On the surface Rwanda is thriving, it is appearing to be a strong conference venue for foreign visitors with its policies on global environmental health, equality, housing, and resilience. They have shown the world a model of recovery from the horrors of genocide that appears on the surface to be that of peace and harmony. I myself felt this in my first visit and have been advocating and praising the country as a strong role model to the rest of the world. But as I return I am starting to get a glimpse of what also lies underneath.
Since November I have felt contradictory responses to my presence in Rwanda as a Counselling Psychologist. When I first approached GEI I received a hugely positive response to my being able to help the country somehow with my skills, and this continues. I have also been received warmly and almost god like by those involved in learning and developing areas of mental health. But when it has come down to trying to find a place in which I can anchor my help I have been struggling and feel I am being met with some resistance. At the recent summer school, whilst it was titled as a ‘knowledge sharing opportunity’ it was pointed out early on that this meant they wanted to share their knowledge with us, but not us with them. Quite rightly, and gratefully, I was there to learn about where they were in relation to mental health, but something small stuck in me that said “they are not ready to hear from us yet”. I have now made 3 visits to Rwanda and this last visit gave me some better insight into why this was and what I see may be happening.
For me the key factors are;
· Early stages of learning; addressing Mental Health as we know it is very new for Rwanda and they are still learning. They don’t yet know what I can do to help because they don’t know it themselves yet. Like a child learns, they are still trying to work it out for themselves.
· Financial restraints; there is a slow and gradual recognition and acceptance of the place of Mental Health by those who will contribute financially to staffing, research and training.
· Overarching these issue’s, I believe, may be that of the institutional repression as a way of rebuilding the country. This has been the strategy for recovery but I see now how it may be impeding the development of Psychology and mental health, making it a gradual and gently, gently approach, something I had suspected before my first visit.
This essay explores how I am understanding the development of mental health in Rwanda based on what Rwandans professors, ministers and students have taught me through conferences and discussions. It also examines the underlying dynamics of Rwanda that I am feeling and learning about that is causing me to still feel a little lost in where my place could be there as a Counselling Psychologist. The hope is through this essay I may find a place somewhere that I can help.
HISTORY OF MENTAL HEALTH IN RWANDA
PRE-GENOCIDE
In pre-Colonialism times issues were dealt with by wise men and through rituals. It was thought that an individual’s mental health issue was a message about the community, that their symptoms were as a consequence of a sickness within the community and so issues would be addressed at community level. In todays Western Psychology we will also take this approach in understanding a client’s mental health but we will still treat the individual or may refer to systemic family therapy if this is the source of the problems.
When Germany and then Belgium colonised Rwanda in the 1880’s they gave a dialogue to traditional healers as ‘paganism’ and gradually forced the country to lose contact with their own values and morals that had supported their mental health.
Independence came in 1962 which left Rwanda confused as to how to deal with mental health having lost their moral and spiritual compass and patients were being imprisoned, treated like criminals. 1974 saw the first Psychiatric hospital and the introduction of a pharmacological approach to mental health. But even today the past remains and professionals in mental health are being stigmatised and treated with caution by the people. They may be seen as witch doctors who will get into their heads and do things to them or have an expectation that they will just ‘fix’ them immediately with a pill. Understanding that healing can be located within themselves is a new cultural concept.
These are just some of the issues faced for Rwanda prior to the genocide in 1994. Working with Mental Health was still very new. Until the genocide of 1994 there were no mental health trained professionals and only one psychiatric hospital, that being Ndera hospital in Kigali, which remains and thrives today.
POST-GENOCIDE
In 1994 Rwanda saw one of the most horrific genocides in world history between the Hutu’s and Tutsi’s. Following the implementation of identity cards by the Belgium’s, divisions were created between the tribes. Civil unrest started after independence came as power was fought for and division became strengthened. Since the 1970’s there had been many killings but nothing like what happened in April 1994. Approx. 800,000 Tutsi’s were murdered at the hands of Hutu neighbours with machetes and clubs. Women were raped and abused, left heavily infected with HIV, unwanted pregnancies or internal mutilations. Many Hutu’s went into exile to avoid punishment or having to join the crusade, and many Tutsi’s left Rwanda to avoid death.
