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Case Study: Ten Lessons Learned while Carrying Out a MHPSS Intervention with War-Affected Children in the Democratic Republic of Congo in 2011

Honorary Research Fellow (Queen’s University, Belfast), Education and Child Psychologist (SELB)

Visit for more related articles at International Journal of Emergency Mental Health and Human Resilience

Introduction

Protecting and improving people’s mental health and psychosocial well-being in humanitarian crises has recently emerged from its ‘humanitarian ghetto’ (Wessells, 2009) towards acceptance as a fundamental and essential part of any post-humanitarian emergency provision. Yet, this newly emerging field of mental health and psychosocial support (MHPSS) has a long way to go before acceptance and full integration as an evidence-based component of all postconflict and post-disaster interventions. This is because this incipient field is hampered by gaps in practitioners’ field experience (IASC, 2007), a scarcity of rigorously evaluated research studies (Jordans, Tol, Komproe, Lasuba, Ntamutumba, et al. 2010) and inadequate training of international humanitarian psychologists who deliver these MHPSS interventions in the field (Wessells, 2009). In order to avoid the many pitfalls of inadvertently causing harm through good-intentioned yet ultimately detrimental practices, there is a need to incorporate new emerging insights (IASC, 2007) and learn from the experiences and oversights of others.

One of the greatest oversights in the field to date has been the under-estimation of resilience (Wessells, 2009). This has resulted in a deficit trap whereby researchers focused on the psychopathology of survivors to the detriment of research on the assets and resources that these survivors can draw upon. Resilience is defined as the ability to cope relatively well in situations of adversity (IASC, 2007) and is influenced by the level of family, community and societal support a person can access. Knowledge of these support structures is particularly important in emergency contexts which are by nature fluid, volatile and complex.

Although recent research on resilience is slowly emerging, it is largely confined to a focus on the resilience of adverse groups who are the net beneficiaries of MHPSS interventions. Few studies have thought to examine practitioner resilience – the ability of mental health and psychosocial workers to adapt to and cope with the challenges of working in hostile environments and cultural contexts very different from their own.

This case study seeks to serve two purposes. Firstly, it explores the demands placed on practitioners who carry out MHPSS interventions with war-affected children in DR Congo (McMullen, O’Callaghan, Shannon, Black & Eakin, 2013; O’Callaghan, McMullen, Shannon, Rafferty & Black, 2013). Secondly, it seeks to peel back the surface and share the ‘soft data’ on what life is like in the field. In so doing, it informs the next generation of MHPSS practitioners about the realities of work in emergency contexts - an insight that can often get lost amid the statistics of success and stories of survival that frequently make it into print.

Lesson 1: Do Not Leave your Bags Unattended in an Embassy

It took us 3 days, two borders and journeys by plane, bus, taxi, motorbike and on foot before my colleague and I finally crossed the pot-marked, unpaved no-man’s-land between Rwanda and the Democratic Republic of Congo and arrived safely in the country that is to be our home for the next two months. But what adventures occurred in those three days!

Having missed the early bus from Kampala, Uganda to Kigali, Rwanda by 15 minutes, we had to wait in Kampala for a full day to get the 8.30pm overnight bus to Rwanda’s capital city. Arriving in Kigali at the ungodly hour of 5am we headed straight to the DRC embassy. But from being 15 minutes too late for our bus before, we were now 2 hours too early for the embassy. So we deposited our luggage inside the gate with a kindly watchman and went in search of sustenance. Upon returning we were met by an older, taciturn watchman who shut the gate in our faces and told us to wait outside. Five minutes later we were being ticked off by the head of a private security company for leave our bags in the DRC (the embassy, after all, we were informed, was DRC soil) and were told that in the current security climate leaving bags unaccompanied was not a good idea! Our visas came at a cost: $450 for two people for a two month stay. We were also told that if we wanted our visas processed while we waited, it would cost us an additional $50 – a charge made all the more ridiculous when we saw only three other applicants that whole morning requesting visas.

