Mental Health Capacity Building in Northern Sierra Leone: Lessons Learned and Issues Raised

Shackman & Price

Mental health capacity building in northern Sierra Leone: lessons learned and issues raised

Jane Shackman & Brian K. Price

Ten years after a brutal and protracted war, Sierra international plan for action to improve Leone remains very much in recovery. Despite mental health services as a means to the need for increased and long term mental health lower the burden of disease (Lancet Global services,such resources remain scarce. Mental health Mental Health Group, 2007). Recently, capacity building is required, and includes: the com- the Executive Board of the World Health munitysensitisation of mentalillnessand treatment; Organization (WHO) adopted resolution the training of health professionals and lay persons; WHA65.4, calling for a comprehensive the advocacy for changes in national mental health response to the global burden of mental policy; and the provision of mental health services. illnesses (WHO, 2012b). This consensus, The authors worked during a two-year period emerging among major national and inter- (2010 ^ 2012), supporting a community mental national organisations, has led to a shift health capacity building project in northern Sierra where resources are now being channelled Leone that was designed to address these issues. A into global mental health services and their study was conducted among di¡erent agency and delivery. community stakeholders to assist in the end-of-cycle For many LMICs, descriptions of national programme evaluation. The results illustrate mental health issues have appeared within the broader challenges of providing mental health journals that have historically focused services in the county, and a discussion of issues on providing emergency relief services in and challenges that are likely to be applicable to settings that faced natural and man-made similar projects in Sierra Leone, and other low or crises. A special issue of Intervention (Inter- middle income countries, is provided. vention 9.3,2011)was devoted to global mental health issues, and included topics such as Keywords: evaluation, mental health capa- how responses to complex emergencies can city building, Sierra Leone, sustainability be reconceptualised in a country’s health care system, the need to think long term about the provision of mental health and Introduction psychosocial assistance, and the possibility Previously ignored or neglected in national of using crisis interventions to address long health care systems, the provision of psy- standing shortages (Pe¤rez-Sales et al., 2011). chiatric services in low to middle income Sierra Leone is such an example. Although countries (LMIC) has now become part of little is published on general mental health an international dialogue. A 2007 special issues in Sierra Leone, war related publi- issue of The Lancet provided a signi¢cant cations are abundant. There have been at voice for experts to call for a comprehensive least four publications in Intervention alone

261 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

(Denov, Doucet, & Kamara, 2012; Harris, Development Index (United Nations Devel- 2007; McKay et al., 2011; Stark et al., 2009) opment Programme,2007). The authors wish to contribute to this dialogue by sharing recent experiences as con- Warof1991^2001 sultants to the Mental Health, Behavioural It is impossible to describe Sierra Leone Change, and Social Inclusion programme without mentioning the impact of the (referred to in this article as the mental recent war. The costs have been high, with health programme) for the University of over 50,000 killed and more than a third Makeni in northern Sierra Leone. Recently, of the population displaced. A discussion of WHO identi¢ed Sierra Leone as a priority the factors related to the con£ict is beyond nation for piloting its mental health gap the scope of this paper, and has been well action plan (mhGAP; WHO, 2010). The covered by others. Indeed, it is di⁄cult to authors hope these ¢ndings help to raise ¢nd any outside coverage of Sierra Leone awareness of some issues related to the com- that does not focus on the con£ict. Articles munity mental health project in northern and images on the use of child soldiers, Sierra Leone and potentially similar projects amputations, sexual violence, forced labour, in other LMIC. and large scale massacres are widely available. It is perhaps these graphic images of the con- Background £ict that has led to large scale international Sierra Leone is a small country of approxi- responses, ranging from direct combat to mately six million people, located in western post con£ict consultation, direct social ser- Africa, comprised of a number of di¡erent vice delivery, and policy making. Early post ethnic groups. Administratively, the country con£ict social and mental health services is divided into four geographical areas and focused on reconciliation, child soldier 12 districts. Each district is further divided reintegration, and trauma related counsel- into chiefdoms, governed by local chiefs. ling. Many of these services were provided The project o¡ered services inthe two north- by international nongovernmental organis- ern districts of Bombali and Koinadugu. ations (NGOs).The past ¢ve years have seen Thecountryhassubstantialnaturalresources, a rapid departure of these NGOs, having but has yet to take full advantage of them completed their projects and therefore for the bene¢t of the population as a whole. moving their resources to other parts of Forty years of government corruption, the world. coups d’e¤tat, inter-tribal con£ict and mis- There has been considerable debate on how management, since its independence, well these projects achieved sustainability followedby10years ofcivilwarhave alltaken following the international NGOs depar- their toll on Sierra Leoneans. Most people tures (Bolten, 2008). The in£ux of inter- still rely on subsistence farming or small national aid organisations after the war, trading for work, have a life expectancy of created its own autonomous economy less than 50 years and an adult literacy rate that sometimes fostered dependence. Local of 39%. The average annual income is personnel working for NGOs often times 800 US dollars, making Sierra Leone one of did not ¢nd similar employment following the least developed countries in the world, the end of their contracts. Medical and according to the United Nations Human social services provided by international

