Twenty-six years have passed since the genocide against the Tutsi people, a devastating traumatic experience for the Rwandan population in East Africa. Before the genocide, PTSD was not known in Rwanda. This was likely due to a shortage of professionals in the mental health domain and a different conceptualization of mental health. However, the genocide impacted Rwandans’ mental health due to experiencing and witnessing a range of horrors. Approximately 1 million people were killed, 250,000 women were raped, millions of Rwandans were displaced and 94% of people experienced at least one genocide event (Binagwaho et al. 2014). As a result, approximately 30% of the population was estimated to meet PTSD criteria 18 or 25 years after the genocide (Munyandamutsa et al, 2012, Mutuyimana et al. 2019).
Trauma-afflicted patients arrived at the hospital with symptoms that providers had never encountered before. The first author of this report, for example, experienced the following case presentation: A Rwandan girl came to a clinic in Kigali reporting nausea and the feeling of insects crawling on her face. She complained of the strong smell of faeces and grew increasingly agitated and fearful, describing vivid images of people trying to kill her at that moment. These kinds of unusual symptoms caused the few professionals in mental health and the government to begin studying of PTSD and to consider bolstering access to providers in the community and professional mental health care system as well as training the current health providers in evidenced-based treatment of PTSD.
Cultural Evolution of Knowledge of PTSD in the Mental Health Policy System
Rwanda’s earliest mental health services began with traditional healing practices (Levers et al. 2009). The occurrence of a mental illness was attributed to the ancestral spirit of a deceased family member who was unhappy or angry and later to possession by devil spirits. Treatment at this time consisted of the ritual of “Kubandwa and Guterekera,” which paid homage to certain spirits or religious rituals after the introduction of western religion (Gatarayiha et al. 1991).
Chronically mentally ill people were not well cared for or were kept in prisons. Ndera Neuropsychiatric Hospital in the capital city of Kigali was established in 1968 to release the psychiatric patients from the prisons of the country, and all people with mental disorders were transferred for treatment. However, after recovery, patients faced stigma in the community. The recovered patients were labelled “foolish” in spite of their stable mental well-being. During that period, there was no scientific knowledge about PTSD. Clinicians and older people affirmed that such experiences existed but interpreted them as the person’s inability to manage their problems and people were not encouraged to go to the hospital to receive treatment.
After the genocide, massive numbers of people experienced seemingly mysterious PTSD symptoms and patients with these issues were present in every health facility. At that moment PTSD was a novel cultural experience for Rwanda and there was no word in the local language of Ikinyarwanda to describe this new phenomenon. The first term given to PTSD symptoms was “Ihahamuka,” which meant sudden panic that caused breathlessness (Hagengimana et al., 2003). Later it was found that it was better to use the word “Ihungabana,” to mean displacement of some elements in the psychological functioning of the patients. Due to magnitude of PTSD and the shortage of professionals, the government worked with the only psychiatrist Rwanda had at the time to build the National Trauma Recovery Center in order to train clinical psychologists and psychiatric nurses in the treatment of PTSD patients.
Since 2002, trained professionals, community volunteers and local and international NGOs have provided support to PTSD patients. In 2012, in recognition of the heavy toll of PTSD and other mental disorders, the government integrated psychological and psychiatric services within the general health system for the treatment of PTSD and other mental disorders (Republic of Rwanda, 2011b).
Research on PTSD in Rwanda
The prevalence of PTSD and its consequences on living conditions of the population motivated researchers to be involved in the research of PTSD in Rwanda. The first initiatives were about epidemiologically surveying PTSD within the entire population or specific groups. To date, 20 epidemiological studies have been conducted, and the majority of findings corroborate the high incidence of PTSD occurring in almost 30% of the population, with comorbid disorders of mainly depression, substance abuse and somatic stress-related disorders.
Additional research demonstrated that genocide survivors were four times more likely to exhibit PTSD symptoms than perpetrators (Musanabaganwa et al., 2020, Mutuyimana et al., 2019, Schaal et al. 2012). Findings also demonstrated that complex PTSD may have grave consequences not only for survivors but also for their offspring who were born after the genocide via epigenetic mechanisms (Perroud, et al. 2014 & Shrira et al., 2019). Lastly, researchers have explored the consequences of PTSD within families and communities; primarily looking at intimate partner violence and family conflict associated with substance abuse and inadequate parenting styles (Ntaganira et al. 2008). Research on the efficacy and use of different methods of psychotherapy used to treat PTSD are still limited.
Trend of Relevant PTSD Literature Since 1996
Diagnosis and Treatment of PTSD in Rwanda
The clinical management of PTSD has been broadened from grassroots initiatives to interventions at the institutional and professional levels. Since PTSD was a new concept in Rwanda its diagnostics and treatment had been initially managed by using known cultural methods to deal with these unknown “bizarre” symptoms. Charitable community members, church leaders and international NGOs identified and treated individuals exhibiting “Ihahamuka.”
