Community Wellbeing And Mental Health Project among Refugees in Uganda (CLAMP-RU Project)
By Helen Liebling, Penelope Yanni, Dorothy Kizza, Janet Nakigudde, Nasta Chemetai
Background
Sub-Saharan Africa is host to 18 million refugees or 26% of the global refugee population (UNHCR, 2019). Of these, Uganda hosts Africa’s largest refugee population consisting of 54,000 urban refugees and 1.4 million refugees in rural settlements (13 rural settlements (UNOCHA, 2019). A recent systematic review on the long-term mental health problems of war-affected refugees by Bogic and colleagues (2015) involving 29 studies and a total of 16,010 war-affected refugees reported the following rates of mental health problems:
Types of mental health problems
- Depression (range 2.3–80 %)
- Post-Traumatic Stress Disorder (PTSD) (4.4–86 %)
- Unspecified anxiety disorder (20.3–88 %).
The risk factors for these mental health problems include:
- Exposure to pre-migration traumatic experiences (gun-shot injuries, grenade blasts, rape, forced tying, killing of family members, abduction)
- Post-migration stress (Sexual and gender-based violence and continued torture and war trauma even in host country, difficulties with regularising asylum status, health care and welfare related problems, social difficulties)
- Post-migration socio-economic problems
Solutions
To address Pre-migration traumatic experiences we need to hold African governments accountable to their people since many of them are already signatories to international conventions against torture and war crimes. In the countries of asylum and refugee a lot can be done to address post-migration stress (psychological interventions) and poor post-migration socio-economic status (social enterprise intervention) such as we are suggesting in this project.
To comprehensively respondent to the needs of these refugees, on 24th March 2017, Uganda officially launched the Comprehensive Refugee Response Framework (CRRF). The CRRF is a multi-stakeholder coordination model on refugee matters that focuses on humanitarian and development needs of both refugees and host communities. At the heart of the CRRF is the idea that refugees should be included in the communities from the very beginning. CRRF
allows for refugees to benefit from national services (education, labour and health) and for integrating them into national development plans which is consistent with the pledge to “leave no one behind” in the 2030 Agenda for Sustainable Development (UNHCR, 2019). Uganda’s integrated refugee response that incorporates host communities has received global acclaim (UNOCHA, 2019). Despite this progress, the majority of response in the country does not provide comprehensive psychological and essential physical health care for refugees.
CLAMP-RU Project
Currently in Uganda, non-governmental organisations such as Interaid provide centre based mental health service with referrals to Butabika National Psychiatric Referral Hospital. While this model is good for responding to clients with florid mental health symptoms, it does not identify those community members with the less overt but equally disabling common mental disorders.
The CLAMP RU mental health treatment model for refugees makes the following observations:
- As a result of traumatic experiences including SGBV and torture, the burden of psychological problems affecting post-conflict communities is high
- That most of the immediate host counties of refugees in Africa such as Uganda are of low- and middle-income (LMIC) status and hence already have over-stretched social services including mental health services
- That there is a scarcity of psychological and physical health professionals in these
countries hosting refugees; particularly to screen and treat refugee survivors of SGBV
and torture including the stigma and shame arising from these experiences.
In the Community weLlbeing And Mental Health Project among Refugees in Uganda (CLAMP-RU) project, we propose to develop a refugee peer counsellor led community mental health service.
To overcome these challenges, the CLAMP RU model proposes a stepped care model for addressing refugee mental health problems that comprises of three steps:
- Step 1: A refugee Peer Counselor led psychological intervention
- Step 2: Psychiatric nurse/psychiatric clinical officer led second step intervention
- Step 3: Referral to a mental health department at the regional or national referral hospital where specialised mental health services are available including assessment and treatment by psychiatrists, clinical psychologists, psychiatric nurses, psychiatric social workers and occupational therapists.
- Development of the Refugee Peer Counsellor led psychological intervention
- Undertook interviews and recruited refugee peer counsellors (from the Somali and
Congolese community) - Held a series of workshops to brainstorm on the best psychotherapeutic approach to
adopt
-Problem Management Plus (PM+) intervention developed by the WHO, 2018 - Undertook a series of workshops to develop the content of a training manual for
Refugee Peer Counsellors - Apprenticeship model led by a clinical psychologist was used to train Refugee Peer
Counsellors
- Undertook interviews and recruited refugee peer counsellors (from the Somali and
Outputs
To date have so far trained and supervised a total of 7 Refugee Peer Counsellors from both the Somali and Congolese communities.
