Person-centered mental healthcare in Rwanda

The International Journal of Person Centered Medicine Vol 2 Issue 1 pp 109-113 FROM THE FOURTH GENEVA CONFERENCE ON PERSON CENTERED MEDICINE: CONTRIBUTIONS TO THE ADVANCEMENT OF PERSON-CENTERED CARE Person-centered mental healthcare in Rwanda Yvonne Kayiteshonga Psch PhD Head of Mental Health Division, Rwanda Biomedical Center, Ministry of Health, Rwanda Abstract Between April and July 1994, genocide was perpetrated in Rwanda during which more than one million and seventy four thousand (1,074,000) Tutsi were killed. This was a genocide planned and executed by the national authorities; it was also a mass genocide and genocide of proximity. The psycho-traumatic consequences in the population of Tutsi survivors were assessed through a longitudinal study conducted on genocide survivors seeking services at the Psychosocial Consultations Centre based in Kigali, Rwanda, during the period between 2000 and 2008. The research focused on assessment of the evolution of post traumatic stress disorder (PTSD) they were suffering from by reviewing medical records of 55 patients, using the international classification of mental diseases and also interviewing patients as well as clinicians. The study findings reveal that a high intensity traumatic event and the low income level of the family are causes of therapeutic failures. Specifically, dissociative aspects of PTSD experienced by victims of sexual rape are indeed a big challenge to the establishment of a therapeutic relationship. It was also observed that traumatic reactivations for some patients caused chronicity or intermittent apparition of psychopathologic manifestations. Another phenomenon observed concerns the somatic diseases concomitant to PTSD. Indeed, we had patients for whom somatic problems obstructed the manifestations of PTSD, hence delaying their treatment. Finally, a phenomenon of aggravation of PTSD by acute depressive disorders for almost all patients was additionally observed. Overall, the experience of the trauma of the survivors of the Genocide of the Tutsi of Rwanda leads the researcher to the recognition of multiple evolutions. It has been possible to observe a benign evolution and also a remission punctuated by periods of relapses and, finally, an evolution towards severity. Mental health in the context of post mass violence is a major clinical reality. On the one hand, we have plenty of mental health illnesses in a strict sense of the word: chronic evolution PTSD, severe depression, psychosis, etc. Those situations often need an individualized medicopsychological approach, that is, basic mental healthcare. On the other hand, all that which genocide causes such as psychological suffering, sadness and emotional distress in people and communities requires group therapy approaches as well as socio-economic support. Person-centred group and community initiatives, delivered in cooperation with different sectors involved in management of those issues, are indicated. Keywords Clinical supervision, community, genocide, integrated services, mental healthcare, person-centered care, psychopathology, PTSD, Rwanda, training Correspondence address Dr. Yvone Kayiteshonga, Head of Mental Health Division, Rwanda Biomedical Center, Ministry of Health, P.O.Box 1543, Kigali, Rwanda. E-mail: ykayiteshonga@gmail.com Accepted for publication: 12 March 2012 Introduction According to the World Health Organization (WHO), mental health is defined as a state of wellbeing in which people realize their own potential, can cope with normal life stresses, can work productively and can contribute to their community development. Between April and July 1994, genocide was perpetrated in Rwanda during which more than one million and seventy four thousand (1,074,000) Tutsi were killed. In comparison to other genocides committed recently in the world, the Tutsi genocide is unique in the sense that it was planned and executed by the authorities; it was also a mass genocide and genocide of proximity. The consequences are multiple and multi-sectoral. The Tutsi genocide not only led to almost indescribable personal loss and grief, but also to the loss of all kinds of human resources, experiences, talents and staffing needed for the efficient functioning of a whole society. The very tangible costs of this genocide are still noticeable today: socially, emotionally and culturally. Post Traumatic Stress Disorder (PTSD) One of the biggest challenges in mental health is the high prevalence of Post Traumatic Stress Disorder (PTSD) 109

Kayiteshonga Person-centered mental health care in Rwanda which is 28.54% among the Rwandan general population [1]. The co-morbidity of PTSD with other psychiatric disorders is actually much more common among genocide survivors. As Munyandamutsa and Mahoro have pointed out, PTSD is associated with at least one other major psychiatric disorder such as depression, alcohol/substance abuse, panic disorder and other anxiety disorders [1]. In Rwanda, among the population suffering from PTSD, 53.93% were found with symptoms of major depression. PTSD has also been found among genocide survivors who have been exposed to prolonged traumatic events, such as rape and sexual abuse. These individuals often exhibit behavioral difficulties such as impulsivity, aggression, sexual acting out, eating disorders, alcohol/drug abuse and self-destructive behaviors. The extreme emotional distresses and mental problems such as fragmented thoughts, dissociation and amnesia are observed during yearly commemoration periods of genocide in Rwanda. During the 2010 Genocide commemoration week in Kigali city, 384 patients (80% female, 20% male) were treated for acute traumatic stress reactions and the majority were aged 15-24 years old. At district level, out of 43 district hospitals, 29 district hospitals reported 2,502 patients with acute traumatic stress symptoms and the majority were female (89%) with and age range of 15-24 years old. The