This also meant that many of the traditional healers and mental health workers were either killed, imprisoned or exiled leaving the country in a state of ‘collective psychosis’ without anybody to treat them. Figures suggest that 1 out of 4 Rwandans lost at least one parent and 80% of Rwandans were exposed to traumatic events.
Ndera hospital was not exempt from the genocide.
The first patient was hospitalized in 1972. The hospital at the time named "center" was planned for 60 patients with the possibility of an extension of 60 patients. From the beginning, we treated women as well as men.
From 1968 to 1994, the hospital experienced remarkable growth in infrastructure, personnel and expansion. It was able to create an antenna in Butare in the south of the country, officially opened on October 30, 1978 and functional since 1980. At the beginning the center had 20 beds. The hospital also initiated the mobile teams to reach the most of the patients who were inside the country.
At the time of the genocide perpetrated against the Tutsi in 1994, the hospital was not spared. It was destroyed, the staff massacred, the rest taking the path of exile. The equipment was looted and some archives missing.
After the genocide
From 1995 to 1996, the brothers of charity resumed activities and with the help of Swiss cooperation, Belgian cooperation, the hospital was rehabilitated, the new staff trained, the hospital re-equipped.
Since the resumption of operations in 1996, the hospital has been growing rapidly. Patients who arrive in a state of acute crisis quickly leave the crisis room for the rehabilitation room. Infrastructure has also improved. This is how a center for children and adolescents was created in 2004 with 12 beds. In addition, a psychotherapeutic center was opened in Kicukiro in October 2003 to care for patients traumatized by the genocide. It has a possibility of hospitalization of 8 beds. The center plans to increase services by integrating the care of drug users and drug addicts.
http://caraesnderahospital.rw/historique-2/
As well as physical harm the genocide caused a breakdown of trust between and within families and communities causing a psychosocial suffering. Many research figures have shown a rapid increase in cases of PTSD since the genocide, many of which were not immediately exposed to the genocide directly but through inherent trauma experiences from families involved. Depression and anxiety also increased with thoughts of “why me?” “what did I do to deserve this?” or even survivors guilt of “why not me when the rest of my family have gone?”. Through physical blows to the head, there was an increase in epilepsy and brain damage related mental health issues.
It soon became apparent that a model of Psychological treatment was required within the country if they were to recover. Rwanda is now taking a BioPsychoSocial approach and there has been a significant increase in mental health support and training. However there is still a lot of progress to be made and gaps to be filled whilst acknowledging the challenges that are faced in doing so.
Until 1994 Now
Psychiatrist 0 8+11 residents
Neurologist 0 4 (Ndera, CHUK University Central teaching hospital of Rwanda, CHUButare)
Psychiatric nurse 0 500
Clinical Psychologists 0 >2000
G.Nurse trained in HC’s 0 500
CHWs trained 0 15000
Hospitals providing MH 1 (Ndera) 45
Psychotropic drug on LME 0 22 including anti-epileptic drugs
Reflections
It is becoming more and more apparent to me that whilst there is a dialogue that suggests an openness and want of our western help when it is actually offered there is resistance. I was always sensitive to tread carefully and to learn from the culture and not enforce my ways onto them as being ‘right’ or the ‘only way it should be’. To understand their culture first and understand how it will be received and implemented.
But each time I think I am understanding, when I go to create something that may work I feel I cannot quite place myself or my work anywhere. Speaking to the Scandinavian Assistant Director of the Mental Health Centre he echoed this experience which reassured me that this was not me but the system there.
There is something of a void in which something is not anchored and I am trying to understand what this void may be.
