When reintegration fails: Stigmatization drives the ongoing violence of ex-combatants in Eastern Democratic Republic of the Congo

Breaking the cycles of violence with narrative exposure: Development and feasibility of NETfacts, a community-based intervention for populations living under continuous threat

BACKGROUND

Interpersonal violence damages mental health and frequently leads to aggressive defence strategies. If survivors are subsequently blamed for the events, both consequences worsen. Stigma flourishes, especially when survivors are silenced so that details of the trauma remain unknown. Breaking the secrecy both at the individual and collective level is key to enable the healing and reconciliation of individuals and communities living under continuous threat.

METHOD

The NETfacts health system is a stepped care model with three components: (1) Narrative Exposure Therapy (NET), an evidence-based trauma therapy that includes survivor testimony (2) NET for Forensic Offender Rehabilitation (FORNET) acknowledges that perpetrators are frequently also victims and assists in reducing aggression and the attraction to violence, and (3) a community intervention disseminating and discussing Facts derived from NET treatment (NETfacts) to challenge the collective avoidance of atrocities and other traumatic material. The intervention was piloted in a community with 497 adult residents in Eastern Democratic Republic of Congo. The willingness of clients to consent to sharing their anonymised testimonies (with a focus on sexual violence survivors and ex-combatants) was investigated, together with other components of feasibility including security and clinical safety, extent of support of respected local authorities and participation rates. As secondary outcomes, clinical and social measures were assessed before and post NETfacts among 200 village residents of whom 160 self-enrolled and 40 had not participated in any form of treatment.

RESULTS

Implementation was feasible with 248 clients from a partner project giving consent to use their testimonies and high support of respected local authorities and participation rates (56% of residents self-enrolled in NETfacts). Immediate beneficial effects were shown for posttraumatic stress and rejection of rape myths among NETfacts participants who experienced multiple traumatic events in their own past. Attitudes towards ex-combatants improved and the perceived lack of social acknowledgement after trauma increased independent from participation. No significant change was observed for depressive symptoms.

CONCLUSION

NETfacts is a feasible and promising approach to challenge the culture of secrecy surrounding trauma, suppression and social exclusion. Long term effectiveness requires further evaluation.

NETfacts: An integrated intervention at the individual and collective level to treat communities affected by organized violence

War and crises cause tremendous suffering and hardship and contribute to wider problems in our globalized world (e.g., mass migration, modern slavery, poverty). Yet theoretically anchored, evidence-based tools to mitigate the negative effects and restore resilience in affected communities have remained scarce, despite costly international programs. This article presents a longitudinal trial building on evidence from psychological trauma treatment and peacebuilding. Using trauma-focused individual treatment combined with a community-based intervention, we show that ignominious social norms and attitudes can be addressed effectively with the community-based intervention and thus indirectly reduce ongoing violence.

War and crises affect mental health, social attitudes, and cultural norms, which can exacerbate the state of long-term insecurity. With decades of armed conflict, the Democratic Republic of Congo is one example, and violence has become normalized in civilian settings. In this study, we tested the effectiveness of the NETfacts health system, an integrated model of evidence-based individual trauma treatment (Narrative Exposure Therapy [NET]) and a trauma-informed community-based intervention (NETfacts). Alongside changes in mental health outcomes (posttraumatic stress disorder, depression, social disapproval, and shame) we also investigated change in attitudes, including rape myth acceptance, stigmatization of survivors of sexual violence, and skepticism about the reintegration of former combatants. To test whether the additional community intervention is superior to individual NET alone, we implemented a randomized controlled design with six villages and interviewed a sample of 1,066 community members. Our results demonstrate that the NETfacts health system in comparison with NET alone more effectively reduced rape myth acceptance and with it ongoing victimization and perpetration. Community members of the NETfacts group also presented with less stigmatizing attitudes against survivors of sexual violence. Skepticism about the reintegration of former combatants declined in both groups. NETfacts appears to have increased motivation to engage in individual treatment. Synergizing the healing effects of individual and collective trauma exposure, the NETfacts health system appears to be an effective and scalable approach to correct degrading or ignominious norms and restore functioning and mental health in postconflict communities.

Recurrent Ebola outbreaks in the eastern Democratic Republic of the Congo: A wake-up call to scale up the integrated disease surveillance and response strategy

Ebola virus disease (EVD) is a dangerous viral zoonotic hemorrhagic fever caused by a deadly pathogenic filovirus. Frugivorous bats are recognized as being the natural reservoir, playing a pivotal role in the epidemiological dynamics. Since its discovery in 1976, the disease has been shown to be endemic in the Democratic Republic of the Congo (DRC). So far, thirteen outbreaks have occurred, and EVD has been prioritized in the national surveillance system. Additionally, EVD is targeted by the Integrated Disease Surveillance and Response (IDSR) strategy in DRC. The IDSR strategy is a collaborative, comprehensive and innovative surveillance approach developed and adopted by WHO's African region member states (WHO/Afro) to strengthen their surveillance capacity at all levels for early detection, response and recovery from priority diseases and public health events.

We provide an overview of the IDSR strategy and the issues that can prevent its expected outcome (early detection for timely response) in eastern DRC where there are still delays in EVD outbreaks detection and weaknesses in response capacity and health crisis recovery. Therefore, this paper highlights the advantages linked to the implementation of the IDSR and calls for an urgent need to scale up its materialization against the recurrent Ebola outbreaks in eastern DRC. Consequently, the paper advocates for rapidly addressing the obstacles hindering its operationalization and adapting the approach to the local context using implementation science.

When reintegration fails: Stigmatization drives the ongoing violence of ex-combatants in Eastern Democratic Republic of the Congo

Reintegration of ex-combatants involves multiple challenges. In addition to the trauma-related psychological sequelae, social obstacles in the community can aggravate psychopathological aggressive tendencies and lead to the continuation of violence in civilian life. However, the association between others' negative attitudes and ex-combatants' ongoing perpetration of violence remains largely unexplored. Between September 2018 and May 2019, we assessed a representative community sample of adults in Eastern DR Congo (N = 1,058) and measured trauma exposure, perpetration, mental health problems (PTSD, depression, and appetitive aggression), perceived stigma (shame, perceived lack of social acknowledgement), experienced stigma, and skepticism toward reintegration with ex-combatants. Male ex-combatants (12%, n = 129) had more past trauma and violence perpetration than other community members and a greater number of recent conflicts (including both victimization and perpetration) within the community and with strangers/organized violence. They reported more experienced stigma, more severe PTSD symptoms but were less skeptical about reintegration. Ex-combatants' ongoing violence was predicted by an interplay of the community's skepticism toward reintegration and ex-combatants' perceived and recently experienced stigma (often attributed to the armed group history) and mental health problems, in addition to lifetime traumatization. These findings promote the need for combined interventions that address individual mental health problems including aggression and collective discriminatory attitudes and behaviors.