, show impressive reduction in the CRIES- 8 score post CATT.
Four of the children referred to her for CATT therapy took part in this
research, along with parents or carers. When asked if they could remember
how they felt before the therapy and shown a chart of emoji faces with a
scale of emotions from sad to happy, three pointed to 0 and one child
pointed to 2 at the bottom of the scale. Asked to show how they felt now,
they all pointed to 10 on the scale - the happiest face. As well as having
their traumatic symptoms reduced, they all talked about the new
opportunities they had been given as a result of Sister Florence's
intervention.
The questionnaire presents a more nuanced picture of outcomes. Counsellors
were asked how many children responded well to CATT, as shown by CRIES-8
scores or feedback from family and others. Given a scale of answers from
"a few" to "some" and "many", a little over half of respondents reported
that many children responded well.
Although the sample size is too small to infer significant differences,
results to this question did vary somewhat based on other variables. A
slightly higher proportion of respondents based in regional referral
hospitals gave more positive assessments than those based in other
predominately non-clinical or refugee settings, with 93% reporting some or
many positive responses compared to 80% for other locations.
Results to the same question based on respondents' job title also varied,
although less clearly. Paradoxically, while those in specialist roles were
more likely to say that "many" children responded well (69% compared to
36% for non-specialists), specialists were more likely than
non-specialists to report that "few" children responded well (15% compared
to 9%).
A detailed account of individual workplaces and systems throws some light
on these variations. For instance, counsellors working in regional
referral hospitals tend to be more highly qualified and better supported
in terms of supervision and peer support, which may attribute for a higher
success rate. Many of the counsellors who were interviewed stressed the
importance of supervision or peer support, both to improve their practice
and avoid burn-out.
“You find that may be in the hospital you trained one or two people and
they're at the same level and may be supervision is not enough. And again,
they don't come together to share their cases, what I call peer
supervision. So I don't think there's been enough, but I think that is the
way to go, to encourage them where they don't have a senior person at
least to do peer supervision.” —Elias B
“I miss that so much. You know, sometimes it's like feeling stuck, like,
what do I do? Or you've seen a case that has really stressed you so much.
And you feel like talking to somebody who understands what you are going
through, but this person is not available. And I would really need
somebody who can offer me support supervision.” —Martha A
Benefits of using CATT
Asked what they liked about using CATT, the most frequent responses in the
questionnaire related to it being child-centred (19% of responses), its
narrative method (19%), and that it was effective (9%).
"CATT is cheap compared to other therapies and more interactive."
“I like CATT because when done right, it is magical.”
“Even children with limited use of language or who don't speak your
language can be engaged.”
“A therapist works with the child and the systems that the child and
carers have identified.”
Most counsellors reported that CATT had an impact not only on individual
children but on their families, for instance by relieving symptoms of
trauma, helping the child return to school, improving relationships and
teaching parenting skills.
“CATT has had a great positive impact on children's family because the
family comes to understand the child better and gets involved in
addressing the problem.”
“Families previous dysfunctional and socially disintegrated have become
functional and socially connected.”
“Children are able to work well and so it reduces burden on families.”
“Families who used not to have peace and rest due to behaviours shown by
their children are able to have a big smile on their faces after
successful CATT therapy.”
In addition to its therapeutic benefits, a number of counsellors said in
their interview that CATT training had changed their entire working
practice, highlighting the value of psychoeducation as a means of
sensitising the wider community to issues of mental health and trauma.
This had improved their professional standing and self-esteem.
“I realized many children and adolescents have been taking medicine when
they really would not need it. That was the most thing that impacted my
life. Most children are taking drugs or medicine when they can be well on
psychological therapies. So I found the CATT so helpful in such a way that
some adolescents and children get better without medicine, and which is
helping their general health and helping their families.”
—Prima S, general nurse
“My teaching has been made different ... Here we have a culture of beating
children. The child does a mistake - you beat. Some were beaten and ran
from school. Parents tried to bring them back. This time they run from
home. So they wait on the street. I follow those children, I brought them
back. Slowly by slowly. Now, by the time we ended, they had settled in
class study; the head teacher will say, what is this? ... Actually, the
school nurse asked me, “Which tablet did you give these children?” I said,
“I'm not a doctor. I've not given them any tablet, but I have talked to
them”. He said, “No, you have something special in you”. I just praised
the Lord for that.”
