Traumatised by his experiences as a child soldier in South Sudan, 14-year-old Peter decided to settle an argument with two other children by taking an AK-47 from the local military barracks to shoot them.
Peter, whose name has been changed to protect his identity, was one of nearly 1,800 children being reintegrated into their communities after their release earlier this year from the South Sudan Democratic Army Cobra Faction in eastern Jonglei state.
Some were withdrawn and unable to trust people around them.
Some, like Peter – who was disarmed before he could open fire – were prone to aggressive outbursts.
Counsellor Shaun Collins, who has recently returned to Britain after six months as a leader on the UN children's agency (Unicef) programme which helped release and reintegrate the children, decided not to offer Peter formal therapy.
Short of time and resources, Collins thought it better to teach the boy techniques to help him calm down, and draw in community elders, family, social workers and his teacher to help him change his behaviour.
“We had no formal post-traumatic stress disorder-type services to work with this boy, so we worked with what we had,” Collins said, referring to a condition that can affect people like Peter who have had traumatic experiences.
Eventually the boy calmed down enough to reveal that while fighting his way out of an ambush, he killed several people and saw close friends die. He became both victim and perpetrator.
South Sudan has just a handful of mental health professionals to serve a population who have experienced decades of war.
In countries recovering from conflict, experts like Collins want to see mental health services prioritised alongside housing, healthcare and education.
“You can see the problem somewhere like Sierra Leone where you didn't address trauma,” said Collins, who worked in what was Sierra Leone's only psychiatric hospital.
“The problem doesn't just go away with the passage of time, it just becomes chronic,” he added.
Many say trauma can affect not only families and communities, but also a country's prospects of long-term peace, and economic and political development.
The World Bank views trauma as an obstacle to economic development in West Africa, and this year launched a programme to try to address it in Liberia, which has been deeply affected by the Ebola crisis and civil war.
“Research shows trauma is cumulative. So the more terrible things happen to people, the higher the risk of developing mental health problems,” said Inka Weissbecker, global mental health and psychosocial adviser at International Medical Corps.
In places suffering long-term conflict like Gaza or Afghanistan, people are much more on edge, there is more family violence, people have difficulty trusting each other, she said.
“People only talk about the loss of life, but never about the loss of a future,” said Inge Missmahl who is working with the Afghan government to introduce a trained psychosocial counsellor in every public health clinic in the country.
“People who have experienced traumatic incidences ... have shattered basic assumptions about life – the sun goes up, the sun goes down but everything else is different,” Missmahl said.
If people do not have too many traumatic experiences, and can find a safe environment in which to live, symptoms of trauma can ease with time. But if the experiences are repeated or if war continues for a long time, then the symptoms can become chronic.
“People don't really know why they have changed, why they are ... not the same loving father as before. The knowledge that this is perhaps a normal reaction to an exposure to an abnormal situation is a relief for people.
“If whole generations grow up with violence at home and conflict in their communities ... they learn to solve problems in a violent way,” said Missmahl, who founded the International Psychosocial Organisation (IPSO), whose team has so far trained about 300 psychosocial counsellors in Afghanistan.
More than 60% of people who attend public health clinics in Afghanistan are reported to show symptoms of depression, fear and anxiety, Missmahl said.
“The social costs are high. People who feel like this struggle to find work and recreate a meaningful life for themselves and their families,” Missmahl added.
The process of helping people cope with trauma is also crucial to building national peace, she said.
If unaddressed, trauma becomes a potential cause of the next round of violence and conflict, said Vesna Matovic who, as head of training for London-based NGO International Alert, trains UN agencies, the World Bank and governments in peacebuilding.
“If you don't deal with collective trauma, where you can see the population being passive, depressed, living in the past, you have blockages in economic development and political life,” she added.
For example, Serbia and Croatia have developed trade and cultural relationships with each other, but in other ways the former enemies have not moved since the war ended 20 years ago.
Referring to recent commemorations of victims of the Yugoslav war, Matovic said: “It was almost possible to sense in the air that the conflict is just frozen and it could go back to where it was ... it's not dealt with. Moving on would mean establishing new political relationships, and not always talking about what happened (in the past).”
Germany after World War II as a nation faced its past and its actions, she said.
“I think that acknowledging what happened was healing for them as a society. They did quite a good job in not covering up issues, or putting it under the carpet. I think they were facing their past, and that's always the first step. And without that I don't think any society can progress so much.”
Much has been done in Rwanda to help people recover from the 1994 genocide, at both the national, community and individual levels.
“It takes ages to rebuild something that can be destroyed overnight,” Matovic said.
Important steps include acknowledging that different people suffered differently – men, women, children, elderly, different ethnic groups, different social strata.
Crucial, too, is for societies to create space to understand why and how the violence happened, to prevent the next cycle.
“Otherwise those victims can become perpetrators,” Matovic added. “The cycle goes on.” – Thomson Reuters Foundation
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