**4. Discussion**

In the course of two decades of brutal civil war in Northern Uganda between a rebel army, The Lord's Resistance Army (LRA), and government forces, the Uganda Peoples' Defense Forces (UPDF), 98% of the population experienced firsthand the atrocities that occurred in the north of the country. The war left many with bitter hearts and memories [8, 14]. In a review of research done in Northern Uganda, Dokkedhal et al. [15] reported a review of the literature on the widespread harmful mental health outcomes of the Northern Uganda war on the population. Even children were not exempt, and Ovuga and Larroque [16] and Ovuga et al. [17] reported the mental health, suicidal, and physical health effects of the work on children. An epidemic of suicidal behavior followed the people in the region attributed to the spirits of the dead who died in the crossfire. The locals also attributed some of the suicides to excessive consumption of alcohol, domestic violence, and widespread poverty as well as genetic or familial factors, as they observed that not everyone but members of certain families and clans who were prone to commit suicide did so. Religious leaders, on the other hand, explained the suicides on demonic possessions. Against this background, this chapter describes the processes and outcomes of training volunteer lay counselors in response to the emergence of the suicide epidemic. An earlier experience in the neighboring district of Adjumani showed that volunteer lay counselors and put down the rate of suicide in that district by integrating mental health services in the general district health service [18].

A pre-training self-assessment of suicide risk among the volunteer lay counselor recruits indicated that 9.3% of the participants scored highly for suicidality, while post-training assessment indicated that 11.1% of the trainees were suicidal. These rates were comparable to the study of Ovuga et al. [10]. The higher post-training score for suicidality arose out of the fact that some of the individuals who did selfassessment post-training were not present during the pretest and on 3 days of the 5 days training period. In the course of training and thereafter, three members of the training team continued to provide psychological support to the lay counselors to improve the counselors' personal mental wellbeing and to provide advice and guidance in how to proceed with the work of helping people in distress. The training took the form of *"experiential training*,*"* meaning that the methods of instruction used lived experiences to create relevance, meaning, and understanding of mental health and suicide prevention concepts.

Results of the suicide prevention program were a participatory community response to the wave of suicides in Gulu District. The results showed that 9.3–11.1% of recruits whom their community leaders selected for training were initially suicidal, even though the recruits appeared "*normal.*" Based on the content and structure of the Response Inventory for Stressful Life Events (RISLE), the training centered on equipping the trainees to pay attention to the origins of suicidal feelings in daily living. Suicide in Uganda is a criminal act, and a failed suicide bid is liable to criminal prosecution [16]. Because of this, the trainees received in-depth training on the ethics of counseling, lasting 6 hours of introductory talk, exercises, group discussions, and a plenary session. Post-training self-assessment showed better overall mental wellbeing among the trainees. According to Haney et al. [19], it is risky to predict the outcome

of suicide research. Suicide ideation is a personal matter. Some distressed and suicidal individuals therefore tend to be secretive. The fear associated with talking to suicidal individuals within a research atmosphere is the possibility of introducing the courage and determination for them to implement their suicidal urge. Because of this, those who screened positive for moderately severe suicidal risk received in-training psychological support in addition to ongoing professional support supervision after the training.

The current results suggest that training in small groups can result in improved mental wellbeing among individuals who have experienced prolonged mass trauma. This conclusion arises from the results of logistic regression that indicated significant reductions in mean RISLE item scores for several component items, namely stress toleration, coping abilities in difficult situations, improved attitude to social support, and reduction in maladaptive behavior as an escape strategy in difficult circumstances. The results further suggest that males benefitted more from the training than did females. Similarly, the married also benefitted from the training more than those who were not. It is possible that men learned coping skills from the training faster than females. However, it is also possible that females took long to work through the cumulative effects of domestic violence, which mainly affected them. For the married, it appears that those who were married were able to relate their own roles in their respective marital difficulties practically and were therefore able to plan to use their knowledge and skills to address marital problems as the training progressed.

The drawbacks in the current study stem from the fact that the study was an emergency response to a community outcry and need. To address this limitation, a larger and randomized study aimed to improve overall mental wellbeing in the community would be beneficial. Not every one of the lay counselor recruits participated in the training or self-assessments. However, the results suggest that training in mental health can lead to improved mental wellbeing, as reported by Haney et al. [19]. Nine African countries including Uganda participated in a World Health Organisation (WHO) study, which investigated, through training, the effect of raising awareness on mental health issues among secondary school students, their parents and teachers in representative schools in each of the countries. In that study, awareness was raised using printed materials specifically developed for the purpose, and distributed to the students, their parents and teachers. In the case of Uganda the study took place in randomly selected schools in the districts of Kampala and Wakiso. Results from the nine countries cos countries showed that raising awareness about mental health and well-being led to improved attitude toward individuals with mental illness after two weeks of training. Secondly, students who received awareness training indicated that they would seek help for their colleagues that might show signs of mental illness. The same results applied to teachers and respective parents of the students that participated in the study [19]. These results show support for the recommendation for using strategies to improve the mental health of individuals who volunteer to deliver first aid mental health services for people in crisis. Nevertheless, the small sample size probably limited the levels of significance that a larger and randomized sample size would have provided. The fact that ongoing support supervision revealed improved confidence, psychosocial wellbeing, and functioning suggests that the training had a positive impact on the lives of the lay counselors. The present results therefore demonstrate that trained lay counselors, with support supervision, can win the confidence of the community, promote mental health in the community, and help to prevent or at least control suicide after very traumatic stress. It is important that using volunteer

*Lay Counselors' Mental Wellness in Suicide Prevention after Prolonged Mass Trauma… DOI: http://dx.doi.org/10.5772/intechopen.106620*

lay counselors to deliver counseling services should be of very sound mind, hence the need for their prior training and support supervision.