report from the district hospitals, in the same period showed that out of 43 district hospitals 35 reported that of 3,352 patients with acute traumatic stress symptoms, (76%) were female, (7%) were male and 17% gender not reported, aged between 15-24 years old. Working with individual and working with groups A study conducted at the Psychosocial Consultations Centre (SCPS) in Kigali City, Rwanda, on the psychotraumatic consequences in genocide survivors, assessing the evolution of PTSD using the international classification of mental diseases and medical records for 55 patients, revealed that a high intensity traumatic event and family precariousness are causes of therapeutic failures [2]. Particularly, dissociative aspects of PTSD experienced by victims of sexual rape are a big challenge to the establishment of a therapeutic relationship. Also, while reviewing clinical cases, traumatic reactivations for some patients that caused chronicity or intermittent apparition of psychopathologic manifestations were observed. Other phenomena observed were the somatic diseases concomitant to PTSD. The same study found that patients, for whom somatic problems obstructed the manifestations of PTSD, delays in treatment were evident. Finally, the researcher reported a phenomenon of aggravation of PTSD by acute depressive disorders for most all the patients. Overall, the clinical symptoms of trauma in the survivors of the Tutsi Genocide have led the researcher to observe three types of evolutions. These are a benign evolution, a remission punctuated by periods of relapses and, finally, an evolution towards gravity. The treatment of such patients takes an extended amount of time, may progress at a much slower rate and it requires a sensitive and highly structured, integrated and comprehensive mental healthcare program delivered by a team of mental health specialists. In the aftermath of the Tutsi genocide in Rwanda, mental health problems represent a complex clinical reality. We find, on the one hand, mental illnesses in a "classical sense", often with complex symptomatology. On the other hand, we see individuals and groups with psychological distress and "somatic disorders". This imposes the need to develop oriented and supported mental health approaches on a large scale along with group and community approaches. It is also essential to establish mechanisms of collaboration with somatic medicine through the integration of mental health in the primary healthcare setting and also with liaison psychiatry. Given the cross-cutting character of mental health problems, care should be based on integrated approaches and it is necessary to support vulnerable groups who are most likely to suffer from the many consequences of the genocide. The implementation of these strategies remains limited by the lack of qualified human resources and an under-funding of mental health services. Additionally relevant here is the fact that some service sectors, such as Education and Youth, despite occasionally successful collaborations with the national mental health program, fail to integrate mental health into their plan of action, therefore delaying the creation of any multi-sectoral framework in the field of mental health. The community has always been a central priority of the National Mental Health Policy. Some community health workers have been trained. They accompany families and patients to health facilities and they also provide active listening, especially during the genocide commemoration period. They also play the role of firstlevel caregivers during the GACACA process - popular courts established to trial perpetrators of the genocide - when they were managing emotional problems and trauma manifested in the discovery of truth by the survivors. At the community level, community health workers have reached a satisfactory level of care for diseases with high rates of morbidity and mortality. However, current training targeting to discourage the tendency of these community health workers to consider their mental health interventions as purely mechanical offer a new hope for an excellent future for the community mental health interventions. With the support of the Ministry of Local Government [3] and the Ministry of Health [4], civil society is also organized into associations to provide psychosocial support when needed. These initiatives are mainly found among young and widowed genocide survivors. Key initiatives deal with psychological trauma. The training of "trauma counselors" that took place in the National Trauma Centre (CNT), established in 1995 in Kigali functioned well in example. Currently, the training of trauma counselors is provided by a local Non-Governmental Organization (NGO), the Rwandan Association of Trauma Counselors (ARCT) and the Fund for Assistance to Genocide Survivors (FARG), where psychology is included in its programs. FARG has placed consultants in 110

The International Journal of Person Centered Medicine several trauma care facilities across the country. Currently ARCT is mostly engaged in counseling to support people living with HIV/AIDS. MSF-Belgium (MSF-B), via local NGOs (AVEGA, ICYUZUZO and URUNANA) provide psychological support to women victims of violence and Handicap International (HI) helps the orphans. MFS-B left Rwanda in 2007, but the local associations continue their activities. More than thirteen thousand community health workers were trained. The aim of the training is to foster a community response to psychological trauma resulting from genocide, particularly to support people in the GACACA courts. Following the recommendations of the National Mental Health coordination exercises, different associations with mental health activities are involved in a consultative committee with the objective to reflect together on various issues of mental health. This committee's responsibilities include establishing a system of supervision of psychopathological manifestations of the annual