Table Of ContentNovember 2009
LESSONS FROM EXPERIENCE:
KNOW-HOW ANALYSIS
Supporting persons
living with trauma
by rebuilding social
and community links
AN EXAMPLE OF A COMMUNITY-BASED
MENTAL HEALTH APPROACH AFTER
THE RWANDAN GENOCIDE OF THE TUTSIS
With fnancial support from the
Accentus Foundation and AFD
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Translation: Alison Moir (A2ms) for Handicap International
Proofreading: Kim Barrett for Handicap International
Edited by: Handicap International, Technical Resources Division, Prevention and Health Unit – Mental Health
Corrections and Editing
Knowledge Management Unit, Stéphanie Deygas
Layout: Multicom - Rwanda ; Fred Escoffer
Printing: Vassel Graphique
Contacts : Handicap International Rwanda - BP 747 - 261, Avenue Paul VI – Kiyovu - Kigali
Photos: © G. Pegon for Handicap International
Use or reproduction of this paper is permitted for non-commercial purposes only, on condition that the source is cited.
This paper was prepared with support from the: Accentus Foundation, AFD (Agence Française de Développement).
ISBN: 978-2-909064-38-3
Sommaire
Contributions page 4
Acknowledgements page 5
Acronyms page 6
Introduction page 7
Summary page 8
Why a capitalisation document? page 10
Methodology page 11
Par t Presentation of the Rwandan context page 13
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Par t The caring capacity of the community:
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the foundation of the approach page 23
Par t Supporting the resurgence of existing strengths
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in the community, by means of the intervention
framework page 27
Par t Stimulating community strengths using
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comprehensive care management
systems and capacity building page 35
Par t Changes observed in the community page 49
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Par t Limits of the community-based
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mental health project page 57
Par t Recommendations for continuing the project page 59
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Bibliography page 62
Appendices page 66
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Contribution
This paper intends to draw lessons from expe- Narame, Psychologist; Ruth Nzayihimbaza,
rience. It was produced by Xuan Phan, Clinical Psychiatric Nurse; Felix Harindintwali, Psy-
Psychologist and Public Health Consultant, chosocial Counsellor; Euphrasie Mukandengo,
reporting to Marc Vaernewyck, Field Pro- Psychosocial Counsellor; Languide Nyiraba-
gramme Director, (Development Department, hire, Counsellor in Associative Development.
Rwanda Programme) and Guillaume Pegon,
Technical Advisor in Mental Health, (Techni- Technical support
cal Resources Division, Prevention and Health
Cécile de Ryckel, Psychologist Advisor, Techni-
Unit), Handicap International.
cal Resources Division, Rwanda Mental Health
Project, Handicap International.
A variety of reports (including the project docu-
Augustin Nziguheba, Head of Mental Health
ment and mission reports) produced by the
Project, Rwanda Programme, Handicap
Rwanda HI mental health project team, HI
International.
Psychologist Advisors and the HI Technical
Advisor in Mental Health were used to prepare
Methodological support
this document, along with the working groups
held with the Rwanda HI mental health project Catherine Dixon, Professional Publications
team: Marie Louise Musonera, Psychologist; Manager, Technical Resources Department,
Virgile Uzabumugabo, Psychologist; Ernestine Handicap International.
Picture 1: Group of benefciaries presenting
their life experience through a drama game
sequence in the Kimihurura sector
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Acknowledgements
Handicap International is extremely grateful to Programme; Simon Gasibirege, Manager of the
all those who have contributed to the prepara- Life Injuries Recovery Centre; Simon Nsabiyeze,
tion of this learning-from-experience paper and National Coordinator of the Psychosocial Pro-
more generally to the implementation of the gramme of the NGO CAFOD; Caritas in the
project to promote community mental health in Catholic parish of Rulindo; Human Rights First
Rwanda, including: the managers of our par- Rwanda of the Adventist University of Kigali
tner organisations (Association des Familles (UNILAK), Vie Life Programme, the Ministry of
d’Accueil de Kimicanga (AFAK), Association Justice ‘Maison d’Accès à la Justice’ service,
Fondation Tumurere (AFT), Association Uyi- Nemba Hospital; Hope and Homes for Children,
senga n’Manzi, Association Icyuzuzo, Mental Hope Ministries Church; Care International;
Health University Centre (CUNISAM)); Yvonne Remera Rukoma Hospital; Compassion, World
Kayiteshonga, Coordinator of the National Vision, World Relief, Kacyiru Police Hospital;
Mental Health / Minihealth Programme; the the Mayors of the Districts of Gasabo, Kamonyi
Psychosocial Consultations Service (PCS) and Rulindo; the Executive Secretaries of the
and the Ndera Neuro Psychiatric Hospital; Dr Sectors of Bushoki, Kimihurura, Mugina and
Naasson Munyandamutsa, Psychotherapy Ndera; the Heads of Social Affairs in these 4
Psychiatrist; Dr Achour Ait Mohand, Belgian sectors; the 120 focal points and 600 reference
Technical Cooperation Deputy Director for the persons; and the 8000 direct and indirect bene-
co-management of the National Mental Health fciaries of the 4 project sectors of intervention.