NGOs were never replaced by their local More complicated cases are referred to counterparts. Bene¢ciaries of vocational community health centres, which are sta¡ed training, provided as part of rehabilitation by community health o⁄cers (CHOs) and of youth soldiers, have never had the are located at the level of Chiefdom. CHOs opportunity to work in their new trades. also provide supervision of CHPs. Both types Tenyears after the war, a signi¢cant number of PHUs can refer to the district hospital, of social and political issues remain relevant. which provides secondary level care, as Population pressures are still problematic. well as housing the District Medical O⁄cer, Freetown, the country’s capital, received a who has primary responsibility for all substantial burden of displaced persons. services and clinical personnel for the They had initially £ed the rebel advances district. Bombali and Koinadugu comprise during the war, but have since chosen to two of the 12 districts in Sierra Leone. remain in the city. Some of the same pre Mental health services are severely lacking. con£ict risk factors, described by Abdullah The only psychiatric hospital is in Freetown (1998), such as high unemployment (especi- and the recent retirement of the sole psy- ally among its youth), concerns about chiatrist left the country without a board crime and drug use, and the loss of familial certi¢ed psychiatrist. There are only two ties are all mentioned, and are as equally formally trained psychiatric nurses in the signi¢cant today as they were before the capital, and none outside it. Until recently, war. Many members of vulnerable popu- there was no professional training pro- lations, such as child soldiers (Betancourt gramme in mental health. With the support et al., 2010) and young women associated from a multiple partner mental health with the Revolutionary United Front capacity project funded by the European (RUF) rebels (Burman & McKay, 2007), Commission and called Enabling Access to experienced all of the stressors above, in Mental Health, the University of Sierra additionto stigma andcommunity rejection. Leone’s College of Medicine and Allied Health Sciences recently approved 12 and Mental health services in Sierra Leone 18 month training programmes in mental Health care in Sierra Leone is provided health nursing. The ¢rst class cohort, of primarily through a combination of services 22 students, was matriculated in January o¡ered by the government, local and inter- 2012 and is expected to complete both national NGOs, and faith based organis- didactic and clinical training by mid 2013. ations. Traditional healers and traditional A number of international NGOs trained birthattendants provide a signi¢cant amount Sierra Leoneans in mental health inter- of health care services (Ministry of Health vention skills in their ‘training of trainers’ and Sanitation (MOHS),2009b). programmes after the war. Some of those Government health care services are based trained continue to be employed by local on a primary health care concept (MOHS, agencies following the international NGOs’ 2009b), with three levels of peripheral completion of projects, but many others have health units (PHUs), district hospitals, and been forced to look for di¡erent forms of regional/national hospitals. PHUs include work (Asare & Jones, 2005). community health posts (CHP) and are In addition to the shortage of providers, the sta¡ed by state enrolled community health services that do exist operate independently. nurses. CHPs are housed at the village level. There is little coordination between