We have to consider that, as in therapy, we as therapists can only go as far with our clients as we are prepared to go ourselves. Those who are trying to encourage, teach and practice mental health in the country will also have their own experiences of the genocide. Something I have now discovered from talking to people in the privacy of their own homes is that oppression is real, not just a possible theory I had. Institutional oppression blocks people from truly talking about the past, about belonging to different tribes, about past heritage and truthfully about how they feel about their experience of genocide.
I believe this leaves Psychologists as ‘wounded healers’ hiding behind the science and safety of research but not truly applying therapeutic practice. Not one person is exempt from the impact of the genocide. They all have their stories, their traumas, their family narratives about it. But have they themselves done the work for themselves that allows them to accept the intimacy and closeness that therapy brings? How can they in a country where it is not to be talked about in this way. As therapists can they really dare to give therapy knowing how close to their own issues it will come.
For most Western Psychological training we have to embark on extensive amount of personal therapy because this is paramount in relation to psychological theory. To be a blank slate (as best we can), a neutral place with no bias of judgement we have to know ourselves first. To facilitate a client to go to the place they need to go we need to be able to go there ourselves. So I therefore have to question, maybe unfairly and not wanting to dismiss individual experiences, have those that know what is needed and who are trying to enforce and teach the government done their own work on their story of the genocide. Is this where the resistance lies in being confronted with actual progress?
I noticed that the conferences are full of presentations of research to explore what is needed and what may work. But how this is to be done comes from presentations by Western visitors to the conferences.
I wonder if it is safer to hide behind both scientific research and also the black and white distinction of medical psychology instead of therapeutic psychology. But I also see a hunger from the young students to know ‘how’, not ‘why’. When a workshop is presented you can see them asking the questions of real curiosity and hunger, wanting to develop this understanding further. This new generation is ready to start doing the real work, not just talk about it because the genocide is somewhat removed from their experience. It is only narratives and stories, and family dynamics, not the violence they experienced.
I was fortunate to spend time with the new generation, who were only young children at the time of the genocide. In the privacy of their own homes they feel free to speak and there is a clear under current of frustration over the oppression that has been implemented by the government. These men are intelligent guys and passionate in their studies on journalism and human rights which says a lot to me that they are really crying out to have their voices heard. They are confused by the way the government has enforced a shared identity given that their heritage is embedded in separate tribes. Whilst I and they can appreciate why the government has done this, to eliminate division as a way to prevent future genocide, it leaves people feeling very lost in where they came from. What do new children learn about their history? They are one tribe but they came from two tribes but they don’t know which one as it is not to be talked about? They must call themselves Rwandans. But what is their past narrative they use to understand where they belong in history?
And do they really need it? I this a Western, psychotherapeutic idea that we look at our past constructs to understand ourselves now, instead of just working with the Here and Now an changing this. But is not having a sense of belonging crucial for everybody. Whilst they are all called Rwandans there is still indicators of divisions throughout the country, so how can people people really feel they belong as a Rwandan? The commemorative week aims to bring together perpetrators and victims to reconcile, but to the young how do they understand the genocide if they were of the same tribe? And how do those who did belong to either a Tutsi or Hutu suddenly feel a belonging to the Rwandan tribe? Can it just happen because by just not talking about it? It seems to maybe create more confusions and complexities than solutions underneath when we consider each individual as a human being with their own minds and their own struggles to know where they belong.