—Didas M, teacher
“My teaching has been made different ... Here we have a culture of beating
children. The child does a mistake - you beat. Some were beaten and ran
from school. Parents tried to bring them back. This time they run from
home. So they wait on the street. I follow those children, I brought them
back. Slowly by slowly. Now, by the time we ended, they had settled in
class study; the head teacher will say, what is this? ... Actually, the
school nurse asked me, “Which tablet did you give these children?” I said,
“I'm not a doctor. I've not given them any tablet, but I have talked to
them”. He said, “No, you have something special in you”. I just praised
the Lord for that.”
—Beatrice K
Challenges of using CATT
Respondents to the questionnaire were asked to list some of the challenges
of using CATT. Again, their answers and the evidence of detailed
interviews shed light on structural issues as well as individual
caseloads.
In a country with about 40 living languages and a large refugee
population, it is perhaps not surprising that language was seen as one of
the biggest challenges, mentioned almost equally by those working in
referral hospitals and those in other settings. One counsellor pointed out
that some local languages lacked words such as 'depression' and in some
rural districts there was no one who could translate into English. Those
working in refugee camps reported having to rely for translation on a
child's relative or other refugees. Non-specialists and respondents
working outside a hospital setting were more likely to mention the
complexity of cases as well as the number of sessions required and
challenges with transport.
A number of counsellors are volunteers who have to fit their CATT sessions
in between regular duties. Apart from the counsellors employed by CRESS,
most work singly without the benefit of a team. Others are employed on
short-term contracts. Conditions of employment have a profound effect on
their practice.
“Projects operate within a timeframe ... your project probably has a
contract of six months, you are working with a child. Probably I got in
contact with this child two months after the project has started, but I'm
getting in touch with this particular child. The first steps of my CATT
practice are taking about two, three weeks, to anchor the child into the
next phase of treatment. And before I know it, the project is phasing
before the child heals fully.”
—Jackson M
“Today everyone is running. So many times they will give you about an hour
and you have to divide that between your group and your individual
sessions. If they give me about two days a week, I can say one day for a
group and I get appointments for the second time I go to that school. But
still, getting two hours in a week is very, very difficult because every
teacher is trying to catch up with the syllabus. An hour would be a good
time but you find that sometimes it's not complete. Children want to
explain. So you find you've done 40 minutes and they are explaining to you
and telling you, especially in the first session.”
—Paul W
“They still consider me as a teacher. And that's why sometimes I become
overwhelmed. I have to teach my lessons and children pass and get marks.
... Now the case comes in. A child is difficult in primary seven, they
bring him to me; a child in primary four, they bring him to me. I'm in the
middle of the lesson teaching. So what do I do? I receive this child.
Another challenge I have, I don't have a place where you sit with the
child and feel relaxed, where I can now set all these materials ... So I
would wish entirely to specialise on handling, not teaching.”—Didas M
The less time counsellors are allocated for each case and the further they
have to travel, the more likely they are to see the number of sessions
required as a problem. Several reported that school administrators and
parents would often cut the therapy short because they wanted a child back
in class.
“Sometimes people complain that, you know, children are brought to them
and then the next time they want to see the child, the child's been taken
away and gone, you know, to another place or is put in school again and
they won't give the time to it. But if they knew that for three days
solidly, they would be there with the counsellor. That would be a good
thing.”—James N
The cost of transport and distances covered present further challenges,
particularly for counsellors working in rural areas or refugee
settlements. Non-specialists and volunteers may also struggle to balance
the needs of their CATT clients with professional and personal
commitments.
“You are on duty as a general nurse, and then you have to spare time for
these patients of CATT. And when you delay them, they get tired. They also
go home. So you find it is not easy. You cannot work with the child
without the family. So going to the families, it becomes expensive and it
is time costing. So you find, we are missing out so many clients because
of that ... And me as a health worker, I also don't have transport to go
to their villages. And these are hill areas. You need time to walk and
move to the mountains. So it becomes so difficult.”—Prima S
“West Nile comprises of around eight districts, so all are very far, very
far ... If I'm to take motorbike, sometimes I can take something like five
hours on the road. The roads are terrible. You have to plan your time as a
counsellor. Because if you will be moving every week, or every two to
three days, then your family needs you; you need to go to the field and
dig for your family to survive. So balancing these things sometime becomes
very tricky.”—Lulu E
The CATT protocol requires counsellors to conduct a needs assessment and
ensure that basic needs are met, such as food, water, shelter, clothing
and bedding. They work with systems around the child to build resilience
and a sense of sustained well-being. In a country where a quarter of the
population live below the poverty line and in large refugee settlements
where people struggle for limited resources, this can present an almost
insurmountable challenge.
