Group Psychological Counseling Approach for Torture Survivors in Prison Setting

1. Group Psychological Counseling Approach for Torture Survivors in Prison Setting Approach Developed by ACTV in 2015 under EIDHR-2013/2016 Presented by: Kizito Wamala Clinical Psychologist African Centre for treatment and Rehabilitation of Torture Victims (ACTV), Uganda Email: clinicalpsychologist@actvuganda.org kizitowamala@gmail.com

2. Background • Mental illness is one of the Non Communicable Diseases (NCD) according to the Government of Uganda Ministry of Health (2010) • No baseline survey on risk factors and the magnitude of NCDs in Uganda  No comprehensive data. • No NCD Policy, strategic plan, and standards and guidelines for managing NCDs’ interventions” (MoH of Uganda: Health Sector Strategic Plan III, 2010/11-2014/15).

3. Background Cont. • Uganda Government recognizes mental health as a public health concern • Uganda population stands at 34.9 million (UBoS National Census, 2014) • Mental cases are projected to reach 15 percent of the general population by the year 2020 (Ministry of Health Uganda Health Sector Strategic Plan HSSP (III) (2010 – 2014) • Mental health significantly under funded (1% of the health expenditure going to mental health)

4. Background Cont. • There are over 50,000 prisoners in Uganda prisons(Human Rights Watch, 2013). • High rate of mental disorders in prisons in Uganda, Nyalugwe (2011) in his work, “A human rights based approach to the psychiatric treatment of mental illness among prisoners in Uganda.” • Psychological distress with depression, anxiety and post traumatic stress disorder are the most common psychiatrist presentations among prisoners (Nyalugwe, 2011).

5. Background Cont. • Disorders may be present before admission to prison/further exacerbated by the stress of imprisonment. • May also develop during imprisonment itself as a consequence of prevailing conditions. • However, the mental health needs of prisoners are unlikely to be identified, assessed and treated with the immediacy and efficacy they require.

6. Background Cont. • Inmates with mental disabilities at some prisons are simply isolated in punishment cells with no treatment. (Human Rights Watch, 2010: http://www.hrw.org (accessed on 20 July 2011). • No attempt at psychotherapy or other forms of alternative mental healthcare. • ACTV provided multidisciplinary services in Uganda prisons since 2004, • Used no specific evidence-based approach for mental health service delivery.

7. Statement of Problem • Many torture survivors with mental health needs find themselves in prisons all over Uganda • Many people go to prisons to offer “counseling.” • No specific evidence-based culture sensitive psychological counseling model for helping torture survivors in prison settings. • Therefore, ACTV needed to develop one.

8. Objectives Intervention study guided by objectives: 1. To identify inmates (torture survivors) who needed psychological care in prison setting. 2. To assess the mental health needs of the inmates (torture survivors) who would receive the psychological care service of ACTV in prison setting. 3. To provide group psychological counseling to the assessed torture survivors in prison setting. 4. To evaluate the impact of the psychological care provided by ACTV to the clients in prison setting.

9. Scope • Inmates who were torture survivors, male, aged 18 – 50 years. • Addressing physical symptoms, anxiety, depression, PTSD and behavioral functioning. • Using group psychological counseling, 10-sessions model developed on the principles of TF-CBT, NET and TF-ACT. • Treatment offered over 10 weeks period, one session per week, February – April, 2015. • Follow-up assessment done 1 month after 10th session

10. Significance • An evidence-based culture sensitive group psychological counseling approach to close the gap of lack of one for use with torture survivors in prison settings.

11. Literature Review Reviewed literature on: • Trauma-focused CBT for group work (TF-CBT) • Trauma-focused Acceptance and Commitment Therapy (TF-ACT) • ACT for group work with trauma survivors • Narrative exposure theory and therapy (NET) • Group Support Psychotherapy (GSP)

12. Methodology Design • Intervention study design was used. Population Sample • Torture survivor prisoners/inmates, male, aged 18 – 50 years. Sampling and Sample size • Previous visits to different prisons led to compiling a long list of prisoners for enrollment into ACTV’s care services. • A hundred (100) male prisoners identified for the study in 2 prisons – Kigo in Central & Gulu in Northern Uganda. • On screening, 76 qualified for enrollment into the study. • Forty eight were selected using lottery for random sampling. • Two experimental groups and two control groups of 12 members each were formed for piloting.