But our brush with embassy bureaucracy pale into insignificance when compared to the trouble visitors can have trying to enter the DRC at the border. It’s bizarre that a country so few want to visit (bar the odd missionary, mercenary, or mental health practitioner) makes it so difficult for those who do come to enter. So, I was really dreading the border crossing having read blogs about Westerners being hassled, arrested, refused entry or charged exorbitant ‘additional fees’. But forewarned is forearmed and prior to departing I secretly rehearsed my ‘Swahili speech’ to oil the wheels of bureaucracy. It’s incredible the power a local language wields. From being disinterested and brusque the border guard transformed into a jolly ebullient man who quickly returned to bring his ‘Swahili-speaking oddity’ to see the head border guard and her female assistant. Every one of the last 1,000 hours spent studying the language was put to the test as I fielded a multitude of good-natured questions on which I was, where I was from, what I was doing etc.

Lesson 2: Divide your Money into Small Bundles when Travelling

Everything was going according to plan until Mama Fatuma spotted a bulging money waist bag beneath my shirt. What’s that she asked? My heart sank. “It’s a money belt,” I stammered, my Swahili deserting me for the first time since entering the room. “How much money have you got in it?” She looked at my quizzically. I wanted to tell her that it was none of her business but my colleague and I needed her approval otherwise we would be denied access to her country. “Write it down for me or this paper,” she demanded. My mind raced. I had over $1300 US dollars around my waist. (Carrying large sums of money is not uncommon in war-affected regions with no ATMs, no access to online banking and where shops and hotels do not accept credit cards). I panicked. I scribbled down £700 and prayed she wouldn’t know the exchange rate between the pound and the dollar. “Don’t you know you can’t bring in large amounts of money into the country?” she continued importantly. “Take all your money out and put it on the table”. Once again, I stalled. “Don’t be afraid” she soothed. “You can trust me”. I choked and stalled again. “Paul, take out your money and leave it on the table”. She wasn’t for backing down. Slowly, I lifted up my shirt and fumbled at the zips. I opened the wallet and looked inside. I couldn’t believe it. There was only €70 in that pocket. Prior to leaving I had unknowingly separated my money into two pockets in the money bag and put all the other dollars in the back. I gingerly placed my euro on the table. “Is that all you’ve got?” she asked. “Yes”, I answered (after all, it was all the euro notes I had, so technically it wasn’t a lie!). “Make sure you change your money in a bank,” she added. “No problem”, I responded, my voice returning to its usual tone and pitch again. “And don’t forget to come in and say hello when you pass again”, she reminded me before handing me my passport and the all-important stamp. I left the building weak-kneed and relieved to still have all my US dollars and thanked God for the goodness of friends whose last minute donations saved me from having to leave a small fortune in US dollars at the border crossing that day.

Lesson 3: Never, Ever Take Pictures of Military Installations or Soldiers

The DRC is awash with guns. You see them everywhere you go. Perhaps I should not have been so surprised. After all the DRC conflict is the longest running, bloodiest and certainly the most brutal war in African history. Since 1998, over 5 million people have lost their lives in the Democratic Republic of Congo. Although many were killed in rebel attacks or skirmishes between the government and local militias (most hillsides in DRC have their own militias) the majority died from malnutrition and disease which spread through refugee camps like wildfires. As a part of life, death shapes communities and businesses dealing in death thrive. Coffin makers in town advertise their enterprises by displaying velvet-coated coffins of various colours and sizes outside on the street.

Every hotel in town has at least 3 or 4 armed, uniformed policemen on guard at the gate. Personal mansions cower behind 10-foot high blast-proof walls. Collectively these private pads must have enough razor wire to encircle Ireland twice over. Even NGO employs armed private security firms. Police patrols are armed, army patrols are armed and UN army patrols are armed. In fact, if all the weapons were simultaneously handed in there would probably be enough metal in the city to re-make another Eiffel Tower. Coming from a country where even the police don’t carry weapons, it’s hard not to stare when a pick-up truck passes you at silly speed, bouncing a small private army around in the back and a dizzying number of rifles, machine guns, grenades, rocket launchers and mortars. However, never, ever, make direct eye contact or take pictures of any military installations or soldiers. I’ll always remember our translator’s reply to a colleague’s question of whether it was okay to take a picture of an armed Congolese soldier standing at an army post. In a drool, matter-of-fact voice, he responded, “Yeah sure, take the picture if you like, but he will shoot you”.