commemoration of the genocide, where a commemoration is held every year between April and early July. The coordination committee also assisted the GACACA process. The preparation began in 2002 and the first trials began in March 2005. Psychological interventions carried out during the GACACA courts have been executed according to a strategic plan for psychosocial interventions available in a document coproduced by the Ministry of Health in its Mental Health Department and the Ministry of Justice. The Mental Health Department undertakes social mobilization. Mobilization occurs weekly through radio program broadcasting on national radio. The content of these programs is provided by mental health professionals from the national referral structures as well as university lecturers. Mental health policy, in addition to providing necessary basic mental healthcare to the people, must also deal with the aftermath of genocide, making the decentralization and integration of mental healthcare, as well as ongoing staff training, necessary. Recognizing this, the Ministry of Health has developed a mental health strategic plan for the period 2008 to 2012. All activities of the mental health division, as well as for other partners in mental health, must be done according to that strategic plan. The mental health strategic plan refers to the recent findings that different psychiatric disorders are very marked by the violence the victims suffer from; many of these disorders range from simple anxiety to severe psychotraumatic and psychiatric disorders. The situation is further complicated by existential problems which are added to other difficulties experienced by patients. Despite efforts made since 1994, the development of mental health in Rwanda is experiencing some difficulties, namely, the lack of qualified human resources personnel, lack of specialized mental health institutions and financial resources, poor understanding of mental health problems, the stigma experienced by patients with mental disorders and the increasing reports of harmful use of alcohol and drugs, especially among young people. In summary, the main interventions of the National Mental Health Program [5] are based on the following principles: (i) actions to support the health system; (ii) actions to strengthen healthcare providers; (iii) measures undertaken with community stakeholders with a view to supporting patients and their reintegration into society & (iv) inter-sectoral action. Actions to support the health system Mental healthcare has been decentralized at different levels of the health system and integrated into primary healthcare, so that all care services treat mental illnesses in the same way as physical illnesses. Currently, this integration is effective in all the 41 district hospitals in the country. Decentralized structures have a framework for reception, examination, monitoring and hospitalization in internal medicine units, as well as for the clinical supervision of health centers. Currently, these decentralized structures provide an important role in the next integrated complementary package of activities of district hospitals. Individualized mental healthcare is provided by mental health nurses working under the supervision of a General Practitioner (GP) also trained in mental health. Six district hospitals have been equipped with special beds for patients with mental disorders and designated to be the regional referral mental health services. The regional referral mental health services are the first referral level for the district hospitals in their respective areas. Actions to strengthen caregivers The integration of mental healthcare in general hospitals has been strengthened by regular continuing education for general practitioners. The objectives of the training are to increase the knowledge of general health professionals in mental healthcare so that they will be able to make appropriate diagnoses and prescribe adequate treatment. This training also makes them aware of the psychotropic medication and basic psychotherapeutic interventions available. Once trained, the GP is able to initiate the establishment of liaison psychiatry and provide leadership to the mental health service in the hospital where he is working. A general practitioner, even with limitations of time or when under pressure, can conduct effective and essential interventions when these are executed early. This is especially important, given that people with mental illnesses and their families are mostly unwilling or resistant to seeking help. However, the general practitioner may refer the patient to specialized programs or to mental health specialists. General Nurses also receive ongoing training in mental health. Their training, in turn, has improved multidisciplinary team approach and treatment of mental disorders. The training of these two categories of professionals has had the advantage of compensating for the crucial shortage of mental health professionals in Rwanda. 111

Kayiteshonga Person-centered mental health care in Rwanda All clinicians receive regular clinical supervision. This supervision focuses on the capacity of clinicians to receive a mental patient and perform a clinical examination, to issue appropriate prescriptions and to interact with families. It is also a useful time for clinicians to exchange experiences around presentations of clinical cases and to engage in mutual support. During this clinical supervision, family risk factors for mental disorders and precipitating factors or predisposing factors of chronicity are a systematic area of educational focus. The assessment of a patient s capacity to work autonomously and integrate into the community is also examined systematically. These "meetings as a case study" involve all care givers trained in mental health, in addition to mental health nurses. Once a week, (in fact, every Wednesday afternoon), a clinical supervision (mentorship) session for clinical staff from the two referral