Below are testimonies of the beneficiaries of this training
“I am Saidi Mbilizi, a Congolese refugee, married with 2 children. I work at the CLAMP Project as a peer support counsellor and I am proud of this because we are helping refugees suffering with trauma and depression. We started the project in 2019 with a training that has since helped me very much to support fellow refugees here in Kampala. The training equipped me with knowledge about trauma, stress, depression and PTSD and with skills in counselling. I am now using this knowledge and skills to help other refugees. I used to have depression and PTSD but did not know that I was suffering from these conditions. However, through the training that we received in which we were taught the signs and symptoms of these conditions, I got to know my problem/condition. I received support from the clinical psychologist Dr. Dorothy Kiza and having healed am now able to help others. Or psychiatric nurse an clinical psychol gist have also continued to help us when we experience secondary trauma from listening to the trauma stories of our clients.
I am now able to differentiate between the normal people and the mentally disturbed and I am able to help them through assessment, psychoeducation and counselling on stress management. This project has really changed the lives of refugees in Kampala; it should be expanded to other areas as well. Social enterprise should also be promoted because refugees equally need financial empowerment.”
“I came to CLAMP full of trauma and stress because I did not know what to do with my life. I was formally a victim of rape during the war in Congo at the age of 13 years which resulted in pregnancy (I now have a daughter whose father I don’t know). I fled Congo some years back to Uganda where I thought life would be better. However, the situation in Uganda was so difficult, I was homeless and some friend decided to take me in with my daughter. All was well until I was diagnosed with Hepatitis B, this friend begun mistreating because she knew I was sick and started accusing me that I will infect her sons. I did not have anywhere to go and had no job. Life became so difficult that I thought of ending my life. One day I met Dorcas (one of the CLAMP Peer Counsellors) and she introduced me to Dr. Dorothy Kizza (the clinical psychologist of the Project) and I was started on therapy. I was feeling so depressed to the level of being suicidal because sometimes, I would go to the road in order to jump before a moving vehicle so that I could die and have peace. Dr. Dorothy Kizza referred me to Butabika National Psychiatric Referral Hospital because my depression was so severe where I was admitted for three days and got treatment and counselling that helped me get better. I went back home and got a job, and started my life with my daughter. I was later offered a job in CLAMP RU as a peer support counsellor, I was so happy to be a part of the team that helped get me back onto my feet and now it is my turn to help my fellow refugees who have been through the same trauma and difficult situations as mine. I am strong now and more than ready to help others.”
“I joined the mentioned project in April 2019 and I serve as a peer counsellor. While still in my home country of Congo, I experience traumatic events following the atrocities that I went through, which had been affecting me for over three years before joining this project. I did not know that what I was experiencing were mental health consequences of trauma because I had never received any knowledge about trauma and depression. However, from the trainings I had with CLAMP on PTSD and Depression management from 2019 to 2021, my perception about trauma has greatly changed. This training has helped me cope with my own traumatic experiences and also helped me support my fellow refugees who have had similar experiences like my mine. Supporting my fellow refugees to overcome PTSD and depression is a fulfilling experience since I feel better when I interact with my fellow refugees, listen to their concern especially mental disorder and help them through the healing process. From my experience working with fellow refugees under this project, many clients approach the clinic when they are hopeless and having suicidal ideas as a result of the atrocities they have experienced in their country of origin and life challenges that they are undergoing in the host country. Some are even contemplating running away and abandoning their families, but after going through a number of therapy sessions their mental wellbeing greatly improves. However, mental illness is still unknown in the refugee community since it continues to receive little attention from refugee helping organizations. This is pushing many refugees into developing medical complications such as high blood pressure and peptic ulcers and mental health problems such as committing suicide, abusing alcohol and as a consequence abandoning their families. Many refugee youths are joining bad peer groups that engage in drugs abuse (marijuana) as a coping mechanism. My sincere thanks go to CLAMP Project and its funders the CLAMP Family for bringing up such a great project that has helped refugees and asylum seekers like myself address the traumatic experiences and their mental health consequences that we have gone through. I have been a blessing to fellow refugees and I am determined to support them until they overcome mental challenges”.
“My name is Joel Bahaya; I am a peer counsellor at the CLAMP Project, Congolese by nationality. CLAMP has given me an opportunity to build a career in psychosocial support to fellow refugees. The training I have received has also benefitted me personally to deal with life’s stressors and solve real life difficulties. I have also been empowered to help refugees within my community. I am so grateful to CLAMP.”
- Development of the social enterprise component of the intervention
This component was adopted to address the post-migration socio-economic problems that refugees face in the host communities. It builds on the authors previous research and work with South Sudanese refugee survivors of SGBV and torture (Liebling & Barrett, 2021; Liebling etal. 2020; 2020b). It also extends the social enterprise projects utilised with South Sudanese refugees which was cited by UNHCR as a model of good practice on their global compact for refuges website: Social Enterprise Groups for South Sudanese Refugee Survivors | The Global Compact on Refugees | Digital platform (globalcompactrefugees.org)
Held a series of meetings and eventually a workshop to develop the social enterprise component
It was noted that the aim of this component of the intervention was to enhancing the recovery of clients who were suffering from psychological effects of war trauma
Selected approach that was eventually adopted was based on problem solving for economic empowerment which involved guiding clients through setting realistic economic and financial goals which are measurable and achievable in a reasonable time.