Lesson 4: Don’t be Alarmed by Armed Convoys of Speeding Pick-Up Trucks

Hotel Beni was a ‘3-star hotel’ that is the town’s pride and joy. Although it has no running water (scalding water is delivered by bucket to our rooms for the evening ablutions) or electricity (we get 5 hours of generator power every evening) Hotel Beni is home to scruffy researchers, visiting big wigs and local VIPs. Last week a convoy of three pick-up trucks sped into our courtyard and out jumped 20 armed police with rifles at the ready. We initially thought the hotel was being raided until we saw ‘the big man’ with trademark white suit and dark sunglasses emerge from one of the cars. Apparently he was a Police Inspector from Kinshasa sent to Beni to inspect the force. I guess he thought he’d bring the police to him instead for he must have emptied quite a few local police stations to make up his personal security detail. Hotel Beni, houses a lot more though than police inspectors. At night ladies of the night ply their trade from the bar and even follow guests to their rooms to offer a range of unsolicited services. The mornings belong to hawkers selling carvings and masks made by ‘pot-smoking’ pygmies in the nearby rain forest while outside our gate, ‘Vietnam’ is sold to the masses (Vietnam is the name used for second-hand clothes here).

Lesson 5: Roasted Meat and Slaughtered Chickens can cause Trauma Flashbacks

Once accommodation was sorted, the next step was to meet the participants and facilitators that would be part of our lives and work for the next few weeks. For this intervention, participants were former child soldiers, orphans, street boys or runaways and abused girls who clothe and feed themselves and their children by selling their bodies for $5 (or less) per punter. Many of the girls had personal experience of rape, most were orphans and the majority lived in brothels where they compete with each other for a few grubby dollars or a bowl of food at night. All manner of human misery and pain has been experienced by these girls: parental divorce or separation, death, drunkenness, sexual violence, abduction, accusations of witchcraft, stigmatisation, seeing loved ones being killed and this was all before we include the war experiences they had lived through. I know there is a tendency in every project to claim that ‘the current group’ are the most traumatised, the most distressed etc. but I think you would have to travel far and wide to find an equivalent group more psychologically vulnerable than the girls we worked with on that particular project.

But it was just the study participants who survived trauma, our local translators and facilitators had to. One day, after one of the sessions on trauma education our translator confided that he could no longer slaughter a chicken for the sight of the blood spurting reminded him of a rebel captive who was given a ‘vest’ (a code word for chopping off both arms with a machete). One of the girls mentioned that she wouldn’t eat meat anymore either after seeing human flesh being cooked and roasted by members of a militia group called ‘Mayi-Mayi’ (water-water). The Mayi-Mayi got their name from a practice of smearing their bodies with water and then telling their fighters that the water will protect them from gunshot wounds. So powerful is this belief that our well-educated translator, who runs his own English school here in Beni, swears blindly that he has seen bullets fired at Mayi-Mayi fighters fall to the ground like drops of water and the fighters remain completely unscathed. Yet weird rituals around water are mild in comparison to other more odious practices. Last week a child soldier described how Mayi-Mayi fighters would kill a person, eat their heart and drink their blood. Mayi-Mayi fighters have also been accused of committed mass gang rapes in the twisted belief that multiple sexual experiences prior to war enhance one’s conquests on the battlefield.

Lesson 6: Keep your Sense of Humour

In the midst of so many stories of brutality and cruelty, an unexpected smile came in the form of the names we encountered among participants. Firstly, we had a girl called ‘Jaffa cake’ in our project, an innocent street boy of 14 named Sadaam Hussein, a buxom, heavy set teenager who squeezes into a T-shirt with the words ‘skinny bitch’ emblazoned on the front and to round it all off, our whole project was overseen by a Pastor called Pinos. At the mere mention of his ‘unmentionables’ my colleague and I chortled with mirth; a laughter made all the worst by the complete deference and respect everyone else held the good man in! Just as the name Pavlov rings a bell, Pinos cued muffled laughter all round and my colleague and I had to bite our lips each time we met the poor man in public, hoping that he did not take offence at our mirth. In addition to his unfortunate name, Pinos apparently was not a great animal lover for according to some of the boys in the child soldier centre, when Pinos heard the boys were feeding a wild gorilla he found a hotel in Bukavu that wanted to buy the gorilla and sold it for a tidy profit! A tall tale perhaps from boys who may not know the difference between a gorilla and a tree monkey but if I ever get to Bukavu I look forward to checking out the tale of Pinos and the luxury hotel that bought a gorilla from him for its guests!