Since 2002, and after the university graduation of the first psychologists and psychiatric nurses, different NGOs began recruiting professionals to work in different health facilities, prompting professionals to begin looking at the cultural context and cultural manifestation of PTSD in Rwandans. There was initially a lack of diagnostic instruments; however, a number of PTSD scales have since been validated for use in this population including the Harvard Trauma Questionnaire, DSM-IV PTSD Check list, Life Events Questionnaire, Anxiety Sensitivity Index, and Mini International Neuropsychiatric Interview (Biracyaza, 2019& Rieder et al.2013). In addition, DSM-guided approaches to diagnosis became standard among mental health professionals, adopting an individualistic paradigm common in the Global North rather than a sociocentric model (Maercker and Hecker, 2016).
At the present time, the diagnosis and treatment of PTSD is typically managed by a multidisciplinary team of a psychologist, medical doctor and psychiatrist. A number of techniques are being used to treat PTSD in Rwanda, primarily trauma-focused cognitive behavioral therapy, narrative exposure therapy, Eye Movement Desensitization and Reprocessing, and community-based sociotherapy (Matthe, 2009, Schaal et al. 2009& Sezibera et al., 2009). The increased use of evidence-based approaches has been supported by policy changes. Since 2013, all clinical psychologists were required to obtain a licence from a professional body: The Rwanda Allied Health Professionals (RAHP). This body of work goes hand in hand with the Rwanda Psychological Society (RPS) which provides continuing professional development trainings and supervision to ensure quality care for beneficiaries and practitioner wellness.
Conclusion
PTSD in Rwandans has undergone a significant evolution over the past several decades in terms of knowledge, research and treatment. Currently, the research affirms that the burden of PTSD in the general Rwandan population has declined significantly over time, likely due to the treatment of symptoms through strong national mental health programs, peace building and resolution of symptoms over time (Musanabaganwa et al, 2020). Mental health survey results from the Rwanda Biomedical Center (2018) indicated that 72.6% of patients with PTSD were aware of where to seek a help, however the actual use of services was only 14%. This constellation may contribute to the continuation of a high prevalence rate (37%) of PTSD among genocide survivors, considerably higher than the general Rwandan population. Therefore, inside and outside Rwanda, more work is needed in the area of scaling up community techniques to provide appropriate care and healing for PTSD.
About the Authors
Celestin Mutuyimana works in the Division of Psychopathology and Clinical Interventions at the University of Zurich, Switzerland, and the University of Rwanda/Center for mental health.
Andreas Maercker works at the University of Rwanda Center for Mental Health.
References
Binagwaho, A., Farmer, P. E., Nsanzimana, S., Karema, C., Gasana, M., de Dieu Ngirabega, J., & ... Drobac, P. C. (2014). Rwanda 20 years on: Investing in life.The Lancet, 384(9940), 371-375.
Maercker, A., & Hecker, T. (2016). Broadening perspectives on trauma and recovery: a socio interpersonal view of PTSD. European journal of psychotraumatology, 7, 29303. https://doi.org/10.3402/ejpt.v7.29303.
Munyandamutsa, N., Mahoro Nkubamugisha, P., Gex-Fabry, M., & Eytan, A. (2012). Mental and physical health in Rwanda 14 years after the genocide. Social psychiatry and psychiatric epidemiology, 47(11),1753-1761.
Mutuyimana, C., Sezibera, V., Nsabimana, E., Mugabo, L., Cassady, C., Musanabaganwa, C., & Kayiteshonga, Y. (2019). PTSD prevalence among resident mothers and their offspring in Rwanda 25 years after the 1994 genocide against the Tutsi. BMC psychology, 7(1), 84. https://doi.org/10.1186/s40359-019-0362-4
Perroud, Nader & Rutembesa, Eugene & Paoloni-Giacobino, Ariane & Mutabaruka, Jean & Mutesa, Leon & Stenz, Ludwig & Malafosse, Alain & Karege, Felicien. (2014). The Tutsi genocide and transgenerational transmission of maternal stress: Epigenetics and biology of the HPA axis. World journal of biological psychiatry. 15.10.3109/15622975.2013.866693.
Rudahindwa, Susan & Mutesa, Léon & Rutembesa, Eugene & Mutabaruka, Jean & Qu, Annie & Wildman, Derek & Jansen, Stefan & Uddin, Monica. (2018). Transgenerational effects of the genocide against the Tutsi in Rwanda: A post-traumatic stress disorder symptom domain analysis. AAS Open Research. 1. 10. 10.12688/aasopenres.12848.1
Shrira, A., Mollov, B., & Mudahogora, C. (2019). Complex PTSD and intergenerational transmission of distress and resilience among Tutsi genocide survivors and their offspring: A preliminary report. Psychiatry research, 271, 121–123.