263 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

agencies, other than arranging for hospital- completed their treatment. A signi¢cant isations in Freetown. At the national level, amount of the project’s early administration the MOHS recently adopted a national and training was done through a network mental health policy and strategic plan, four of international experts and volunteers. years after receiving a draft (MOHS, 2009a; 2009b).The rights of those with men- Methods tal disorders remain tenuous, however, as The evaluation began with JS reviewing the existing mental health act (‘The Lunacy the available documents and discussing the Act’) is over a century old, and contributes objectives for the evaluation with CAFOD to further discrimination and alienation and UNIMAK administrators. The follow- from society (MOHS, 2009a). ing research objectives for the evaluation were established: review the impact of the The mental health project 2008^2011 project; assess the extent to In 2008, the Catholic Agency for Overseas which the programme goals and outcomes Development (CAFOD) of Sierra Leone were met; document project achievements provided funding for a three year project, and best practices; identify gaps in the in partnership with ¢ve local NGOs in the project implementation; and o¡er recom- northern provinces, in order to address the mendations for ways forward in the project. lack of treatment for people with mental The method of programme evaluation disorders and to advocate for their inclusion employed can best be described as primarily in the community. The lead partner was a qualitative case study.Individual and focus the University of Makeni (UNIMAK), group interviews, with structured interview a Catholic university run by the Diocese of guides, were used. By using this approach, Makeni, which had created the mental the interviewer had an outline of topics or health programme (2006) as part of its com- issues to be covered, but was free to vary munity service to improve mental health the wording and order of the questions, to for the residents of Bombali and Koinadugu some extent. Interview guides were prepared districts. UNIMAK provided 120 hours for partner organisation sta¡, government of awareness and intervention training to agency personnel, counselling centre clients nurses, and 40 hours of awareness and and their families, and community members sensitisation workshops to traditional hea- in di¡erent areas within the two provinces. lers, prison and police o⁄cers and social When possible, corroborative evidence from workers. Two hospitals in the two provincial the project’s didactic and report data, as well capitals set up centres in partnership with as a review of counselling centre records, UNIMAK to provide free medication and was sought to verify interviewee reports. counselling services to those with mental While not part of the program evaluation, illness, and advice and support to their during his stay, the second author (BP) families. Community outreach e¡orts to re-entered data collected by programme promote awareness of mental health issues sta¡ for a 2008 baseline morbidity survey were conducted by a local justice, peace in the Bombali and Koaingugu districts. and human rights commission, and a radio This survey was unique in its inclusion station run by the Diocese. A Catholic of both community health workers and charity in Makeni also agreed to provide traditional healers in estimating the region’s access to livelihood support for those having mental health problems, and how they were