Lesson 7: Strive to Maintain a Healthy, Balanced Diet

They say a hardboiled egg is hard to beat in the morning. But, the inspirationally-named ‘Hotel Beni One’ (there’s also a ‘Hotel Beni Two’) goes one better by providing freshly-baked bread, omelettes, pancakes and powdered milk from Irish cows for its loyal patrons. The pancakes were the ‘piece de resistance’ of the breakfast menu and the main reason we got up every morning! My colleague also found a shop that sold chocolate sauce and combined with thinly cut slices of sweet, baby bananas was a gastronomic delight.

Lunch consisted of half a green or black avocado (cut with a pen-knife and shared), one roll of white bread and about 5 mouthfuls of water. Due to an absence of cups in our school-cum-church where we meet for the intervention, each person takes a few mouthfuls from the same bottle. We drank, what one participant described as, ‘rebel style’– tilting the bottle back and pouring the cool contents straight down the throat.

Dinner choices came in bunches of threes. The meat choice was fish, goat or beef. The side order was rice, chips or ugali. Condiments included pepper, salt or mayonnaise. Drinks were soda, water or beer. Although baboon is eaten here it did not grace any menu I saw and to be honest, the sight of anthropomorphic limbs on a grill would probably have put us all on the first flight back home. For those with thinner wallets there were cheaper choices – a complete roasted goat’s head (including bulging eyes and twisted tongue) set you back a mere $4. A cow’s tail (complete with hairs) could be bought at the market for even less. Every morning, we passed the slaughter house on route to work and once our motorcycle taxi had to take evasive action to avoid colliding with a long-horn heifer making a bid for freedom down the main road.

Lesson 8: Being Poisoned does not always affect your Appetite

But speaking of dinner and death, one of our seminar facilitators took ill during the programme. She sent a text informing us that she had been poisoned and was taking herself off to a traditional healer to get better. Curious to know exactly what that I meant, I enquired from another person if this meant that she would be visiting a witchdoctor. I was informed her treatment involved collecting herbs and grasses from the forest but no incantations or dead chickens. However, the good lady’s voracious appetite was seemingly unaffected by her poisoning. When we invited our co-workers to a meal (to say thank-you for their work – she having done less than ¼ of what the others had done due to her frequent absences) she not only brought her uninvited husband for the free meal but piled her plate so high with food you would think she hadn’t eaten for a month. Throughout the meal she was in the best of form, wiping rivulets of chicken fat from her face and ordering extra drinks for herself. The following day, when we had worked to do, there was no sign of our greedy gourmand and not even a text to explain her absence. Perhaps indigestion kept her away!

Many people that I asked have, attested to the fact that people can be poisoned simply by shaking hands. The assassin smears his right hand with poison prior to greeting you and then the poison passes from their hand to yours and into your mouth when next you eat. How common (or even plausible) this is, I don’t rightly know, but one upside of this belief is that most people wash their hands thoroughly before eating. Even if a cunning businessman began this rumour to sell more hand soap at least hygiene standards are improving and people are more conscious of cleanliness than ever before.

Lesson 9: Allow Plenty of Time for Routine Tasks

In the DRC, unexpected obstacles may appear at any time and heroic effort is required to complete basic administration tasks that would barely cost you a thought in another context. Take for example, the task of photocopying the post-intervention questionnaires. I left early that morning from our hotel on the back of a motorbike to find a stationery shop to get the work done. But that day, the bridge was being repaired and the motorbike driver misheard my directions and took me in the wrong direction. When we eventually re-joined the correct route, we had to take a large detour to avoid a broken bridge. Upon reaching the shop we learn that their printer is out of ink. So, I headed off on foot to another place but this place did not have any power (but plenty of ink!). The third place had ink (whew!), power (thank God!) but the machine hadn’t been serviced and so you could not read the photocopy. Eventually, I found a place and got the photocopies we needed. But something that should have taken 20 minutes took over an hour and by the time I returned to the intervention, I had missed the mayor’s address and some of the certificates being handed out. That evening, we return to our hotel to discover that the toilet in my colleague’s room had exploded and there was three inches of sewage water flooding the bedroom. As if that was not bad enough, one of the staff in a partner NGO booked us on a flight with an airline company that was no longer flying out of Beni. Thoroughly, exhausted after an intensive and emotionally draining intervention, with no bed and no transport out of town, I spent the evening of our graduation party negotiating a sewage-free room from a reluctant hotel manager while my colleague rang the Regional Director of the NGO to resolve our flight plan debacle.

