Improving Access to MHPSS Services in Rwanda

In Rwanda, Mental Health and Psychosocial Support (MHPSS) needs outstrip the capacity of available professionals and the service care provision is hindered by cultural barriers associated with one-on-one therapy approach. Interpeace trains clinical psychologists and mental health nurses to implement a group-based approach, “Resilience-oriented therapy”, at the grassroots level.

Addressing mental health issues among young people in Rwanda

The 2018 Rwanda Mental Health Survey conducted by the Rwanda Biomedical Centre (RBC) highlighted that the trauma from the  Genocide committed against the Tutsi is transmitted from parents to children, including those born after that tragic period. The study has revealed that 27.4% of young Rwandans aged between 14 and 25 suffer from some psychological disorders, including trauma, depression, anxiety, fear, and social isolation. Yet, a few specialists and practitioners are focusing on child and adolescent mental health in the country.

Julien Ishimwe, 20, experienced deep trauma and social isolation for over 15 years. His parents are both survivors of the Genocide. During the annual Genocide commemoration period that usually lasts three months from the 7th of April, he could see his parents’ mental well-being affected by the worst memories of the atrocities they experienced. Growing up, Ishimwe developed hatred and resentment against genocide perpetrators and their descendants. He would not socialise with them as he considered them the worst enemies.

“I hated them so much, as I imagined they were the cause of my parents’ suffering. It was hurting me to see how my parents have suffered the consequences of the Genocide,” narrates Julien, who adds, “I felt a lot of anger when I saw how children of Genocide perpetrators are happy with their grandparents, uncles, and aunties, while I don’t even know how mine looked like,” deplored Ishimwe.

His trauma also affected his school performance. In class, he would avoid as much as he could sitting alongside or playing with someone he suspected was a descendant of a Genocide perpetrator. “I was obliged to attend school because my parents forced me to. I felt discouraged to study when I looked around and noticed that descendants of genocide perpetrators outnumber us. I feared they would kill me as their parents killed my grandparents.” He added, “I had lost my self-esteem and thinking that after graduation, they would get a better job than me.”

Charlotte Mukanyindo, Ishimwe’s mother, worried much about her son, who liked to isolate himself from his siblings. “He would barely talk to us or play with his siblings. He was always angry and bitter.  That was a shock to me seeing how my son is suffering, yet I didn’t know how to help him,” she explained.

Ishimwe started the healing journey when he joined one of the Sociotherapy groups created in Mukamira Sector, Nyabihu District, Western Province, as part of Interpeace’s holistic peacebuilding and societal healing programme present in five districts, namely Nyabihu, Musanze, Nyamagabe, Ngoma and Nyagatare. With financial support from the Government of Sweden and implemented with local partners: Haguruka, Prison Fellowship Rwanda and Dignity in Detention, the programme addresses mental health issues, promotes social cohesion, supports psychological rehabilitation and reintegration of prisoners and improves livelihoods.

The group Ishimwe joined brought together young people from both families of Genocide survivors and Genocide perpetrators to encourage them to engage in discussion about the history and the Genocide and help each other to heal.

The youth-only sociotherapy healing group enabled Ishimwe to heal, overcome hatred and develop strong bonds with those he once hated. “Today, I feel happy and at ease with everyone, including those I hated. Today, many of my friends are descendants of genocide perpetrators. Thanks to Sociotherapy healing dialogues, I learnt that I should not judge them by the crimes of their parents. Through sharing testimonies and life experiences, I discovered they have also suffered trauma, shame, and guilt over their parents’ crimes. The only way to overcome this is to develop friendship and build our future together,” he explains.

Ishimwe has regained interest in pursuing his studies. As he awaits to join university, he has started to take technical and vocational skills courses. His mother, Mukanyindo, could not believe how Ishimwe had changed for the better. “It is a miracle. I could not believe how he had become friendly and sociable and willing to take up any economic activity.”

Ishimwe is among 327 young people from families of genocide survivors and genocide perpetrators who graduated from Sociotherapy Healing Dialogues in June 2023. The community-based healing groups stimulate mutual healing and create a solid foundation for reconciliation. Since the inception of the societal healing programme in October 2020, more than 3450 young people have been reached.