institutions (the Psychosocial Consultation Center and the Ndera Neuropsychiatric Hospital) takes place at Ndera Neuropsychiatric Hospital (HNP). Clinical supervision allows the supervisor to provide emotional support to the therapist when experiencing some weakness or negative feelings with particular patients. Participants in this clinical supervision are clinicians from the two referral institutions (PSCC and NNH), medical and clinical psychology students from the National University of Rwanda and mental health nurses from Kigali Health Institute, as well as students from abroad. During the clinical supervision, a theoretical tutorial is given by supervisors or invited experts or members of clinical staff. Also, once a week, specialized psychiatric and neurological consultations are held at PSCC by specialists in Psychiatry and Neurology. Developing links and partnerships with the community The purpose of the actions undertaken with community stakeholders and civil society is to ensure the orientation and guidance of patients, their social integration and fight against stigmatization. These actions concern the training of a large number of community health workers, who function as a real health focal point in the community. The Mental Health Department provides a continuing sensitization program and coordination of community mental health includes associations, NGOs and international partners. Crosscutting actions The National Mental Health Department solicits and responds promptly to specific requests from other sectors. Thus, with the Ministry of Education, training has been conducted for high schools. Also, in 2006, an assessment of problems of traumatic flashbacks caused by the commemoration of the genocide was conducted in high schools. In 2010, a module on sensitization for psychopathology of children and adolescents has been elaborated in collaboration with the Ministry of Education. In collaboration with the Ministry of Justice, the Mental Health Department in the Ministry of Health provides mental health professionals for clinical evaluation in prisons. With the Ministry of Internal Security, the Department of Mental Health in the Ministry of Health provides training for nurses working in clinics of prisons. In collaboration with the Ministry of Social Affairs and Local Government, the Mental Health Department provides psychological care for vulnerable groups as well as training and sensitization. Finally, with the National Commission for Demobilization of Former Soldiers, the Mental Health Department in the Ministry of Health provides psychosocial support to former soldiers to facilitate their adequate social reintegration. This activity is planned as part of the National Commission for Demobilization and Reintegration of former soldiers annual action plan. Recognizing the need for a formal and permanent inter-sectoral collaboration structure, mental health leaders have taken steps to legalize it. In July 2008 an assessment of the Health Sector Strategic Plan (HSSP I) (2005-2008) recommended a number of activities to be included in the mental health action plan. These activities are namely legislation, integration of mental health, strengthening the supervision and coordination at decentralized level, coordination of stakeholders at central and district level, the updating of records of stakeholders, the involvement of district hospitals directors in mental healthcare and the initiation of an Interministerial Committee for Mental Health and Substance Abuse. In addition to the above, efforts are being made to integrate mental healthcare in health centers. The integrated supervision of all departments, initiated in 2010, is now being implemented. The mental health division has developed specific evaluation indicators and performance evaluation of staff for incorporation into general supervision. Also, a group of national and international experts working under the authority of the Ministry of Health have developed a package called "chronic disease", including mental healthcare, to be incorporated in health centers and community health workers packages of activities. Conclusion In concluding, it is noteworthy that the formalization of protocols is now achieved at all levels. The Mental Health Division is part of a newly established structure called the Rwanda Biomedical Centre (RBC), which includes different health institutions such as medical institutions, pharmaceutical, academic and research institutions. Within the mental health division, there are three units; namely, the development of the mental health services unit, the control and drug abuse prevention unit and, finally, the promotion and community mental health interventions unit. Given the results of the studies of mental health problems in Rwanda and considering the traumatic 112

The International Journal of Person Centered Medicine conditions addressed by mental healthcare services during the annual commemorations of the genocide, we must recognize, despite the efforts that are underway, that a great deal more developmental work remains to be done in mental health in Rwanda. Here, a continuous improvement in both the quality and quantity of services is required in order to provide continuous support to the victims in need of mental health services. References [1] Munyandamutsa, N. &Mahoro, P. (2010). Prevalence of Post Traumatic Stress Disorder among Rwandan population: clinical aspects, drug abuse and other comorbidity. Kigali, 2010. [2] Kayiteshonga, Y. (2011). Evolution of Post-Traumatic Stress Disorder among the survivors of the Tutsi genocide in Rwanda. PhD dissertation, Universite Paris 8. [3] Ministere de l administration locale et des affaires sociales. (2001). Rapport préliminaire du recensement des victimes du génocide des Tutsi du Rwanda en 1994, Kigali. [4] Ministère de la Santé: Politique du Secteur Santé au Rwanda. Kigali, 2005. [5] Rwanda National Mental Health Program, Annual report. Kigali, 2010. 113