13. Measurement 1. Developed qualitative assessment tool for data on: presenting complaints, thoughts, feelings and actions related to prison life, interpersonal relationships within prison, knowledge of, and attitude towards, group psychological counseling. 2. Adopted the Hopkins Symptom Checklist of the Harvard Refugee Programfor its high validity & reliability tested in several international cultural settings for assessing physical symptoms, anxiety, depression, PTSD and behavioral functioning for quantitative data gathering.

14. Interventions Ten (10) closed group counseling sessions designed and facilitated with 2 experimental; no service to 2 control groups. Group Counseling Session Themes: • Orientation session • Interpersonal relationships and trust building (session 1) • Self-esteem and personal responsibility • Psychological adaptive mechanisms to prison life (session 3) • Exploration of the torture experience (sessions 4 & 5) • Anger management (session 6) • Grief and loss (session 7) • Human dignity and value (session 8) • Problem solving and future plans - I (session 9) • Future plans ii & closure of group psychological counseling process (Session 10)

15. Data Management & Analysis Level 1. Quantitativeintake and posttreatment assessment data of the 24 participants was verified for correctness of recording and analysed using percentage worksheets for percentages of time of experiencing the conditions/ symptomatology. • Qualitative data was coded and clustered for use in substantiating the quantitative findings. Level 2. Quantitative posttreatment assessment data of both experimental & control groups was analysed using SPSS for comparing outcomes.

16. Demographic Results by Age

17. Demographic Results by Education

18. Results: Average Percentages of Time (No. of Days) Experiencing Symptoms by Group Members .

19. Psychological Wellbeing of Experimental and Control Groups, posttreatment Conclusion There was a significant difference in levels of psychological well-being between those who received group psychological counseling and those who didn’t (p=.021). Those who received group counseling had higher means (M=94.1429) compared to those who didn’t receive counseling (M=60.7778). It was concluded that the group psychological counseling of ACTV can improve psychological wellbeing among torture victims in prisons compared to no counseling at all.

20. Conclusions • The Group Psychological Counseling approach of ACTV for Torture Survivors in Prison Settings has proved to be highly effective in psychological rehabilitation of torture survivors. • The comparison of psychological condition of the clients, pre- and post- treatment, indicated a highly significant change in the direction of improvement at emotional, cognitive and behavioral levels  high levels of psychological well being. • Qualitative feedback by prison authorities and clients indicated that clients achieved significant positive self-esteem, positive coping mechanisms and developed a sense of meaning for their lives which facilitates their adaptability to prison life as well as positive interactions with fellow inmates and the prison authorities. • The little reduction of physical symptoms may mean a need to combine the group counseling with medical care and relaxation exercises training.

21. Limitations • Lack of trust in NGOs by Uganda Prison Services made process hard, especially at beginning. • Bureaucracy surrounding the permission to enter prison on a weekly basis for 15 weeks led to late starting of intervention plan. • At times clients were locked up for long hours  inconsistencies in session starting and ending time. • Limited funding  limiting of a larger scale randomized controlled study. • Being project-specific, limited the study to project term, thus compromising on some study rigor requirements.

22. Recommendations • Complete current ACTV’s randomized controlled testing of the approach. • Further rigorous testing of the approach in different prisons in Uganda and other parts of the world necessary for further validation. • Testing the approach with female inmate torture survivors ongoing by ACTV, needs to be completed and evaluated for its efficacy. • Combine medical care for physical complaints. • Initiate cordial working relationship with prison service authorities in complete transparency for trust building. • Weekly coordination meetings with local prison authorities necessary for trustful coexistence.

23. Thank You