The programme also works with the Ministry of Health through Rwanda Biomedical Centre (RBC) to strengthen the national mental health system by training mental health professionals and providing equipment which enables them to reach communities in remote areas.

 

 

Promoting mental health and psycho-social support (MHPSS) sensitive journalism for peacebuilding in Rwanda

The recent World Mental Health Report published by the World Health Organization (WHO) in 2022 highlights the low levels of health literacy regarding mental health as one of the major barriers undermining Mental Health and Psycho-social Support (MHPSS) worldwide. The media, both traditional and new, plays a pivotal role in dismantling these barriers by educating society, advocating, and raising awareness. Ironically, media professionals themselves often lack adequate knowledge and understanding of mental health.

As part of its holistic peacebuilding programme that focuses on MHPSS to promote societal healing and reconciliation in Rwanda, Interpeace organised a training session for journalists. The objective was to increase their knowledge, skills and understanding of MHPSS.

The two-day training took place in August 2023 and provided essential tools and skills to 26 participants from various local media outlets, ensuring their ability to produce professional MHPSS and peacebuilding-related content that adhere to ethical standards.

Media involvement in peacebuilding and MHPSS processes is paramount in Rwanda, where the population continues to grapple with mental health disorders stemming from the Genocide committed against the Tutsi nearly three decades ago.

The training featured theories, case studies, and practical exercises to deepen participants’ understanding of mental health and the ethical considerations that must guide their reporting. The participants commended the training for bolstering their capacity and igniting their willingness for mental health sensitive reporting.

Producing in-depth, well-researched programmes and reports will promote advocacy among various stakeholders, including government officials, experts, and donors, aiming to advance and influence mental health policies and practices in the country.

Oswald Mutuyeyezu, one of the most influential radio journalists, expressed his desire for regular workshops. “We have learnt a lot from this workshop. We have understood Rwanda's most current diagnosed mental health disorders/illnesses and the techniques and approaches required for reporting on them. While it may be too demanding to hold this training every month, I suggest it be organised at least every quarter to refresh our minds and knowledge,” suggested Mutuyeyezu.

Scovia Mutesi, one of the most influential independent female journalists, a social media influencer, and owner of the online newspaper “Mama Urwagasabo” and a YouTube channel, proposed expanding the training to include younger journalists to ensure the initiative's sustainability.

The participants committed to producing more content related to MHPSS and peacebuilding to educate communities and raise awareness. This will contribute to an increase in mental health service utilisation in the country, which currently stands at 5.3%. It will help combat the deep-rooted stigma and discrimination often faced by people living with mental health conditions, which hinders the demand for mental health care.

Interpeace organised the training workshop in partnership with the Rwanda Media Commission (RMC), the regulatory body for the media sector in Rwanda, responsible for building its capacity. Emmanuel Mugisha, RMC’s Executive Secretary, commended the partnership with Interpeace for organising this training. He further encouraged trained journalists to utilise the skills gained to foster their professionalism and fulfil their role as the fourth estate.

“We believe in your capacity and power to drive change. Therefore, we anticipate an increase in stories, documentaries and programmes that educate Rwandans about mental health and advocate for a strong and decentralised mental health system. This training lays the foundation for a strong and fruitful partnership between Interpeace and the media sector in promoting MHPSS and peacebuilding in Rwanda,” said Mugisha.

Decentralising mental health and psycho-social support services in Rwanda

Close to three decades after the Genocide against the Tutsi in Rwanda, Rwandans are still experiencing its effects on mental health, socio-economic development, social cohesion, and reconciliation. The recent Rwanda Mental Health Survey conducted in 2018 by the Rwanda Biomedical Centre (RBC) revealed that the prevalence of mental health disorders among the Rwandan population is higher than the global average and is particularly elevated among genocide survivors. Interpeace’s recent research studies corroborated the findings of the 2018 national survey. The most commonly diagnosed mental illnesses are major depression, post-stress traumatic disorder, anxiety, panic disorder, substance dependency, and social phobia. To address these longstanding consequences, strengthening and supporting the decentralisation of the National Mental Health and Psycho-social Support System is of paramount importance.

