It was 2009, in the aftermath of the Uganda Civil War. Millions of Ugandans —those who survived—had been displaced by the Lord’s Resistance Army (LRA), a political faction that rose to power nearly two decades earlier and endeavored to govern according to the Bible’s ten commandments. LRA rebels wielded their power through campaigns of terror and violence in which they tortured, conscripted and enslaved civilians, including children, resulting in what the United Nations called one of the worst humanitarian crises in the word.

Upon its withdrawal, the LRA’s insurgency left an entire region grappling with the widespread devastation and trauma it had inflicted. Humanitarian aid projects designed to address these challenges focused primarily on restoring basic needs and offered some psychosocial support. “However, many people needed a different, more specialized intervention to recover from the psychological wounds they suffered during the war,” observed Gabriele Marini, psychotherapist/trainer for CVT Uganda. “The services being offered weren’t yielding sufficient results.”

This fact did not go unnoticed by the Trust Fund for Victims (TFV), a unique global movement established by the International Criminal Court (ICC) to support survivors of war crimes. The fund sought out grantees who promoted a rigorous and technical approach to counseling and identified CVT as an organization with the expertise to meet the demand.

“The Trust Fund realized the need for a consistent approach to care and needed a partner for ongoing, consistent technical assistance, training and support for counselors working in the region,” said Neal Porter, director of international services. “Given the scope and scale of the human rights atrocities that had been perpetrated in northern Uganda  – which were very well documented –  we thought that CVT’s capacity building services for counselors in the region would be beneficial.”

Getting Started

So starting in October 2009, TFV began funding a new CVT capacity development program in Gulu. CVT Uganda launched with a staff of one: Gabriele Marini, brought on in early 2010 to improve the quality of care being offered in the area, handling supervision and training of counselors from organizations already providing psychosocial services. The first year staff was actually technically fewer than one person, Neal noted, because Gabriele was based in Nairobi, Kenya, and divided his time until he moved to Uganda the following year.

During the first five years, survivors who received healing care from CVT were selected by other organizations, with therapy administered via co-therapy with partner counselors and Gabriele in a training role. The NGOs —from TPO Uganda, to African Centre for Treatment & Rehabilitation of Torture Victims (ACTV), to Associazione Volontari per il Servizio iInternazionale (AVSI), to Cooperazione Internazionale (COOPI)— completed client screenings and intake sessions, and then therapy was conducted individually. Gabriele saw hundreds of clients each year. “In the first five years, I personally held sessions with 933 survivors,” said Gabriele. “And through the CVT training, we realized that many of our partner organizations were increasing their skills in service provision.”

In 2015, Everything Changed

But something was missing: CVT was rarely able to implement complete psychological services. According to Gabriele, this means consistency in service provision (one session every week for seven to eight consecutive weeks); clarity of roles (the counselor is not providing other types of services that meet a client’s material, medical and livelihood needs); and adequate time allotted for the completion of clinical documentation, clinical supervision, and self-care for service providers – all of which were foundational to CVT’s approach and trainings.

Then, in 2015, everything changed. CVT began offering care directly to clients. Gabriele was able to hire his own staff (three counselors and one office coordinator), rent an office, and negotiate with Uganda’s National Social Security Fund (NSSF) to increase the financial and logistical components of his duties. “The number of clients reached reduced,” Gabriele noted, “but the care each client received was now guaranteed to meet CVT’s high standards for quality.”

The program began to follow the process used in CVT’s international services programs, which starts with community sensitization (outreach) efforts, continuing with screenings, followed by a 10-week group therapy cycle. After the cycle, counselors hold follow-up sessions with clients after three and six months. Gabriele witnessed the quality of services improve under CVT’s control, and notes that since 2015, the clients CVT has worked with in Gulu are all direct survivors of torture. “These are survivors who are so very affected by the trauma they’ve endured, but also very motivated by their symptoms,” he said. “They’re eager to engage in psychological care and the rehabilitation process.”

Transforming the Landscape of Healing in Uganda

CVT Uganda has, since its inception, focused on three levels of service: Capacity Building, to strengthen the ability of organizations working in northern Uganda; networking among different mental health stakeholders in northern Uganda; and counseling to war and torture survivors at rural sites.

“The three goals are interconnected,” Gabriele said, “because of the capacity building component. It’s designed to empower all local organizations engaged in trauma counseling.” As a result, CVT’s annual trauma training program – which in 2014 became the CVT-Makerere University School of Psychology Trauma Training – has been a connecting place for a large number of organizations, NGOs and institutions. The Makerere School of Psychology is considered the most important educational institution for psychological services in the country. Its partnership with CVT is huge because, as Gabriele noticed when he started at CVT Uganda in 2010, “there were no university programs for psychology or counseling in northern Uganda. Counselors had no practical skills that could help them make an impact. In fact, at the time there was very little trust in ‘talk therapy.’” At universities in other parts of the country the best students could hope for was to become a lecturer. There weren’t many opportunities to actually practice psychotherapy and get a job seeing clients. Graduates possessed a theoretical, university-trained background but no extensive, practical clinical skills. “CVT offered a very different approach, helping students move beyond theoretical knowledge,” Gabriele said.