addressed. Secondly, a review protocol health services, but they mostly worked was developed for examining counselling independently of government oversight and centre records for the approximately adoption, and their programmes were only 270 clients, in order to provide a detailed short term. The authors interviewed several understanding of a variety of social, medical nurses, CHOs, and volunteers who received and diagnostic factors a¡ecting clients multiple trainings from NGOs with incon- served by counselling centre. sistent outcomes. Few medical personnel were su⁄ciently trained to diagnose and Data collection and analysis prescribe medication properly. Training To assure adequate coverage and language recipients rarely developed advanced skills abilities, ¢ve university students were from subsequent programmes. recruited and received training on how to Those who could o¡er services, whether use the interview guides and record ancillary or direct, were often poorly paid responses. Interviews with key stakeholders and constantly under the threat of losing took place in the two districts, and in Free- their position at the end of a project cycle. town, from 29 August ^ 21September 2011. Two counsellors, employed at one centre A total of 260 people were interviewed, in treating over 600 clients, received less than approximately eight towns and villages. 25 US dollars a week and did not know if After the interview data was recorded and they would be able to continue working at organised, they were analysed using induc- the end of athree-year contract. Community tive and interpretive processes and summar- outreach services were adversely a¡ected ised by identifying signi¢cant themes and when volunteers for the local peace, patterns from similar respondents (Braun justice, and human rights commission left & Clarke, 2006; Leedy & Ormrod, 2005). for paid positions. Other support issues were easily observed. Ethics At the service level, nurses and counsellors The Freetown o⁄ce of CAFOD andthe vice- lacked consistent supplies to do their work. chancellor, Father Joseph Turay, of the Much of the therapeutic bene¢ts that clients University of Makeni approved permission received were adversely a¡ected by the to discuss the ¢ndings of the end-of-cycle lack of a reliable supply of medication. project evaluation. The institutional review Record keeping was also di⁄cult in the board of the Adler School of Professional clinics. Most documents were recorded in Psychology approval was also provided to journal entry books, or on scraps of paper, the second author to publish archival results which made storage and retrieval of client from his ¢ndings in this paper. data di⁄cult for both service providers and administrators. Findings The authors concluded that sustainability Issue one: government buy-in and sustainability would require formal ownership for One major issue was sustainability.E¡orts to providing services by the Sierra Leonean assure the long term o¡ering of mental government. Recent steps taken by the health services in Sierra Leone faced a lot government appear promising for assuring of challenges. The di¡erent NGOs that had expanded delivery of services for the long arrived during, and immediately after, the term. The recently adopted mental health war provided needed training and mental policy (MOHS, 2009a), outlines a plan to

265 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

improve access to mental health services. capitals. Many heard about the mental Changes related to sustainability include: health programme for the ¢rst time during the integration of mental health services the interviews.They were interested in hear- into a comprehensive health care coverage: ing more, and many requested that services fostering e¡ective collaborative partner- be provided in their own community. ships; networks for mental health with Geographical issues also a¡ected the di¡erent stakeholders, involving community selection of those who receiving training. participation in all stages of service delivery; It was more di⁄cult to train health workers and decentralising services. The policy also in Koinadugu than in Bombali, due to trans- states that medications for psychiatric con- portation di⁄culties. The original training ditions should be included in the national, programme was intended for more highly essential medicines list. Finally, it includes a quali¢ed nursing sta¡ working in PHUs, plan to develop mental health curricula, for so as to o¡er localised support to those both general and specialised health workers, su¡ering from mental illnesses. However, a at major medical training institutions in large number of trainees came from the the country. regional hospital in Koinadugu with lower levels of quali¢cation and not easily accessi- Issue two: impact of location ble to those in outlying villages. The level Like other resource limited countries, geo- of the course had to be adjusted, particularly graphical distance and transport di⁄culties for those who did not have high literacy outside of the capital or regional towns were skills. This distorted the level of trained frequently seen as a problem for acquiring workers across di¡erent chiefdoms. services, attending training opportunities, These experiences indicated the need to or learning from outreach e¡orts. Families plan for services that do not concentrate on seeking treatment for an ill family member urban areas. Possible solutions that our found it di⁄cult enoughto reachthe regional interviewees proposed, included the pro- town for initial treatment, let alone travel- vision of mobile clinics or providing better ling to Freetown for specialist hospital training and logistical support for nurses in treatment where the family would also have the rural PHUs. to continue providing support and meals. Frequent relapses of patients were reported Issue three: collaboration between traditional by families, primarily because of lack of healers and MOHS medication and transport di⁄culties. Like other settings in Africa, traditional healers play a prominent role in providing ‘Tomove with a sick person is not easy, the cost mental health services in Sierra Leone. of feeding, housing and transportation and As well as their historical and cultural other related charges are also barriers.’ importance in tribal society, traditional (Family member) healers were an important resource for help when many formally educated Sierra Being situated even a short distance from Leoneans £ed the country, during and after the regional towns a¡ected programme the war. Additionally, traditional healers outcomes. Community members’awareness are mentioned in the national strategic plan of the counselling centres dropped substan- for mental health services. According to tially if they lived outside the two regional the recently adopted national mental health