Picture 2: Intervention in a primary school in the Bushoki sector
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Acronyms
IGA Incomes Generating Activity
CAFOD Catholic Agency For Overseas Development
IEC Information, Education, Communication
HI Handicap International
WHO World Health Organisation
OMHA Operational Mental Health Areas
PCS Psychosocial Consultations Service
CMH Community-based Mental Health
UNICEF United Nations Children’s Fund
HIV/AIDS Human Immunodefciency Virus/Acquired Immunodefciency Syndrome
Picture 3: A group of benefciaries in the N’dera sector
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Introduction
For more than three years, as a Psychology really feels at home except among inert objects,
Adviser, I accompanied the implementation of and is therefore “incapable of representing the
the community mental health project covered true nature of life” (Bergson, 1959).
by this paper. I congratulate you on the work
achieved. It shows both the commitment of However, during these three long years, in the
the local team to listening to others, and to course of which I accompanied my Rwandan
obtaining an in-depth understanding of the colleagues, I relished listening to them multiply
specifcities of the Rwandan mental health the images and metaphors used reveal to me
context, as well as the subtleties of the project their life experiences. Each time, a complete
theory and practices. world would unfurl like a symphony, whose
notes continue to ring out long after having
This document manages to combine the left the concert hall. At these times, I felt it was
requirements of a capitalisation document possible to transcend the cultural differences,
which aims to share feld experience beyond because their images and metaphors reached
the limits of HI, and in particular with mental the deepest layers of my soul, where joy and
health stakeholders, with more sensitive requi- suffering are found to be universal.
rements, such as remaining true to the ways For this experience, I thank each and every
of thinking and the culture of the project’s key one. If ever, despite everything, the Rwandan
protagonists: the Rwandans. participants in the project, at times no longer
recognised themselves in it, I ask them to for-
There was a substantial risk that they might give us and guide us so that in the future we will
feel dispossessed of their knowledge. Firstly, better be able to listen to them. Only then will
because the imperatives of legitimacy and we be able to work together towards a genuine
transparency to which an NGO is subjected universal development of knowledge with res-
by its funding bodies and by international ins- pect, equality and reciprocity in our exchanges.
titutions are often greatly distanced from the
mental representations of local cultures: in this Cécile de Ryckel,
case the Rwandan culture. Secondly, because Project Psychologist Adviser
HI needs to unify the transcription of its feld
experiences in order to share the knowledge
constructed within the various cultural contexts
in which it operates. Finally, the current trend
towards standardising knowledge, combined
with our more or less conscious propensity to
believe our way of thinking is universal, could
form a trap into which it would have been all
too easy and natural to fall. This document
clearly avoids this trap. The numerous perso-
nal accounts running through this document
testify to this. These unedited accounts remind
that our mental conception of the world is only
one of many and that our particular intelligence
is specifc to us as westerners. As the philo-
sopher Bergson stated, our intelligence never Picture 4: A group of benefciaries in the Bushoki sector
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Summary
The genocide of the Tutsis in 1994, resulted order to cover basic needs) and fnally psycho-
in more than a million deaths in just a few logical aspects (support groups, individual
weeks (including the murders and massacres therapies, use of generating activities as a
that affected the other Rwandan communities, therapeutic mediator).
opponents, moderate Hutus and those who
tried to prevent the genocide, human rights After nearly three years of implementing this
campaigners, etc.), was extremely brutal. It approach, we can see a number of changes,
had signifcant ramifcations, both on the com- including: the rebuilding of social links, the
munity level (destruction of social fabric and inclusion of individuals into the commu-
traditional links of solidarity) and on the indi- nity; the reconstruction of individual and
vidual level (manifestations of psychological community identity; a change in community
suffering – episodes of revivifcation, violent representations of mental health and of vulne-
acts, avoidance behaviour). These symptoms rable people; an overall improvement in the
come out in social, family and community life. living conditions gradually giving people back
In 2007, with more than thirteen years of expe- their socioeconomic life.
