Fighting Mental Health Burden in Rwanda Through Community Healing Spaces

By Steve Nsamaza

For years, silence held Caroline Mukandoli captive. Haunted by the genocide against the Tutsi, she grappled with depression and isolation. But then, she found a circle of support – a community healing space – that helped her reclaim her life and rebuild hope for the future.

Mukandoli’s dark period began during genocide when men wielding machetes descended upon her home and killed her husband and the rest of the family between April and July 1994. She survived but was left with physical and mental wounds.

“After the genocide, I wanted to end my life. There was nothing left besides my daughters. My entire family was destroyed and murdered, which left me with deeper trauma challenges that worsened due to lack of medical care.”

The lasting impact of the genocide still burdens Rwandan society today, as the East African country continues to struggle with the weight of trauma and mental health conditions.

These traumatic events had given rise to a high prevalence of mental health problems where the health system had been destroyed.

Figures from the most comprehensive Rwanda Mental Health Survey (RMHS 2018) conducted by the Government’s Rwanda Biomedical Center (RBC) show that about 12% of the Rwandan population of about 13 million face major depression and panic disorders, while Genocide survivors were threefold at 35%.

Official statistics show that the prevalence of post-traumatic stress disorder (PTSD) is 3.6% and 27.9% among Genocide survivors. Other mental disorders such as panic and obsessive-compulsive disorder present considerable figures as well, while alcohol use disorder is 1.6%.

The latest findings show that the burden of PTSD in Rwanda declined over time, likely due to the treatment of symptoms through national solid mental health programs, peacebuilding, and resolution of symptoms.

Despite the high prevalence of mental disorders among Rwandans, findings revealed that up to 94.7% did not use mental health services. While 62% of the population is aware of where mental health services are provided and recognize it as a health problem, barriers such as lack of money, fear of stigmatization, and difficulty accessing services prevent many from seeking help. In contrast, others seek assistance from traditional healers or religious leaders.

Community healing safe spaces take root.

In light of these challenges, Mukandoli sought refuge and support from Aheza Healing Centre, which has set up community-based healing spaces led by a dozen counselors trained by the center to facilitate group discussions.

Each group comprises about 10 to 25 participants. Trained facilitators are deployed at the community level to focus on strategies such as conversations with family and friends, engagement through social media platforms, and participation in religion or spirituality.

This initiative, implemented by an Alumni of Genocide Survivors Groupe des Ancient Etudiant Rescapees du Genocide (GAERG), is part of the Societal Trauma Healing Programme in Rwanda and is funded by Survivors Fund (SURF), Interpeace, Imbuto Foundation, Ministry of Health through Rwanda Biomedical Center (RBC) and Ministry of National Unity & Civic Engagement (MINUBUMWE).

The conversations facilitated by assigned mental health experts and, which last for three months each, focus mainly on stress, post-traumatic stress disorder, depression, and narcotics addiction to provide psychosocial support to those struggling with psychological distress and strengthen their mental resilience.

Redempta Kayitesi, a counselor at the center, says the healing group safe spaces provide therapy sessions that allow people to share their stories and find solace in the collective healing experience by performing meditation, physical stretching, and breathing exercises.

The therapy focuses on emotion regulation to address anxiety or depression, behavioral self-management to tackle substance abuse or aggression, and identity development to address chronic emptiness or alienation.

Trans-generational trauma is also discussed to reduce the number of suicides and cases of narcotic addictions.

Participants gather in group sessions for 2-3 hours every week. These free-of-charge sessions usually bring together people in the same community to share their traumatic experiences, stories, or daily challenges and empower them to support and help each other in the healing process.

The basic physical formation of the healing space is a circle arrangement of dining chairs, which, according to the center, often represents a sense of togetherness and shared purpose with the support of the assigned mentor.

Facilitated by well-trained psychologists, participants elect leaders trained to take over from their facilitators as volunteers after forming the group.

“Meditation works very well with the brain while breathing exercises with emotions; consequently, they help manage stress. Breathing exercises are the most important. They take 70 percent of the whole session and involve the body, mind, and soul,” Kayitesi explains.

Jean Baptiste Munyankole, 85, a survivor of the genocide residing near Aheza Healing Centre in Ntarama, Bugesera District, was once lonely, vulnerable, and reserved until he was encouraged by colleagues from GEARG to participate in group sessions. These sessions have enabled him to connect with others.

“At first, I believed I was too old to partake in therapy and physical exercises, but the facilitators did an incredible job in helping me and others. Our physical and mental well-being have improved significantly. I can now walk longer distances and enjoy better sleep,” he emphasizes.

Fidele Nsengiyaremye, Executive Director of GAERG, notes that they unveiled Aheza Healing Centre in 2019 and, after that, scaled up the program to offer psychosocial support to those struggling with psychological distress through conversations with family and friends and engagement with community members.

He emphasizes the importance of providing safe spaces for people to discuss the deep wounds inflicted by genocide. Healing requires opportunities for survivors to share their experiences with empathetic listeners who can offer support and understanding.

Nsengiyaremye says that since 2019, their program’s primary objective of helping individuals cope with anxiety and trauma has benefited approximately 5,000 people through group sessions across the country.

Facilitated by their leaders, groups are designed to replicate a family’s support network. The concept was inspired by student genocide survivors who created artificial families to cultivate a sense of belonging. They addressed the absence of their biological families by forming alternative parental and sibling roles.

Grace Mukamusoni, a widow of the genocide residing in Icyezere village, Nyarugunga sector on the outskirts of Kigali, finds solace in sharing her story and burdens during group sessions, she explains.

