Psychiatrists Help Rwandans Recover From Trauma of Brutal War

The genocide in Rwanda occurred 15 years ago, but people in the African country are still coming to grips with its psychological and social aftermath in a process that is likely to continue for years, said speakers at APA's 2009 annual meeting in San Francisco in May.

During three months in 1994, between 800,000 and 1 million ethnic minority Tutsis and their moderate Hutu allies were killed by Hutus, who made up 84 percent of the population. The dead included men and women, adults and children, often cut down by neighbors with whom they had been living peacefully for many years, said Lisa Rone, M.D., an assistant professor of clinical psychiatry and behavioral sciences at Northwestern University's Feinberg School of Medicine.

Following the genocide, more than 250,000 women were raped, leaving 70 percent of the victims infected with HIV and thousands of their“ children of hate” left to grow up with those facts as part of their legacy. More than 90 percent of Tutsi children lost at least one family member, and 56 percent saw relatives killed.

In 2008, Rone and colleague Kristin Welch, M.D., a psychiatrist in private practice who is affiliated with the Heartland Alliance in Chicago, established a psychiatric clinic as part of the existing Women's Equity in Access to Care and Treatment (WE-ACTx) in Kigali, the capital. The clinic provides HIV testing, antiretroviral therapy, and trauma counseling.

Besides trying to help the survivors, the two Americans hoped to minimize the intergenerational transmission of trauma by people who found it“ impossible to forgive and impossible to judge,” said Rone.

“Traumatized parents can be a source of traumatic stress for their children,” said Rone. In Rwanda, parents weren't able to protect themselves or their children during the genocide and now fear “emotional contamination” if they talk about it, she said.

The affective and cognitive consequences of parental trauma on children are ameliorated to some degree by creating safety, continuity, and predictability to their lives. Several measures have been adopted to further those outcomes.

Rwandans are beginning to recreate social bonds, often adopting orphaned children and creating new families to replace ones lost in the genocide, said Welch.

A sense of political and social safety is slowly developing through the gacaca system—village tribunals in which victims tell their stories, and perpetrators recount their deeds and accept some punishment.

“Hearing perpetrators' and survivors' stories in these tribunals brings some sense of justice,” said Rone.

While this process sounds hopeful in theory, the reality is more complex. Some fear retraumatizing survivors. One boy, for example, wanted to testify about his mother's rape at a gacaca trial “to give my shame to the killers,” but his mother said she would commit suicide if he did so.

Welch quoted Rwandan President Paul Kagama as saying, “It's the best we have, but nobody likes it.”

At the WE-ACTx clinic Rone and Welch initiated interventions to provide simple, inexpensive ways to treat psychiatric symptoms as part of broader recovery efforts. Many patients had not slept without nightmares for 14 years but were helped by a mix of social engagement, peer support, and medications. A simple group-therapy room, consisting of a roof surrounded by curtains, allows women to tell their stories, assisted by trauma counselors.

However, nothing will be simple in helping Rwandans live with their tragedy, said Welch.

“I thought I'd heard it all after working with torture survivors, but Rwanda haunts me,” she said. Victims and perpetrators still live next door to each other in a small, densely populated country.

While she believes that a psychologically healthy society is necesssary to bring about needed postconflict development in the country, Welch has found no consensus on the best practices to accomplish that.

There is general agreement that mental health care ought to be integrated into primary care in Rwanda, but that, too, is not easy. Many doctors were killed in the genocide. Psychiatry is not included in the curriculum of the nation's only medical school. Doctors and nurses are already very busy, and few resources exist for training and supervising them in psychiatric ideas and methods, said Welch. Routine psychopharmacological therapy is little used because local doctors are unfamiliar with psychotropic medications.

To help overcome stigma, the WE-ACTx Clinic hired a Rwandan psychiatric nurse who could reassure patients that it was all right to take medications or use psychotherapy.

But the steps are small, and the work is vast.

“It is not possible to forget or to get too far from the past,” said Naason Munyandamutsa, M.D., a Rwandan psychiatrist, in a video presented by Rone and Welch. “We have to live together, but how do we deal with our past?” he asked. “We need justice, but we must also find a way to reconciliation. It is not easy to find that compromise.” ▪