I started ‘Letters from the Heart of Africa’ over 15 months ago and now, 34 posts and 50,000 words later I’m finally nearing the home straight. Thanks so much for following this series so far, I’ve certainly enjoyed writing it and going through my journal which had lay untouched for 10 years before I starting blogging. In fact, if it hadn’t been for my wife Sarah’s continual asking me to write it up, it would still be gathering dust somewhere, having only ever been read by me. It’s been a process of reminiscing and reminding me of my experiences; so much, if not written down, gets lost because the weakest ink is better than the best memory as the Chinese proverb goes.
I have just five more posts left probably, unless my journal throws up something new. I’ve tried to mix up the posts as much as I can, the fun ones with the sad ones and I hope the series in its entirety is giving a balanced view of my life in Rwanda and a flavour of the country.
Today’s particular post, ‘Healing the Memories’ was a little harder to write given its technical nature (and I’m not a technical person) but I’m hoping you’ll find it insightful on mental well-being and PTSD in Rwanda.
Travels with Doctor Muss – healing the memories.
The Rwandan dry season continued; a top hotel in the city started to drain its swimming pool for drinking water; I stopped adding ice to my G’n’Ts – I know what children do in swimming pools.
With the audio guides delivered at the Kigali Genocide Memorial Centre my next project assigned by VSO a UK based volunteering organisation, was to co-ordinate a series of training workshops for coping with post traumatic stress disorder (PTSD) for a specialist volunteer, Dr David Muss.
People who witness a traumatic event like a car accident or a murder can suffer from PTSD. Memories can rush at them so that they relive the experience and it can lead to depression, drug abuse, alcoholism, nightmares, flashbacks and hallucinations and become utterly debilitating.
Doctor Muss had developed a pioneering new therapy called the Rewind Technique which enabled sufferers to control their PTSD; he’d had success in helping ex-service people from Afghanistan, Iraq, Bosnia, Northern Ireland and the Falklands, some of whom had been on the brink of suicide and was now keen to see it work in Rwanda on a larger, one to many, scale.
David’s ‘Rewind Technique’ technique was fast (it needed just one or two sessions), it was drug-free and because he could train people to give sessions en masse, it had a big reach. In a country like Rwanda where it was estimated in 2008 over 200,000 people still suffered from this condition, and the entire adult population had some sort of recall of the 1994 genocide, it was ideal. There was clearly enough people to help.
Meeting Aimee, without a turban
The Kigali Genocide Memorial Centre put up a poster advertising free training workshops, followed by an email campaign to local NGOs, hospitals and counsellors. A few days later I got an email from a lady called Aimee Josephine Utuza, the National Program Officer and a qualified counsellor from an NGO called Swiss Development Co-operation, saying she wanted to help out.
We agreed to meet at Bourbon Coffee in the main shopping mall one evening after work – I knew it well, a native Starbucks-like coffee hangout, that had strong coffee and weak wifi and was the haunt for tourists looking up their social media looking down at their MacBooks.
When I got there I realised I didn’t know what Aimee looked like. Behind me a voice called my name, I turned and in front of me was a young woman, her hair in tidy cornrows, her eyes large and bright with a Colgate smile.
‘You said you looked like an Indian,’ she said.
‘I do,’ I replied.
‘I was expecting you to wear a turban,’ she said.
We started off with a giggle, bought our coffees and with notebooks in front of us, started to plan. Aimee imparted her advice carefully. ‘
‘We should have training workshops all across the country so that Dr Muss can reach as many people as possible – so many don’t have the means to travel to Kigali. But first, we need a government introduction from the Ministry of Health, Minisante or better still a letter of approval, that would clear the way for our project,’ she advised.
There was already by then, infrastructure in Rwanda to deal with mental health. There were clinics and hospitals at district and sector levels such as the referral hospital of Ndera in Kigali which treated as many as 2,500 patients a month. Before the genocide there were no known problems with mental health but after 1994 there was a real awakening to PTSD and people had only just started to become aware that the condition could be helped; therapies such as Cognitive Behaviour Therapy and, for children, drawing classes had already commenced.
Rwanda it seemed was writing a whole new chapter to the history of PTSD. In the first few years after 1994, Rwanda was still in too much shock, only after 2004 did it start to become treatable and by 2008 they were ready to be healed. Left on its own, nothing would happen.
Aimee would prove to be lynchpin to the project’s success – she was a counsellor, articulate and intelligent and knew how to navigate the gatekeepers. That was a vital skill.
Dr Muss arrives and gets lost
Dr Muss arrived in Kigali in early August – he came off the flight from London with his characteristic energy and drive, wearing a crisp blue shirt, beige chinos and a ready smile. He was a consummate professional, determined and focussed, but he also had a fun side with a good sense of humour. I enjoyed sharing the VSO volunteers’ house with him; he played a great game of tennis with a wickedly fast serve, and we’d spend time skidding around on dusty clay courts at Novotel on some evenings. Every morning he’d play classical music from his laptop and as we got ready for work he’d sometimes make poached eggs, improvising a poacher by floating the eggs in a spinning, boiling brine of water and vinegar.