This generation are not angry, but they are frustrated. They are able to be happy, to laugh a lot, to talk openly with each other in private about their different views without fear of retribution. They speak intelligently but respectfully with each other. But they are still passionate to stop the repression and feel they have a voice. Whilst they are frustrated they also have a sense that the moment permission is given to speak out so much anger, guilt, and grief will explode and be potentially catastrophic. So, whilst it may be oppression, the government have enforced a strong grieving and reconciliation structure which in someways reflect the boundary setting of the therapy room. But maybe it is too controlled. Only one week a year in April it is ok for Rwandans to grieve, it is encouraged, to express all of your feelings of the genocide openly, to help heal and create reconciliation. But then after this life has to go on as normal until next year. So they open up the wounds and then shut them down before they are fully expressed and healed. Maybe this reflects how a therapist opens a client up and shuts it down at the end of session but is one week a year enough? Grief and anger is a process and needs to be supported outside of this contained space to enable a continuation of the process. But outside of this space they are not to speak of it unless it is within the clinical setting of the Genocide memorial. Maybe, whilst the young people are frustrated maybe the government have it right in pacing the healing in order to create stronger resilience, to learnt to cope alongside their grief and trauma. But it seems the danger is that people don’t stop hurting outside of the therapy room so what do they then do with this if they feel there is nowhere to go?
If we consider this also in relation to the growing attempts to develop Psychological treatment, how do the clients consolidate the enforced repression of the government and the freedom of speech encouraged in therapy. How can they feel it is ok to speak out to a therapist when the government says it is not ok? And so maybe the resistance I feel is fear. Maybe there is an unconscious fear within the Psychology and Mental Health departments to really say “It is ok to talk about your experiences of the genocide”.
Is it safer to hide behind the medical and clinical model of Psychology of diagnosis whilst shying away from the underlying and more complex issues going on in society . It seems acceptable to acknowledge PTSD as a result of the genocide. But what about acknowledging stress caused by repression? I challenged one student at the conference who became defensive when I suggested they could draw on research from other countries. He protested that the country was unique in its experiences and so they would not be culturally relevant. I alerted him to be cautious not to relate all mental health issues to the genocide. People will still have everyday stressors and anxieties that are universal, such as addictions, bereavement, money etc.
Also, if clients they weren’t around at the time of the genocide what then caused their PTSD? And should we readily jump to this diagnosis? One friend told me his sister suffered badly from PTSD because his grandmother continually spoke angrily about it at home. But could that young girl tell a therapist this was what her grandmother was doing when they were not supposed to be talking about it? Is she then betraying her grandmother? Would she then get into trouble?
I don’t believe this is all about resistance due to oppression but also needing to allow them to learn at their own pace. They are still in a position of learning and so we have to appreciate the level in which they are understanding psychology and if we are to take it too advanced this will overwhelm them. If they feel what we offer is too advanced they will push back, as any child does when trying to help them with schoolwork.
Rwanda is a country of juxtapositions
It has one of the most beautiful landscapes with it’s sweeping 100 hills, but the hills have experienced the horror of genocide.
They present as an almost too perfect stable, clean, safe and peaceful country whilst underneath repressed tensions are strife.
Whilst a large percentage of Rwandans live a simple life of farming they are still intelligent and individual people.
The country comes from a community based culture whilst we are trying to deal with individuals in therapy. How do they get their heads around this? My personal experience has shown me that an individual may isolate themselves from community because of their mental health. By addressing it as an individual it can allow them to reintegrate into the community and give themselves greater purpose.
There is still a divide between clinical/medical and therapeutic model that I believe would help them to create more of a community service as they compliment each other. This year’s conference introduced their awareness that physical health and mental health have to be supported together. But I still observe that they still see them as separate. They still seem to lack and understanding of the micro-relationships between them. But they are only learning about a bio-psycho-social concept now and they are still trying to negotiate what this actually means. I was referencing this principle back in 2010 for my MSc research in relation to fibromyalgia. It is not a new concept but to them it seems to be.
So what does this mean for me and my position here? I think I still need to focus on the practical tools as there is a hunger for this. I need to make it simple and basic so it does not feel too overwhelming to understand in terms of concept. But also to respect they are intelligent people and can understand comprehensive concepts. But in practical terms this may be harder to absorb given they have to involve their own sense of being into the learning, and this presents many institutional and personal issues that need to be respected.