Lesson 10: Remember to Record the Stories of Participants

But on to happier things...the first thing to report was that the intervention was empirically shown to reduce trauma, depression and anxiety in war-affected boys and girls. So, mission accomplished!! But what took us most by surprise was the high reduction in symptoms of psychological distress that the children reported after the intervention. When working with a traumatised population, there is always the risk that therapy can inadvertently or accidentally make their distress even more acute and this could be catastrophic for such a vulnerable group. Thus, my colleague and I were absolutely ecstatic when we discovered that not only had we got a statistically significant reduction in post-traumatic symptoms, depression, anxiety, conduct problems and even somatic complaints in the treatment group but that when the treatment group were compared with the waiting list control group, the intervention was still shown to be significant. Finding such a large effect size after treatment in a Randomised Control Trial is rare in the literature and a real joy for us both, for it offered proof to the scientific community that Trauma-Focused Cognitive Behaviour Therapy could be used successfully to reduce trauma in a population that has never used this intervention before.

But much more important than statistics, what really convinced us that we had made a difference in the lives of these young people was hearing them stand up in front of parents, peers and local public figures at the graduation day and talk about how the seminar had helped greatly in controlling their negative thoughts, reducing their suicidal ideation and improving their relationships with peers and family too. As this project continued to provide psychosocial support to participants from our partner NGOs, for months after the intervention stopped, we were confident that we had left behind us something much more valuable than money or gifts: a skill set and support structure that would make recovery an on-going process.

Conclusion

When I look back on our time in Congo I feel blessed and fortunate for having met some of the finest and most competent people in the country to help us with our intervention. Firstly, there was Marie*, a wonderful motherly woman who was present for every single session, diligently took notes, visited a host of families of the girls and boys we were concerned about and never lost her sense of humour and joy.

Then there was Jacque*, our translator and all-round local fixer. Now, Jacque’s English was not perfect (he once asked the difference between ‘Hamlet’ and ‘omelette’ and set up an NGO ‘for raping girls’–an unfortunate confusion between the gerund and the past participle). His judgements were somewhat hasty; all girls he met in Hotel Beni were ‘harlots’, most child soldiers were ‘possessed by demons’ and beer was the ‘drink of the devil’. But despite his erstwhile faults, he was a colourful communicator and talented teacher. He quickly picked up the principles underlying Cognitive Behaviour Therapy and soaked up its techniques and learning points. He then regurgitated this knowledge in his own imitable style. In fact, so committed was he to the seminar, he even taught his wife one of the mental imagery task we taught the children and reported that it worked brilliantly for her too.

But to close, of all the participants that were involved in the project, the one person I will always remember is a small pot-bellied boy called Jean*. When we started the seminar, Jean was disrespectful, disinterested and distracted others. He stole our colouring pencils and laughed at others who wanted to learn. But four weeks into the intervention, Jean was a changed man. During the graduation ceremony he shared on how much the seminar had impacted him. He reported that now he falls asleep straight away at night and wakes up refreshed and rested. He no longer has nightmares or is troubled by suicidal thoughts. He interacts better with his peers. Teachers in the child soldier reception centre talk about how much the intervention has improved their relationships with Jean. For me, Jean’s progress puts all our photocopying problems, sanitary situations and travel troubles in perspective. In the end, this project was ultimately about saving lives, and it was truly an honour to play our role in helping to bring this outcome about.

References

1. Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.
2. Jordans, M., Tol, W., Komproe, I., Lasuba, A., Ntamutumba, P., Susanty, D., Vallipuram, A. & de Jong, J.T.V.M. (2010). Comprehensive psychosocial support for children in areas of armed conflict. International Journal of Mental Health Systems, 415, 1-12.
3. McMullen, J., O’Callaghan, P., Shannon, C., Black, A. & Eakin, J. (2013). Group trauma-focused cognitive-behavioral therapy with former child soldiers and other war-affected boys in the DR Congo: A Randomized Controlled Trial. Journal of Child Psychology and Psychiatry, 54, 1231-41.
4. O’Callaghan, P., McMullen, J., Shannon, C., Rafferty, H., & Black, A. (2013). A randomized controlled trial of Trauma-Focused Cognitive Behavioral Therapy for sexually exploited, war-affected, Congolese Girls. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 359-369.
5. Wessells, M. (2009). Do No Harm: Toward Contextually Appropriate Psychosocial Support in International Emergencies. American Psychologist, 64, 842-854.