On his first day I told him he didn’t need to be at the Memorial Centre until later in the day so I headed off to work first. Later that morning I got a phone call from him.
‘Where are you?’
‘On the back of a motorbike taxi.’
‘What can you see?’
‘Some fields, a few hills.’
In Kigali, one the hilliest cities in the world, that didn’t help.
‘Tell him you need to get to the Kigali Genocide Memorial in Gisozi.’
‘I did, he doesn’t know where that is.’
‘Really, it’s the number one tourist spot in the city.’
It was evident the motorbike taxi rider was taking him for a ride in more ways than one and a short conversation from a colleague in native Kinyarwanda solved the issue and Doctor Muss was welcomed at the centre by Freddy.
Aimee had already set up a meeting for us at Minisante, the health ministry, with the Interim Charge of Psychology Claire Misago who examined our proposal and workplan – she granted her approval of the work.
For someone with no background in pyschology, I found following the conversation at times quiet hard – the various treatments that had begun like Cognitive Behavioural Therapy or Eye Movement Desensitization and Reprocessing. It was even more harder to follow because it was in French and Aimee was having to translate.
Rwanda’s first session in the Rewind Technique
One morning Doctor Muss held the first training session in the main room of the Kigali Genocide Memorial Centre where around 40 people, including NGO workers, counsellors, nurses, colleagues and even the UK’s Deputy Ambassador had congregated.
He started off with a welcome and an outline of the three hour session. ‘In a normal country about 2% of the population suffer from PTSD. In Rwanda 2% DON’T suffer from ptsd.”
At that moment something very strange and surprising happened – some people started giggling. It was something that I noticed every now and again during my time there – Rwandans have a ready sense of humour, quite a straightforward one, devoid of sarcasm or irony. The national psyche is both forward looking and reflective, and both melancholy and humour co-exist there too. Although Dr Muss never intended to provoke laughter, it certainly broke the ice.
Over the course of the session sufferers were asked to recall the disturbing episode step by step in their own minds. There was no need to explain to anyone else what happened, it was their own re-creation in their own time, in their own recall. This was quite a departure from how I imagined a therapy session would be; I had always imagined psychologists being people who let others lie on a couch while they poured out their grief and torment. In Rwanda where people are naturally quite reserved this privacy was really important.
The period of silence, as people re-created the episode in their own minds, was noticeably long, much longer than in a normal session. More than twenty minutes passed in silence – it was evident some people were recalling the details of multiple events, some lasting days or even weeks.
He then starting talking them through the essence of the Rewind Technique after which, the memory would no longer have the power to intrude uninvited; they would have a key to lock away that memory, and they and only they would be able to unlock it.
Some people were crying, some gave feedback. One person felt anger because he knew the person who murdered his family; one mentioned a car accident; one said only after he went and reported it to the police did he start to feel better.
A man at the back said his traumatic event was that one day he was chased by a dog. Again there were giggles.
‘No it must be a serious event, life threatening not just being chased by a dog.’ Slowly the giggles subsided.
Mr Deputy Ambassador is displeased
The next day I got a phone call from the UK’s Deputy Ambassador to Rwanda, someone I had met occasionally at the pub in the embassy called the Goat and Gorilla. He was keen to give me some feedback.
‘The technique, it’s a bit intrusive isn’t it?’
‘How do you mean?’
‘Asking people to tell their testimonies of the genocide?’
I told him I couldn’t quite understand what he meant – at no point was any person asked to tell their memory. I explained to them that all VSO volunteers had to undergo a few days of cultural training on arrival and we had learned never to ask people of their experience of 1994. Sometimes people volunteered them to me, others would ask if I knew their stories, and some of my colleagues had published their real-life accounts. But David I knew never to ask, and for this Rewind was ideal and I really wasn’t sure what the Deputy Ambassador was on about.
Vedaste and Patrick join our team
It was a crazy first week – we had met officials from Minisante, the Dean of the University, and many NGOs, FACT, PSF, MMHA in Butare, WFP, IJM and other acronyms.
We needed to repeat these workshops around the country and we were joined by two other people, my friends Vedaste Nkuranga a law student who volunteered at the Memorial Centre, and Patrick Mutware, a priest and NGO worker – the five of us became a team that travelled the corners of the country to help manage Dr Muss’s training sessions.
On the 6th August we visited a Project at Saint Francis and the early feedback was that people were already managing to control their PTSD.
Aimee, Vedaste and Patrick were also useful interpreter of English in to Kinyarwanda. At some sessions, the rooms would fill with whispers. This wasn’t a sign of attention distraction – people were translating for people sitting next to them. Every now and again there would be a phrase or idiom that didn’t translate very easily, for example ‘waves on the sea’ (Rwanda is landlocked), ‘Railways’ (Rwanda has no trains) and the old occasional English word like ‘numb’ which was harder to translate in to Kinyarwanda.
