**7.5 Psychotherapy**

204 Post Traumatic Stress Disorders in a Global Context

b. *Assessing the nature and severity of physical injury:* An adequate assessment of the nature, type and severity of injury and associated complications usually involves collaboration with other health care specialists including general surgeons, gynaecologists, neurologists, and general physicians. On the basis of a comprehensive assessment of findings, it will then be possible to plan a comprehensive care program targeting the

c. *To prevent further re-traumatisation:* This often involves removing the individual from the traumatising situation e.g. from a fire, war-front or from domestically an abusive home

d. Prevention of further injury or provision of immediate first aid to care for injuries e.g. to prevent bleeding, to immobilise unstable fractures or treatment for surgical shock: Often, traumatised individuals experience psychological shock and panic. In such emotionally laden situations, victims of trauma cannot make rational decisions. They need support and someone else to make decisions for them; e.g. not to run back in a raving fire in order to rescue someone or property. Removing someone from the scene of trauma to an area of safety, provision of security, ensuring protection from rain, cold, or other harsh environmental condition, providing food and immediate shelter and giving emotional support are all part of crisis intervention. After crisis intervention, one then embarks on planning the longer-term treatments based on an assessment of risk

This involves those treatments necessary to mitigate the effects of the trauma or limit the progression of the psychological sequel into chronic or complicated phase. Intervention follows a thorough psychiatric assessment and then treatment planning involving the individual in which the interventions are individualized depending on the needs of each

The use of medications in PTSD is for the control of symptoms that include insomnia, agitation, anxiety, panic, depression or those specific to the organs injured e.g. epilepsy, . Anxiety, panic and agitation are especially common and will respond to minor tranquillisers such as alprazolam, diazepam, and clorazepam. Depression, panic disorder and phobias will respond to antidepressants such as fluoxetine, paroxetine, amitryptiline. Specific medications for other health problems may be indicated such as Anticonvulsants for Seizures due to brain injury, such as Phenytoin or carbamazepine or antipsychotics such as

step in trauma management.

needs of each trauma victim.

(sexually or domestic violence).

factors for post-traumatic stress disorder.

patient. These interventions include (as deemed necessary):

Management of co-morbid physical and psychiatric disorders.

**7.3 Short-term treatment** 

 Medication Psychotherapy Counselling

**7.4 Medications** 

haloperidol or chlorpromazine.

exposure (Engdahl et al, 1997), sex, previous experience of trauma and the subjective appraisal of threat to life (Stallard, Velleman & Baldwin, 1998). Assessment and identification of predictive risk factors for posttraumatic stress disorder and addressing these at the earliest opportunity after exposure to traumatic experience is a vital first

Psychotherapy involves talk therapies popularly termed "counselling" in the Ugandan context. Various types psychotherapy have been used by trained counsellors and members of humanitarian agencies in PTSD in Uganda including individual counselling of a supportive nature, group counselling such as Interpersonal Psychotherapy, Cognitive Behaviour Therapy, Narrative Exposure Therapy, Play therapy for children, and Art therapy for both children and adults. Specific issues are dealt with during psychotherapy e.g. helping clients overcome the problems of memory loss and denial related to the traumatic stress experience, exploring social resources available to the client, strategies the client might have used in coping with symptoms of PTSD before seeking professional help, how to come to terms with a shameful trauma such as rape, imprisonment, and how to deal with perpetrators who may be in the victims environment such as police officers, prison guards or rebel abductors in the victim's community, and how the client can reconstruct his/her life so as to continue living positively. For psychotherapy to be successful, the environment for psychotherapy should be neutral so that the client can feel safe to share or receive support in coping with his/her traumatic experiences. The role of the therapist/counsellor is to facilitate the validation of the client's traumatic experience and foster recovery.

#### **7.6 Management of co morbidities**

PTSD in northern Uganda tends to be associated with other specific psychiatric illnesses and physical complications (Ovuga, Oyok and Moro, 2008), which need treatment. Co-morbid psychiatric disorders include Depression, Anxiety and Panic disorder, social phobia, sexual disorders and alcohol dependence. Often, these occur in multiple combinations. Specific interventions are directed to these disorders as appropriate e.g. treatment of depression, addictions, and counselling or family interventions for unwanted babies of rape etc. Often there's a need for, or age and gender specific intervention as well as spiritual atonement in line with cultural traditional practice, and the individual needs of specific clients. Specialised surgical interventions include removal of foreign bodies, correction of contractures and deformities and surgery for osteomyelitis to prevent prolonged effects of physical disability.

#### **7.7 Rehabilitation**

The aim of rehabilitation in PTSD in northern Uganda is to integrate the victim back into his/her society as a fully functioning individual with dignity. Many of these victims were abducted as young children and missed the opportunity for formal education. Other individuals got institutionalized to camp life in internally displaced persons' camps and require adaptation to life outside camp life. The various types of rehabilitation that are tailored to the individual needs of victims include job acquisition or vocational skills re/training; training for social functioning in the family and community with integrity as a leader; and traditional or social remedies to redress financial losses, material supplies e.g. to repossess one's land upon return from camp life; reconciliation rituals and ceremonies aimed to facilitate the acts of forgiveness for acts committed in the course of the northern Uganda war.

#### **7.8 Prevention**

Some forms of PTSD as in landslides, or earthquakes may not be preventable but their longterm impacts on the lives of victims can be mitigated through emergency medical and

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psychological interventions. Evidence suggests that immediate intervention prevents the development of long-term psychological effects of trauma of whatever cause. Availability of services for the early detection of landslides and earth tremors with prompt evacuation of civilians from danger spots prevents unnecessary physical and psychological harm and public sensitisation and education about these services is perhaps the most significant step toward preventing the occurrence of posttraumatic stress disorder.

Secondly, road safety based on controlling the use of alcohol and other intoxicants, following appropriate road safety regulations, and taking measures to promote visibility on public roads and access routes reduces or prevents unnecessary motor vehicle accidents. Parenting skills and availability of family services reduces on domestic violence and child abuse. This should also be extended to child guidance and counselling in schools for teachers and children. Strengthening existing social support systems in the face of disasters will help mitigate the long-term harmful effects of traumatic experience.

Measures to prevent crime should form the armamentarium against PTSD. Issues of poverty reduction, the early detection and treatment of severe mental illness in the household and sensitization on security matters might act together to significantly reduce the incidence of violent traumatic events in the lives of the ordinary individual.

Communities in Northern Uganda are keen to prevent the vicious cycles of militarised violence as seen in perpetual wars in Uganda. This can only be by building institutions for respecting observances of Universal Human Rights and as well as participatory democratic governance which is culturally acceptable and understandable by the cultural diversity of peoples in their various groupings and yet with respect and tolerance of others who may be different. The principles and values of Human Rights should be a taught subject in schools from primary school to the highest levels of learning and in all the colleges of the nation as well as in homes as a sign of good education, civility and culture. Furthermore renewed cycles of violence in African countries can only be stopped if governments make peace and reconciliation with respect for the principles of fairness, justice and equal opportunities for every citizen to participate in governance at the top of their policy agendas for national security and stability that support all other government efforts toward good governance.