policy (MOHS, 2009a), a ‘collaboration with di¡erences between the two approaches. traditional and spiritual healers in the detection, The authors found that traditional healers treatment and follow-up of people with mental were more open to learning new things from disorders will be further explored and researched, the ‘western’ approach and did not believe with a view to de¢ne clear roles and responsibilities their livelihoods to be threatened by the within the next ¢ve years.’ o¡ering of free services by the centres, as Our observations con¢rmed the impact of illustrated in the following: traditional healers in mental health care in the northern provinces. A review of After‘ the training, I now do things different. counselling centre intake records found that Whenever I receive a case of such a nature over 90% of clients received treatment I try, as much as possible, to give courage to from traditional healers prior to coming them, provide food, shelter, and clean them to the two counselling centres. In the mor- instead of discriminating against them, or bidity estimate survey, traditional healers tying them up.Therefore, I made a positive appeared equally sensitised to the preva- change to cure such people. Some with difficult lence of mental disorders intheir community problems, I refer to the centre.’ (Traditional as health workers; the two groups did not healer) di¡er in their community estimates of various psychiatric and substance-related They also showed a high commitment to disorders. The one exception to this was for disseminating all they had learned from psychosis, in which the traditional healers workshops run by the mental health pro- consistently estimated higher numbers. gramme to other healers. Despite similar levels of engagement in the Conversely, medical personnel seemed to community, the two groups appeared to think their knowledge was superior and work independently of each other, and demonstrated less openness to learning traditional healers and community health from, or referring clients to, traditional hea- workers consistently underestimated the lers. At a national mental health coalition number of people being treated by the other conference that the second author attended, group. Both parties felt their own methods a heated exchangebetween the two occurred addressed the real causes of mental health when one traditional healer stated that he problems. A few traditional healers thought diagnosed and treated problems. Medical that medical personnel relied mainly on personnel objected to his use of the term ‘encouragement and prescribing medication,’ ‘diagnose’, which they believed that only they resulting in non lasting treatment, while could use. their way was to try by all means to know Interviewees indicated that the more they the root cause of the problem and ¢nd a knew about the respective skills, expertise lasting solution. In turn, some nurses and approaches of others, the closer they interviewed believed only they addressed could work collaboratively to help clients the real cause of a client’s problem. and families or refer to each other when Both groups expressed a desire to work more appropriate: closely together to help clients. Our observations, however, suggest that more e¡ort ‘Weneed to work as one, as a team, tosolve this will likely be required from the nurses and problem of mental health in the country,tofind community health workers to bridge the a real solution.’ (Traditional healer)