Visiting the National University of Rwanda in Butare
One Saturday we drove down to Butare, to the National University of Rwanda, at the invitation of the Mental Health Association to help train students. Yves’ sister Nadine was studying there and she had helped us co-ordinate it.
The grounds of the campus were expansive and leafy, like a huge botanical garden with carefully curated tree and plants – huge eucalyptus trees, their white bark flaking like scales and smelling sweet and minty, large palms, huge bougainvillea, cacti the size of a house. It was a beautifully manicured setting and we there with the help of medical students Nadine, Calixte and David. Dr Muss was able to perform another session, this time to medical students.
One of the things Dr Muss was keen to see in Rwanda, was the impact his sessions was having on the control of PTSD. Never before had this technqiue been given to a one-to-many situation. The students helped him to translate a questionnaire, the Horowitz questionnaire, typically used to assess changes in a sufferer’s PTSD in a quantified manner. Some of the words in the translated version were charming, I rather liked ‘thoughts and feelings’ which translated to “amaranga mutima”
Anecdotal feedback – it’s working
By the 11th of August we were already getting anecdotal feedback; Serge and Dona (from PSF) said they were feeling better. People were surprised at how simple the technique was compared to older techniques. Lady Bella at WFP said it had worked for her and she did it to her sister, a doctor, who invited her patients home to do the therapy out of hours.
One evening we met up with Aimee at Bourbon Coffee to get some feedback from her. She said the Rewind technique seems very very simple, she thought it would be highly technical being a student of psychology. ‘I think that’s why it was so effective,’ she added, ‘But Rwandans like to listen to stories – not listening to the story was a bit of a jump.’
Aimee then explained why she had a personal connection to this project – her parents were Hutu but her mother remarried to a Tutsi, so if she had a Tutsi in the family, she too would be Tutsi (these groupings of Hutu and Tutsi are rather arbitrary in fact and were originally based on how many cattle the locals owned by the Belgian colonisers.) In the 1994 genocide many of her family were killed. What really affected her was when she saw her father at the end of the genocide, he didn’t even recognise her – he was so psychological affected.
The training progressed smoothly but on some days we had issues – despite the training being done for free, it was an expectation that attendees would be paid lunch and travel expenses. We had no budget for that; it was an awkward conversation. Some people, instead of going through the memories step by steps, got stuck in their recall and reflected on a certain parts of the episode, living it again and reliving the emotions.
This technique had never been done before in Rwanda, nor a technique that could help so many in such a short space of time. These people could then go and train or treat many more and David was giving this tool, this lifeline, free of charge to anyone who needed it.
We just needed to prove it, and that meant doing a clinical trial…
Proving the impact with a clinical trial in the eastern province
On the 15th August we took the 7.30am bus to Kibungo in the eastern province of Rwanda, with Patrick, Nkuranga, David and Aimee. By 10.30 am we were in the municipal office with over 20 people, many of them clinical psychologists. It was pleasing to see the numbers; ARCT, Red Cross and other NGOs were also there.
David started off the session by asking them to assess their condition and we handed out A4 copies of the Horowitz questionnaire that Calixte, David and Nadine from the National University of Rwanda had helped to translate.
The Horowitz Questionnaire had been created in the 1970s and was a method of quantifying the impact of an event that leads to PTSD. It asked questions like how frequently their memories were happening and they would have to tick boxes for ‘I thought about it when I didn’t mean to’, ‘I stayed away from reminders of it’, ‘pictures popped in to my mind’ or ‘I had strong feelings or dreams about it.
A score of 25 or above would indicate a high impact of PTSD. We marked the pre-therapy scores, most of them were in the range of 40-60, only a couple were in the 20s. This indicated the severity of of the issue, that so many years after the genocide many people were unable to get on with their lives due to this condition.
Dr Muss performed a three hours mass session that day; 21 people, all genocide survivors, underwent the therapy.
Post script: an 85% success rate and over 300 people trained in 3 weeks
Two weeks later we asked the 21 survivors to re-assess their condition by filling in the questionnaires again. This time though there was a big difference – the scores showed a significant reduction. They were managing to control their PTSD and Dr Muss had achieved an 85% success rate. The technique had never been tested in a group setting before and the results were astounding. In 2012 Dr Muss and Aimee went on to write a journal article at the American Psychological Association .
Over 3 weeks over 300 counsellors, nurses, doctors, NGO workers, each equipped to help others control the condition had been trained. Trainers would have gone to help some and train others. Only time can judge the full impact of the sessions.
Meanwhile, to this day, countless people in Rwanda continue to live with their traumatic memory recall, reliving through day and night, time and and time again, the worst excesses of the 1994 genocide.