/ 6 March 2020

4.6 million people, one psychologist: The Central African Republic’s mental health crisis

Crisis Returns To Central African Republic
People comfort the sister of a Muslim man who was kidnapped, held for ransom and then murdered when his family could not pay the amount demanded by kidnappers in Paoua town, Central African Republic, January 27, 2018. As CAR's numerous rebel groups continue to spliter and multiply, banditry and extortion have become the norm of the day for civilians in lawless areas.

There are 4.6-million people in the Central African Republic (CAR). Flora Pasquereau, the country’s only practising clinical psychologist, thinks that most of them have some form of post-traumatic stress disorder.

“We cannot deny the facts. The reality in the CAR is not easy,” she says.

This is an understatement. Since it began in late 2012, the civil war has reached every town and village. The violence has altered the fortunes of every family, from every socioeconomic strata, leaving hundreds of thousands homeless and thousands dead.

The country desperately needs counselling, and it is up to Pasquereau to provide it. But how does one psychologist treat 4.6-million people?

“Breathing exercises,” she says. “And dancing.”

Given the scale of mental health problems in the country, offering patients individual attention in hour-long sessions is impossible. Pasquereau has had to learn to spread her expertise as thinly as possible, and to adapt her practice to treat large groups.

When we visited her in Bangui in 2018, Pasquereau was leading a class of about 40 in the neat garden of a Catholic church. Most were older women. “A la zou,” she intones, breathing in, wiggling her hips and lifting her arms above her head. She’s mimicking a famous Central African dance move. The group followed her lead, reciting the words like a mantra. “A la desend.” She breathes out and stretches her hands towards her toes.

The exercises combine deep breathing, stretching and traditional dance moves. In her office, in a house on the outskirts of Bangui that doubles as her home, she explains: “You can call it yoga or meditation. Even if you take one minute, for one minute you forget about everything, so when things that are difficult happen later on, you can go back to this kind of therapy and have your relief. A miracle solution doesn’t exist. Those little things like yoga or meditation can help people”.

Pasquereau grew up in Bangui, but her family left the country when she was 15, part of a never-ending exodus of skills and money seeking safer and more prosperous shores. She studied in France, and then moved to Canada to begin a private practice. But her thoughts were never far from home, and when a new head of state was elected in 2016 — President Faustin-Archange Touadéra — she decided that she wanted to be part of the solution.

At first she was going to offer to serve as an honorary consul for CAR in Toronto. But the more she thought about it, the more she realised that her skills were needed at home. There are already more than enough psychologists in Toronto, she realised.

Imagining a brighter future

In 2017, she returned to Bangui and set up a nongovernmental organisation (NGO) called Obouni, which, in Mbaka, means “no matter what, we will succeed”. She has trained a staff of around a dozen clinicians to provide basic therapy, even though they are not qualified psychologists, and together they run two dozen therapy groups at hospitals, clinics, prisons and community centres in and around Bangui, and are slowly expanding into other parts of the country.

It is exhausting, all-consuming work, but Pasquereau cannot see the CAR recovering without it. “People are so traumatised they start to only live for today, not tomorrow … Imagining a brighter future is very rare. No one wants to be a teacher or a doctor. They want to be a soldier, to kill rebels.”

As far as Pasquereau knows, she is the only clinical psychologist practising in the country. She knows of two others with the necessary qualifications, but they have retired. Some NGOs, such as Doctors Without Borders, offer therapy to their patients, but their staff rarely stays long enough to develop relationships. This has become a major obstacle for Obouni’s members, because they must first convince people that they will not leave after two or three months.

 Obouni, a local nonprofit, organises group therapy exercises and listening sessions in different neighbourhoods in Bangui to help people deal with trauma. The sessions often include a mix of singing, yoga, stretching and discussions. (Will Baxter)

Once trust is established, the hard work begins. The clinicians try to divide people with similar experiences into groups — a group for women who have been raped, for example; one for victims of torture; another for people who have seen their relatives killed — and then teach basic coping mechanisms.

“You can’t tell people: ‘Go home and be safe.’ That’s a lie. You say: ‘Things can happen, but don’t focus on the bad’,” says Pasquereau. She tries to reframe people’s experiences by emphasising resilience, stressing to people how they have already overcome the kinds of emotional challenges that would have broken many others. “The first thing I try to show them is how to forgive themselves. Today you are a victim. Tomorrow you are not. You work on their self-esteem because they have no self-esteem. You focus on the positives. But you must be realistic, because you don’t know what is happening next.”

First, heal thyself

Pasquereau may be the only practicing psychologist, but she is not the only person working on mental health problems in the country. Felicien Ntone-Enyime is a mental health specialist from the University Teaching Hospital of Yaoundé in Cameroon. In 2018, he spent several weeks as a visiting lecturer at the University of Bangui, where he saw just how little capacity exists to address mental health issues. Not that he thinks the situation is much better in Cameroon.

“When you do not have a good mental health condition, you are fragile, and in case there is a change you will be unable to adjust, and that is what is happening in our countries,” said Ntone-Enyime. He sees this even among his students, some of whom use their classes as a therapy session.

“Some of them, when they ask questions, it’s actually a personal concern. They have gone through such experiences. They would like to have an answer, like a kind of therapy, like a quick diagnosis just to clear up a point in their life. So when you answer the question it’s like you are generalising, but you know that the question has been asked specifically for himself.”

This concern was echoed by Paulette Baraka, a psychologist with Doctors Without Border, who spent nine months working at a hospital in Bangui in 2017. “Mental health services are almost not there,” she said. Baraka trained social workers to provide basic psychological tools, but first she had to attend to the social workers’ own trauma. “They have to receive their own healing first, and then help others,” she said.

The Mail & Guardian interviewed Pasquereau again in February, by telephone, three years after she returned to Bangui. She too has had to work through the mental health problems faced by her own staff, which are not always what she expected. “I was prepared for PTSD [post-traumatic distress disorder] and all this trauma for the victim. But many people suffer from ADHD [attention deficit hyperactivity disorder] or learning disorders.” In a conflict zone, these other, more commonplace disorders are usually undiagnosed.

Despite these problems, Obouni has grown. The organisation has held nearly 3000 consultations in three years. With support from the United Nations Development Project, it has just opened a safe house for women who have survived gender-based violence. It has also begun a new programme that helps children living with HIV to come to terms with the disease.

Pasquereau has also succeeded in putting mental healthcare on the national agenda for the first time. She organised a conference in October last year to talk about mental healthcare in the country, and what needs to be done to improve it. She has had positive feedback from the government,

Obouni’s main constraint is funding. It costs about $40000 a year to run in its current form, and Pasquereau is never quite sure where the money will come from — although she always finds a way to pay her staff salaries. “There are many people, in every walk of life, in every level, who need to speak with a professional. There is a demand,” she said.

Pasquereau, and Obouni, exist to meet that demand. But they cannot give each of the CAR’s 4.6-million people the attention they deserve. For now, the breathing exercises will have to do. So stand up, take a deep breath, lift your arms, and repeat after Pasquereau: “A la zou. A la desend. A la zou. A la desend.”

This feature was produced as part of Uncovering Security, a media skills development programme run by the Thomson Reuters Foundation, the Stanley Foundation and the Gerda Henkel Stiftung

Donations can be made at: http://www.obouni-rca.org/