Outputs
Under the individual persons program we trained 5 clients and eventually gave money to 4 clients. This program severed set-back during the COVID-19 pandemic outbreaks of 2020 with clients forced to use the start-up capital for sustenance. The program was re-launched in 2021 and this time under the group model. To date we have 20 participants who are going to participate in this group model of the social enterprise.
“I am thankful to CLAMP because they have changed my life and supported my family to overcome the pain and sorrow that was my daily experience for over 3 years.”
Christine is a single mother with two children and is registered as a refugee in Uganda. She fled with her two children from Beni in Congo in 2015 and sought asylum in Uganda. Christine’s first born child, a daughter aged 14 years is physically and mentally disabled following torture back home, her daughters condition has greatly impaired my ability to fend for her family
When she walked into the CLAMP Clinic at Nsambya on the 1st March 2021, she was crying and was full of sorrow because she was faced with many psychosocial challenges that included: had been evicted from her place of residence due to rent arrears; the poor health condition of her disabled daughter; and the attempted defilement/sexual abuse that her daughter was experiencing from young men in the community.
Upon assessment, the client expressed and disclosed her concerns while crying. She was desperate, moderately suicidal, could not take care of her personal hygiene and had trouble sleeping.
One week later during the 1st session, it was established that she has severe depression but through subsequent counselling sessions her situation greatly improved. To improve her social wellbeing, Christine was enrolled in the social enterprise component on the 14th May 2021 and was able to engage in business selling charcoal and necklaces. From these economic activities she was able to generate money to pay for rent and take care of her children. However, because of the COVID-19 lockdown, her necklace business collapsed but has been able to retain the charcoal selling business.
Through CLAMP, Christine was referred to Norwegian Refugee Council and her case was recommended for resettlement by UNHCR. Currently she is undergoing interviews and cultural orientation awaiting for a visa to travel to USA with her family. Christine’s life is stable and is no longer experienced mental distress.
“I am thankful to CLAMP because they have changed my life and supported my family to
overcome the pain and sorrow that was my daily experience for over 3 years”
- Development of the CLAMP-RU Refugee Peer Counsellor Training Manual
To facilitate the training of Refugee Peer Counsellors, a training manual was developed by a team of mental health specialists including clinical psychologists, psychiatrists and psychiatric
nurses
Output
The training manual was developed with chapters on the following topics: extent of the mental health problems among refugees; the presentation of war trauma and torture; Post Migration stress; Basic Counselling, CLAMP Mental Health Treatment Model for Refugees (CLAMP-RU); Social Enterprise for Refugees; Dealing with Vicarious Trauma; and Questionnaires and Assessment Instruments.
- Provision of Counselling to Refugees
We started providing counselling services to refugee clients on the 11th November 2019. To
date we have provided counselling to 141 clients who have completed their therapy sessions
and been discharged under this program.
Below are testimonies of the beneficiaries of the therapy
“I came to CLAMP in 2021 seeking for help because I heard from my fellow refugees in our community that there is an organization that is helping refugees, when I reached at CLAMP, they assigned a Peer Support Counsellor to talk to me. When I came, I was at a point of deciding to throw myself into a river or a lake and end my life because of life difficulties. Fortunately, I got a Peer counsellor who gave me his time to listen to me and helped me, he didn’t judge me, he understood me, and helped me to get a reason to continue living. He made me understand my situation and helped me to persevere and to gain hope. In addition, he referred me to JRS where I got additional help including getting money to pay 3 months’ house rent and getting a chance of being admitted to an institution of learning to new skills to start a career. Now I have hope, and I have decided to focus on working for the future of my two daughters, I am so thankful to CLAMP.”
“I am called Jean Ruhorimbere, Burundian by nationality, 44 years and single refugee with no children. When I came to CLAMP, I had many challenges, which caused so many mental issues to me. I was told that I had depression and PTSD due to the past traumatic experiences I had gone through in my country and in Uganda. CLAMP provided counselling to me through the peer counsellor and the psychiatric nurse, which counselling has greatly helped me. The feelings of hopelessness and thoughts of ending my life reduced gradually as I gained hope in life and embraced life. I was also referred to other organizations like JRS and AHA, which provided rent and other medications that I required. Now I know how to deal with stressful things that bring depression and to manage the symptoms of PTSD when they arise. I was taught financial management from which I learnt how to come up with a business plan, this helped me get capital from IRC and Mercy Corps and now I have a business am running and it is doing well. I can really testify that CLAMP-RU has really changed my life and am a happy man now. I encourage CLAMP to continue helping the refugees because the life of a refugee is very difficult.”
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