“Here it's quite hard to get a safe place for a child. Sometimes even safe
places like children's homes are not the safest.”—Paul W
“That is quite challenging, especially in some refugee camps. Because you
might find that the food is not enough and you as a counsellor, you cannot
provide the food. There is no safe water. You as a counsellor cannot
provide the safe water. Maybe some children need mattresses. May be the
camp authorities are not in a position to bring mattresses for these
particular children or bring facilities. You might find that maybe there
is no organization, which has the ability to provide those materials. So
you find it still is quite lacking.”—Elias B
“Now if it comes to addressing basic needs of the children, then that
becomes a challenge that we cannot really provide for these children”—Elias B
“Unfortunately, in the refugee camp sometime when you refer these children
to those NGOs for their basic need, there's no feedback. There's nothing
that can be done.”—Lulu E
Retention of CATT counsellors
In order to meet the selection criteria for CATT training, people must
have a diploma or higher qualification, show evidence that they are
working with children and, most importantly, have the right attitude and
interest. Recruitment has accelerated and 14 outstanding counsellors have
now become qualified to train others. However, as in other health service
sectors, retention remains a problem. Only about half of the 160 trained
counsellors are still practising.
“The drop out rate has been fairly high. For example, people who have been
working in refugee camps have lost their jobs because some of them were
laid off, especially during COVID times and maybe some agencies are not
able to pay them. Then of course there are some who are no longer in
active service. For example, in hospitals, either they have retired or
they have been assigned other responsibilities. And therefore if they have
been assigned other responsibilities, then they are no longer in contact
with children. And therefore they cannot practise.”—Elias Byaruhanga, CATT co-ordinator
“We have done a lot of mental health training across the country, training
them the basics, but I think the biggest problem is attitude, that even
when many cadres are trained, they don't have the attitude to do mental
health work. That is something you also find in people who have trained in
CATT. Yes, they have trained with the certificate, but the attitude is not
there.”
—James N, Principal Clinical Psychologist, Butabika National Referral
Hospital
The Ugandan Ministry of Health's 2017 policy guidelines for child and
adolescent mental health mark a significant advance but implementation is
patchy to say the least. Mental health remains a low priority when it
comes to government spending, and child and adolescent mental health is
still not properly integrated into healthcare.
“That (retention) has been a challenge, not only for CATT trained people,
but generally mental health workers, because as a government policy,
mental health is supposed to be integrated into general healthcare but its
implementation has faced many challenges because we have, for example, a
clinical officer at the general hospital, we are supposed to have a
psychiatric nurse at the health centre, but when those people are posted
there, you find they are not doing what they were posted to do. They are
assigned other duties. You find out they're running HIV clinics, they are
running immunisation - things they were not trained to do and you find
they are not doing mental health services.”
—Godfrey Zaari Rukundo, Head of Psychiatry at Mbarara Regional Referral
Hospital
It is not just government departments that prioritise physical over
psychological well-being. In the non-government sector, mental health
tends to be low on the list of priorities, representing only 0.3% of
development assistance for health This affects the choice and structure of
humanitarian projects.
“Most of the projects across the NGO world are designed by project
officers or project managers. Now, project managers in our education
system, largely study project management. They do not study sexual
productive roles or domestic violence per se, psychiatric problems. No. So
they can only design a project based on what the technicalities of a
project are and it becomes very difficult for them to incorporate the
components much needed for mental health.”—Jackson M
Memorable outcomes
Despite these difficulties, CATT counsellors are overwhelmingly positive
about their role. In the questionnaire they were asked to describe any
outcomes they were particularly proud of. Their responses shed light on
the range of traumatic events that can blight children's lives and
underline the value of their work.
“Helping an 11 year-old girl who had been raped multiple times by family
members and neighbours. She developed strange behaviours, acting above her
age with men, wandering from home, problem with sleep, nightmares, crying
most of the time. But now she is well and performing well after eight
sessions.”
“I successfully used CATT to treat four child soldiers/survivors in Khongo
IDP camp and all of them responded so well and this has put a big smile on
my face.”
“A boy with multiple trauma failed at school. His mother had left home and
left him with a grandparent who died while the boy was watching so he is
now head of the family. He was wandering and could not stay at home but is
now in school and doing well at home.”
“A child who was involved in a traffic accident. I saw him work through
his trauma and improving, able to go back to school and now at
university.”
Conclusions and areas for development
When so many children and young people in Uganda are exposed to traumatic
events which can blight their lives, there is an urgent need for effective
and accessible models of care. As this research shows, CATT has become an
important tool for mental health professionals and others working with
children. The number of counsellors and trainers has steadily increased
and respondents to the questionnaire are consistently positive about the
therapy, emphasising its child-centred approach and use of non-verbal
narrative based on play. When asked how many children responded well to
CATT - “many, some or few” - over half the respondents said "many". The
overwhelming majority believe that it has a positive impact on the child's
family and some think it benefits the community at large by increasing an
understanding of mental health. During interviews, several counsellors
remarked on the improvement CATT training had had on their practice.