Over the past 20 years, the Government of Rwanda has made significant efforts to decentralise mental healthcare in referral and district hospitals and integrate it into primary healthcare (health centers) across the country. However, the country still faces challenges such as the scale of mental health needs that outstrips the capacity of available professionals, low awareness and knowledge of mental health issues, poor mental health infrastructure, and low utilisation of mental health services, which stands at 5.3%.

Through its societal healing programme implemented with the financial support of the Government of Sweden, Interpeace works with the Ministry of Health through the Rwanda Biomedical Centre (RBC) to find innovative solutions to those challenges. The programme strengthens the capacity of mental health professionals through training and the provision of equipment. With its partners such as Prison Fellowship Rwanda, Haguruka, Dignity in Detention (DIDE) Rwanda, and Groupe des Anciens Etudiants Rescapees du Genocide (GAERG), Interpeace has also introduced a community-based healing approach known as the Resilience-oriented therapy protocol, a multi-phase group-based treatment for emotional regulation, behavioural self-management, and identity development to complement the one-on-one approach usually used in health facilities across the country.

In July 2023, Interpeace trained 58 clinical psychologists and mental health nurses from seven district hospitals, 32 health centres, and four correctional facilities from the five districts of programme intervention, namely Musanze, Nyabihu, Nyamagabe, Nyagatare and Ngoma, to implement resilience-oriented therapy at health centre level.

Clementine Sezicyeye, a Mental Health Nurse at Kigeme Hospital, located in Nyamagabe District, Southern Rwanda, is among the trainees. Her unit receives over 200 cases of various mental health disorders every month. She mainly offers medication-assisted treatment.  She is convinced that the community-based Resilience-oriented healing spaces will contribute to ensuring easy access to mental health care for more people.

“The one-on-one approach we have been using is good and effective, but it is not enabling us to help as many people as the scale of needs requires. We have learnt a new group-based approach that allows us to help many people at the same time with the possibility for facilitating more than two groups a week. This is an innovative solution to this challenge. We are ready to implement this protocol,” commented Sezicyeye.

The trained health professionals will facilitate resilience-oriented healing spaces created in their health centres, accommodating a group of 10 people each. Group members attend healing dialogues for a period of 30 weeks, composed of 24 weekly healing sessions and six follow-up sessions. Community members are allocated to appropriate healing groups after screening sessions conducted in communities to assess the level of their psychological distress and their needs.

The programme has supported health centres and hospitals with tablet computers for adequate data collection and management during the screening and healing processes. They will also be provided with motorcycles to facilitate the transportation of mental health professionals to remote communities.

“There are many people in communities who don’t even know or recognise that they have mental health issues and those who know but have limited means to access health care. As a health centre, we have a very limited budget to organise large-scale activities in communities. I believe that enabling us to reach out to them is the best way to support them,” said Emmanuel Mbarushimana, the Head of Muhoza Health Centre, located in Musanze District, Northern Province of Rwanda, who added that community screening sessions will be an opportunity to carry out awareness campaigns to increase awareness and knowledge among the community members as well as combat the stigma that people with mental health issues usually face.

The low mental health literacy among heads of health centres still constitutes a stumbling block to service delivery.  All 32 heads of health centres from five districts of the programme have been trained to increase their knowledge and strengthen their capacity in mental health and psycho-social support care.  “My colleagues and I used to undervalue the work of psychologists and mental health nurses because we had little knowledge of what they do and what it requires. We often used them as backup staff when we faced staff shortages. Now I have understood that they do a lot of work and need more time and safe space,” stated Mbarushimana.

My life had no meaning

 

Effective rehabilitation and reintegration should be integral to societal healing and peacebuilding processes in countries like Rwanda, which experienced the worst atrocities, such as the 1994 Genocide against the Tutsi. Listen to how, in Rwanda, Interpeace uses a group-based Sociotherapy healing approach to contribute to the psychological rehabilitation and reintegration of prisoners about to be released.

 

Psychological rehabilitation of prisoners to strengthen social cohesion and reconciliation in Rwanda

The 1994 Genocide against the Tutsi in Rwanda had significant consequences for mental health, social cohesion, and socioeconomic development. By 1996, approximately 130,000 individuals suspected of participating in the genocide had been arrested and detained. One of the major consequences of the genocide has been the severe mental health problems experienced by the survivors due to the horrendous atrocities committed against them and their loved ones. Recent studies have concluded that even genocide convicts experience various psychological distress due to the atrocities they committed, and their incarceration, making their effective reintegration into their families and communities after release quite complex.