rience in the feld, Handicap International
initiated a new project aiming to ‘promote We have been able to identify several ‘lessons
mental health by strengthening community learned’ from this approach, which relate, on
mechanisms for the preventative and curative one hand, to the way in which one can work
care management of children and adolescents on the involvement and the role of the various
experiencing psychological suffering’. This stakeholders (reference persons, focal points,
project was implemented as a joint action with local authorities, benefciaries) in the care
fve Rwandan partner organisations and covers management of benefciaries (joint action, self-
four sectors located in urban and rural areas. empowerment, participatory approach) and, on
It is rooted in a participatory approach which the other, to the way in which one can adapt a
brings together both public and private-sector clinical and organisational mechanism to local
stakeholders. Handicap International decided realities (sociological, cultural, geographical,
to adopt a community-based mental health political) for example by implementing a mobile
approach. The actions target adolescents multidisciplinary team, building the communi-
experiencing psychological suffering, and also ty’s capacity for self-management and working
include the adults involved with these adoles- in networks.
cents. This involves supporting the reference
persons (teachers, community workers, Certain ‘limitations’ were also identifed in
elected representatives, child heads of house- terms of the implementation of the project.
holds, parents) so that they can set up solidarity These concerned the geographical distribution
and care systems for vulnerable people and/ of the benefciaries in a dispersed habitat, an
or refer them to the appropriate care providers. underdeveloped networking and referencing
The action aimed to be multidisciplinary, brin- system, and the lack of availability of partner
ging together the legal (the genocide having organisations due to their geographical loca-
also undermined how people position them- tion and insuffcient resources (human and
selves in relation to the law), the psychosocial fnancial).
(start of welfare system in Rwanda, work with
families and close environment), economic Finally, some ‘recommendations’ for the
development (income generating activities in continuation of the project are proposed.
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These aim to develop primary prevention mate- the referencing network in the intervention
rials (awareness-raising on mental health) and areas and the implementation of the Rwandan
tools for monitoring and evaluation (progress Collective of Parts Active in Mental Health by
of benefciaries) as well as other therapeutic clarifying its remit and governance and to build
methods adapted to Rwandan sociocul- the capacities of the project team by providing
tural practices. In terms of capacity building, specialist training in their respective felds.
recommendations are proposed to strengthen
Picture 5: General view of Kimicanga, a deprived district located in Kimihurura
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Why a learning-from-
experience paper?
Handicap International (HI) has worked in was to strengthen the community system for
Rwanda since 1994, just after the genocide. improving the mental health of children and
Over time, its interventions have closely fol- adolescents experiencing psychological dis-
lowed the country’s development moving from tress, by means of a comprehensive preventive
emergency strategies to reconstruction and and curative approach. The challenge was
then development. The areas of activity have to increase the impact of our actions on the
also evolved over time and have been selected mental health of the children and adolescents,
in line with the association’s remit, for example, based on the ‘lessons learned’ from our earlier
interventions in the feld of functional and com- projects, implemented since 1994.
munity-based rehabilitation (still underway), in
HIV control, in epilepsy control, in the feld of Today, this learning-from-experience initi-
inclusive education and in the psychosocial tiave aims to share our approach, developed
feld. on the basis of work in the feld and in the
Rwandan context in order to inform people
Handicap International has been strongly com- of the approaches and interventions set up.
mitted to working in the psychosocial feld This involves sharing the knowledge produced
since 1994. Initially, this involved supporting about an approach, in response to the specifc
the CENAs (Centres for Unaccompanied Chil- care provided, and the results of the project;
dren) which were taking in the vast number of both internally for the HI mental health project
unaccompanied children, found ‘by the side of managers and externally for the national and
the road’, when the guns fell silent. At that time, international partners involved.
Handicap International became known for its This document also aims to develop objectives
psychological support activities, offered to the and strategies for the 2010-2012 project cycle,
children in the centres, particularly based on as it constitutes a tool that can be used to
forms of mediation using drawing and drama. improve the Rwandan mental health information
The projects then multiplied but all focused on stakeholders’ awareness and understanding of
individual or group therapeutic care. This care the concepts, the intervention framework and
was provided by HI psychologists and par- the activities of our community-based health
tner organisations to children and adolescents approach.
in psychological distress. Between 2002 and
2006, as well as therapeutic care, the projects
also aimed to incorporate interventions in the
psychosocial environment, particularly by pro-
viding training for teachers and psychosocial
care for families.
In 2006, an evaluation of past practices resul-
ted in the design of a project aiming to promote
a community-based mental health approach
(CMH). This 3-year project started in January
2007, to be completed in December 2009.
This Community-based Mental Health pro-
ject aims to be an innovative approach both
for HI and for Rwanda: the initial objective Picture 6: A benefciary in the
N’dera sector
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