Although they are overwhelmingly positive about the CATT protocol and the
therapeutic technique itself, many face challenges when using it on the
ground, such as the need to find reliable translators, the cost of
transport and the number of sessions needed to complete a case.
Some counsellors say they have not received as many referrals as they
would wish and call for more public awareness campaigns, but others report
being overwhelmed by cases. Overload is a particular problem for those
working in refugee communities, where levels of post-traumatic stress are
exceptionally high. These environments may also lack food, clean water and
shelter, making it almost impossible for counsellors to meet a child's
basic needs as the CATT protocol requires. One of those interviewed said
that it was sometimes hard even to ensure a child's safety.
Many of the challenges highlighted in the research are structural,
relating to funding priorities and conditions of employment and are
possibly a contributing factor to the drop-out rate among trained
counsellors, which stands at about half. Child and adolescent mental
health is not yet fully integrated into medical services so practitioners
have to divert to another type of medicine if they want to gain promotion.
Counsellors with other professional responsibilities such as general
nursing or teaching may struggle to find time for voluntary work. Time may
also be a problem for counsellors employed by humanitarian organisations
on short term contracts*. In addition, non specialist CATT counsellors may
lack the supervision and peer support needed to improve practice and
prevent burn-out. They are also more likely to face difficulties when
treating children with complex trauma.
There are lessons to be learned from the two examples of working practice
that are highlighted in this report. Outcomes recorded by the CRESS team
in Northern Uganda and case notes from the Bishop Asil Counselling,
Rehabilitation and Community Centre in Lira demonstrate a significant
reduction in PTSD symptoms following CATT, a success reinforced by the
testimony of four children and their carers who were interviewed for this
research.
There are distinguishing features which help to make these results
outstanding. Unlike most practitioners who took part in this research,
those employed by CRESS work in a team, supporting each other and
reporting to a co-ordinator who monitors their results and feeds them back
to the charity. Although they are volunteers, they receive a modest
remuneration and are provided with bicycles and mobile phones. As refugees
themselves, they are thoroughly embedded in the community they serve.
As director of Bishop Asili Centre and a respected member of a religious
community, Sister Florence is better placed than some other counsellors to
ensure that a child's basic needs are met. In Lira she can house children
at the Centre and in Kisubi she has a network of foster parents to call
on. The four children interviewed no longer showed symptoms of PTSD and
their carers confirmed that they were able to play and go to school.
Moreover, they were enjoying opportunities such as education and sport
that would otherwise not have been available to them.
Areas for development
Many of the challenges facing CATT counsellors could be overcome if the
Government of Uganda implemented its own policy guidelines on child and
adolescent mental health. As a charity, ACT International is responsible
for training counsellors who then go on to train others but has no
responsibility for working conditions. It may be useful, however, to list
areas of improvement that arise from the evidence given by counsellors in
the course of this research.
-
CAMHS (with CATT) needs to be integrated into health system - with a
recognised promotional ladder.
-
Non-specialist counsellors should be given time and space for their CATT
work.
-
The number of counsellors needs to be increased to make existing
workloads more manageable.
-
All counsellors should receive supervision and take part in peer group
counselling to avoid drop -out and emotional fatigue.
-
Counsellors should monitor and report on outcomes and this information
should be held centrally.
- Counsellors need further training about complex health needs.
- Volunteers need remuneration and help with costs.
-
Partner organisations / funders are needed who can help provide
children's basic needs, particularly in poor rural areas and refugee
settlements.
- More translators are needed.
- Transport costs should be met.
-
Counsellors should be encouraged to increase public awareness of mental
health issues through media outlets and forms of public engagement.
The CRESS team in Northern Uganda
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, they 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.”
—Lulu Emmanuel, former co-ordinator
“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."—Beatrice Kiden
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.”—Lulu E
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.”—Beatrice Kiden
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.” —Lulu E
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.” —Sister Florence
Okhot, Atim and Omollo
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.”—Okhot
“Now it is promising because at least now we can sit round a table like this
and we chat, we laugh, we pray together.”—Foster mother to Okhot
“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.”—Omollo
“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.”—Foster mother to Atim
Tomas
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.”
—case note compiled by Sister Florence
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.” —Tomas's mother
“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.”
—Tomas
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.