Each year, as the remembrance of the genocide against the Tutsi approaches, Mukamusoni, like many other survivors, grapples with mental health difficulties such as flashbacks and nightmares.

These challenges would sometimes necessitate seeking medical assistance, resulting in prescriptions of medicine for her persistent headaches.

However, joining the healing group safe spaces helped her improve her psychological distress. She also loved the physical and breathing exercises during the sessions, finding them a source of stress relief that rejuvenated her mind and body.

Practicing breathing exercises also allows participants to think more clearly and reduce feelings of anxiety. In breathing exercises, each participant is encouraged to calm down by changing the inhale-to-exhale ratio, tricking each individual’s brain into thinking about their emotional state.

Supporting Rwanda’s mental health system

Dr. Darius Gishoma, head of Mental Health at Rwanda Biomedical Center (RBC), acknowledges the significant role of community healing centers in addressing mental health challenges. Although no scientific data on their role has yet been compiled, he emphasizes that these centers are invaluable as they provide preventive care and serve as first responders for mental health issues.

Dr. Gishoma explains that every year, as April approaches, the Ministry of Health collaborates closely with organizations that offer community healing sessions to prepare for the mental health challenges that arise during the period of mourning and remembering the victims of the 1994 Genocide against the Tutsi, observed from April to July. These sessions often include relaxation exercises, which help manage stress and relieve those affected if conducted in advance.

In addition to offering therapeutic support, these non-profit organizations, in collaboration with various Government agencies, play a crucial role in raising awareness and improving literacy about mental health issues. RMHS 2018 shows that about 38% of the population is unaware of available mental health services, a significant gap that these organizations are helping to bridge.

Aimee Josiane Umulisa, a clinical psychologist, underscores the importance of mental health therapy at healing clubs, where psychiatric counseling and psychotherapy, as well as community-based healing space deal with a mental illness other than considering medication, which should come as a last resort.

Drugs, while sometimes necessary, can carry significant side effects when consumed over an extended period due to their potency. Therefore, they should be cautiously approached and used with other forms of therapy.

Umulisa values community-driven initiatives that facilitate group discussions, providing a platform where individuals grappling with mental health challenges can be heard and supported by those who understand what they are experiencing.

“The healing centers work closely with the Ministry of Health, and wherever they encounter challenges or complicated cases, they refer them to health centers,” she adds.

She observes that a significant portion of the community, including leaders, still fails to recognize the urgency of providing treatment to individuals facing mental health challenges. While those suffering from diseases like Malaria or tuberculosis are promptly taken to the hospital, individuals grappling with mental health issues are often ignored and, at times, subjected to derogatory labels.

Dativa Nyirakamana, 35, a resident of Karembule in Kicukiro District, has faced a lifelong battle with mental health challenges. Her early years were affected by the disintegration of her family during the genocide. Forced to live with an abusive paternal aunt, she endured hardship, dropped out of school, and fled from home before reaching her teenage years.

“I endured a hard, unhappy childhood, and when I encountered a man who appeared kind and promised a better life, I thought happiness was within reach. However, it quickly turned into a nightmare of domestic violence before our first anniversary,” she reveals.

Now a single mother of three children, Nyirakamana has been admitted to psychiatric care on several occasions. Despite treatment, she remained withdrawn and felt feelings of inexplicable hatred.

Encouraged by neighbors who had found solace in community-based healing spaces, Nyirakamana hesitantly decided to join. Sharing fragments of her troubled life with the group, she grappled with the fear of judgment.

However, as therapy progressed, Nyirakamana experienced a positive transformation. Finding solace in the support of others, she began to regain hope and noticed a gradual shift in how people perceived her.

“I no longer feel weighed down by depression, and the dark clouds of hatred have lifted.” She says.

After three months, Nyirakamana’s healing group meets occasionally as it begins to falter in its regular meetings, succumbing to the pressures of urban life and the myriad responsibilities it entails for each member.

Recognizing the importance of community-based healing spaces, participants also sought to address economic challenges by creating a savings scheme, a common practice among such groups. However, as time constraints mounted and financial contributions became sporadic, attendance waned, and cohesion weakened.

The success of community-based healing spaces depends on diligent follow-up by their initiators, particularly in diverse settings. Without adequate guidance from skilled professionals, these groups are susceptible to disintegration, underscoring the need for ongoing support and mentorship.

The sessions relieved Grace Mukamusoni and her group significantly, but the support was short-lived. They were promised training for group leaders to ensure continuity, but the program abruptly stopped without explanation.

The Executive Director of GAERG explains that projects have timelines lasting over three months and require programs to run for a set period based on funding. Some healing sessions last only 12 weeks, which may not be enough for individuals with deep-seated mental health issues.

He acknowledges their primary challenge lies in limited resources, including financial and skilled personnel. They could extend their reach and empower more people to address their challenges with sufficient funding and support.

Data from RBC shows that Rwanda’s health facilities have only 16 psychiatrists, 164 clinical psychologists, and 448 mental health nurses serving Rwanda’s 13 million population. Therefore, initiatives like community healing centers complement the health system to address mental health issues.

Since volunteers support most community healing centers, they can cover more ground and reach more people nationwide. However, only 10 percent of their staff are specialists and professionals, which may hinder their ability to provide appropriate treatment, especially for complicated cases.

Dr. Gishoma notes that while community healing centers are essential, their approach has limitations when it comes to certain mental disorders that may require specialists and medications.

He stresses that the invisible yet deeply felt wounds persist among many Rwandans year-round, intensifying during the commemoration period. This highlights the vital roles played by community-based healing centers.

This story was first published in Rwanda Dispatch