Now, Master’s Degree students from Makerere join CVT activities in Gulu each year to reinforce their clinical skills under CVT psychotherapists’ supervision. This year a new curriculum of 500 hours has been presented to the university; CVT and Makerere are actively working to implement it. CVT Uganda also offers clinical supervision every two weeks; because there are very few trained clinical supervisors in northern Uganda, these trainings attract counselors from across the region. Trainings consist of theoretical classes and practical application in the field, typically co-therapy sessions led by Gabriele and the trainee. Gabriele still supervises counselors who attended his first-ever training in 2010. Others he trained developed a passion for psychology, continued their education and are now psychologists working and studying all over the world.

Successes and Reflections

The CVT Uganda story is a success story unique within CVT: In Gulu, the program is smaller than other locations and does not serve refugees or asylum seekers. Rather, the focus has been on a population of Ugandans in transition after war. Neal noted that CVT has continued to learn and adapt based on client needs, adding, “One of the benefits of our relationship with TFV has been a co-exploration of what rehabilitative care means for survivors in this context. TFV has remained very open to what we were learning and our ongoing feedback based on the work and the data we were collecting. The program in Gulu is a great example showing that a small program could do very good work without all the resources our other, larger programs enjoy.”

For Gabriele, helping CVT stakeholders and trainees distinguish between psychosocial support and psychological counseling has been key to positively impacting the healing environment in northern Uganda. “Psychosocial support is an intervention intended to help a person cope with stressors at home, work, school or in the community,” Gabriele explained. “The goal for participants is not to achieve psychological changes; there is no formal, specific goal between the clients and service provider. There also isn’t space to reflect about psychological changes induced by the social intervention.” Examples of psychosocial support include HIV/AIDS awareness campaigns, voluntary cleaning of community areas, sports and recreational events or a commemoration of those fallen from war.

Meanwhile, psychological counseling is a process that empowers individuals to establish, re-establish or develop emotional, relational and social strength, and psychological health, through a relational process involving verbal, physical or artistic expression—like talking, drawing, theater, music, etc. “It addresses the internal world of clients,” said Gabriele, “what is happening in their hearts and minds, versus what is happening in their external world—their food, water and shelter needs.” Counseling encourages change in survivors’ vision of themselves and of the opportunities available to them. It’s a process where the client can understand his or her own functioning and learn new strategies and skills. Clients look inward to seek change or growth. There is space for reflection about how psychological changes lead to practical changes, and the intervention is specifically tailored to the client so the goals are unique and agreed upon at the outset between client and therapist, then guide the process.

“This distinction is crucial for counseling efficacy,” said Gabriele, “because psychological rehabilitation takes place when there is active engagement from the client. There are established goals, and the counselor takes into account the survivor’s specific condition, relational context, history and attitudes.” After ten years, there is now a better understanding among organizations in northern Uganda of these two different types of interventions and less confusion among clients about what to expect.

For Gabriele, the most exciting and lively aspects of CVT Uganda’s work occur during group therapy sessions. “I have had wonderful experiences observing client responses; there are unexpected therapeutic successes almost every week,” he said. He recalls working with CVT Uganda’s first trauma therapy group, held in a village so remote “it was practically hidden in a bush, with almost no services provided there. Few people know of it.” Working with this community, Gabriele and his team of four realized then that even hardworking laborers, consumed daily by work, can reap incredible benefits by consistently attending therapy sessions for ten consecutive weeks. At the end of the therapy cycle, there was a village celebration. Gabriele said, “I’ll never forget the compelling dances, the local food specialties and the love and excitement demonstrated for our work there.”

New Expansion – Bidi Bidi, Uganda

This year, CVT Uganda even expanded its services. The organization now offers psychological first aid in Uganda’s Bidi Bidi refugee settlement to South Sudanese refugees in need of immediate stabilization, as well as 10-week group counseling sessions. Plans are already underway to incorporate a physical therapy component to treatment. Meanwhile, Gabriele hopes to add more mentors to his staff and influence the Uganda Ministry of Health to offer psychological counseling at its health centers. “I believe that psychological services enable people to use their ‘life crisis’ to enhance their quality of life,” said Gabriele. “By reflecting on and eventually owning their life experiences, they gain capacity to appreciate the preciosity of each moment.”

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CVT’s program in and around Gulu, Uganda, is supported by the Trust Fund for Victims and Fondation d’Harcourt.

CVT’s work in Bidi Bidi, Uganda, is a gift of the United States Government.