“I was deeply traumatised due to my difficult life in prison and held on too much anger against my family because they didn’t care about me as I would have wished,” said Edi (pseudonym), a Genocide convict detained in the Bugesera correctional facility located in the Eastern Province of Rwanda.

Edi’s case is not isolated, as his colleague Alpan (pseudonym) also experienced deep depression and social isolation for over 27 years. “I felt traumatised and anxious every time I thought about what I did during the genocide and how I disappointed my family and community. I didn’t want to talk to anyone here and had lost interest in everything since I thought my life had no meaning,” narrates Alpan.

A significant number of those convicted of genocide crimes have already been released in recent years.  According to Interpeace’s research studies, released prisoners are likely to cause tensions and anxiety among families of genocide survivors and the community in general, potentially leading to recidivism. Failure to ensure their effective psychological rehabilitation constitutes a major hindrance to unity and reconciliation gains 29 years after the genocide.

Since 2020, Interpeace and its local partners, Dignity in Detention Organisation, Haguruka, and Prison Fellowship Rwanda, with financial support from the European Union and the Government of Sweden, have been implementing a holistic peacebuilding programme that simultaneously addresses mental health, promotes social cohesion, and strengthens economic livelihoods, with a particular focus on the psychological rehabilitation and reintegration of prisoners.

 

Impact of Sociotherapy healing spaces in prisons

Interpeace, together with its local partners, created Sociotherapy healing spaces in five prisons, namely Bugesera, Nyamagabe, Musanze, Nyagatare and Ngoma to provide inmates about to be released with group-based psycho-social support services.

After a rigorous screening process to assess their level of distress and needs, detainees nearing release are allocated into groups of between 12 and 15 members each. Guided by fellow detainees who had been well-trained, they engage in healing dialogues which last for 15 weeks. Conducted in a safe space and conducive environment, these dialogues simulate mutual healing, peace of mind and cohesion.

“Sociotherapy healing spaces enabled me to realise that being in jail is not the end of my life. Before, I was desperate and thought my life had no value. But now, I have regained a new sense of brighter future after my release, which is due in less than two years,” said Alpan, who added, “They have helped me to reconnect with the one I offended. We often talk on phone, and I feel ready to ask her for forgiveness after my release.”

Like his fellow detainees, Sociotherapy healing spaces enabled Edi not only to cope with his distresses and reconnect with his family but also to live in peace and harmony with other detainees. In June 2023, the first group of 182 inmates graduated from healing spaces in four prisons. Previously, more than 50 inmates graduated during a pilot phase of the programme implemented in Bugesera District, eastern Rwanda from 2020 to 2022. According to programme’s target, three groups graduate every year. Those who graduate from healing spaces are facilitated in acquiring hands-on skills that make them better equipped to create livelihood opportunities and earn a living after their release.

Training of Correctional Officers on the implementation of the curriculum

Interpeace worked with Rwanda Correctional Service (RCS) to develop a standardised curriculum for prisoner rehabilitation and reintegration, which was adopted in July 2022. The curriculum serves as a guide to harmonise the process across all correctional facilities and is being implemented by trained correctional officers.

From 5-11 June, RCS, with the support of Interpeace organised a Training of Trainers for 45 Correctional Officers on the implementation of the curriculum. The participants were selected from correctional facilities from across the country. Those who complete the training will also train their in-service colleagues. Superintendent of Prisons Alain Gilbert Mbarushimana, one of the participants commended the training, stating that it has strengthened their capacity to better support inmates.

“During this training we learnt various innovative approaches to prisoner rehabilitation. I feel confident that this will enable us to effectively support inmates to become better individuals. We feel fully equipped to share the knowledge and skills with our colleagues across all correctional facilities,” said Superintendent Mbarushurishama.

During the closing ceremony of the training, Commissioner of Prisons Jean Bosco Kabanda, Ethics and Doctrine Division Manager at RCS, highlighted the importance of the training in enabling the institution to fulfill its mandate of rehabilitating inmates to become better citizens.

He also revealed that the curriculum will be integrated into RCS’s Training School courses offered to newly recruited staff and refresher courses for in-service officers.