267 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

‘It is very good to work together, to form a big the sta¡ at the counselling centres umbrella ^ nurses, traditional healers [Uni- interviewed emphasised the importance of versity of Makeni] UNIMAK.’ (Nurse) supporting the whole family, as opposed to direct support to clients. Interviewees indicated that collaboration One interesting ¢nding was how the nurses and improved understanding would be adapted their new knowledge to their work. enhanced by the provision of joint training, When asked what they understood by regular meetings, and more discussion. The ‘counselling’, their descriptions were often current programme, however, separated its consistent with western notions of inter- training between ministry of health employ- vention, such as not giving advice, letting ees (nurses, midwives and health workers) the person make his or her own decisions, and community members (traditional or providing encouragement. However, healers, prison o⁄cers and police). Future when giving examples from their actual projects would likely bene¢t from integrating work, they usually described more direct these groups more into its training activities. and less autonomous methods, such as telling their clients exactly what to do: ‘Itell them to Issue four: training and support need to be socially stop taking drugs and to control themselves’, ‘I give and culturally appropriate them a positive solution’ or ‘I show them the right A review of the project’s didactic materials way.’ While this was not what they were provided to professionals and lay persons, taught during the training, it may be and interviews with trainees, indicated that appropriate in the sense that they may have the curriculum of the mental health pro- adapted a western counselling model to gramme and other NGO projects heavily better ¢t into their own cultural ways emphasised the biomedical model. Highly of helping. advanced and westernised counselling The authors concluded that more practice techniques were reported being presented, based research is needed in Sierra Leone especially in the form of brief workshops in order to determine how to adapt inter- by international visitors, which were never ventions that were developed elsewhere, followed-up to determine their e¡ectiveness. often in high income countries, to determine Some topics, such as violence risk assessment what works. The mental health programme and criminal o¡ender pro¢ling, were has recently adopted WHO’s mhGAP as covered more in-depth than was probably its curriculum to assist primary care workers warranted within the social context of Sierra in identifying and treating mental health Leone. Conversely, topics looking at speci¢c care at a local level. Based on WHO social and cultural aspects of mental illness, recommendations, the guidelines should and appropriate treatments for Sierra be adapted to meet a particular setting Leone, were often omitted. A more holistic (WHO, 2010). approach of assessment and intervention Livelihood support post treatment was seemed necessary in order to make future cited, by one third of clients and half of training more relevant. In training, the families interviewed, as important to help importance of social and community maintain improved mental health and aid support and working with families was integration back into the community, but often neglected in favour of an individual said this was not o¡ered. This aspect of the approach. However, in practice, nurses and programme was not successful, as the NGO

tasked with providing access to livelihood made statements suggestive of improved support did not achieve this. perceptions toward those with mental illness, such as: Issue ¢ve: stigma and community sensitisation Stigma remained a problem for the ‘Before Iassociated [mental illness] with evil people treated at the counselling centre spirits, curses or swearing, but now I am able and their families. Some reported com- to know that it is cause by alcohol, drug, stress munity members ‘laughing, shouting, being bad and disappointment’. or rude’ to them. However, an equal number ‘Before this time I was thinking that the client said they were treated well and people were is the cause of the illness, but going through friendly; ‘people feel sorry for me and always pray training, I realise that he is not the cause and andhelpme.’Community members themselves he is not aware of the act (his actions and expressed tolerant views in interviews, illness).’ but when considering the social desirability ‘Now I know it is not caused by demons and of this question and the stigma reported witchcraft, and can be helped.’ by others, this may not have re£ected the reality. This led to a kinder, more humane approach Even among health professionals, there towards those su¡ering from mental remains a stigma. While mentioning how illnesses and a reduction of fear when they would no longer be afraid to approach approaching someone with a mental health those with mental illness, or attribute problem, including: ‘I don’t avoid them now,’ blame to clients for their illnesses, some ‘be friendly with them and encourage them as well,’ still mentioned the more serious cases as ‘I use dialogue, patience, kindness’ or ‘I encourage ‘the crazies.’ Colleagues made disparaging by giving hopes that they will one day make it up comments to nurses about their work with (be ok).’ It was not uncommon for nurses to those with mental illness: ‘now you are one of also mention that they provided food and them.’ These attitudes are re£ected at the clothing.The success of the training and out- national level by the low priority given to reachprogrammesto reduce stigma occurred mental health, the lack of resources and in other settings too, as illustrated below: training in this ¢eld, the restriction of medication access in the provinces, and the ‘For them [mentally ill] not to be left out, delay in adopting the national mental but included.Tospeak to them not harshly health policy. but cool, calm and to cajole them and provide However, providing direct services, com- food, clothing and accommodation.’ (Police munity outreach e¡orts and training appear officer) to have reduced stigma toward those with mental disorders. One aspect of training, Radio programmes were the most successful that was appreciated by most participants, outreach activities in terms of reaching was an overview of di¡erent mental illnesses out and disseminating information to com- and alternative understanding of the causes munity members. At the counselling centre, of mental illness. Many trainees, as well most of the clients interviewed stated as community members, initially ascribed that any negative attitudes towards them the causes as ‘evil spirits, fetishes, curses and changed for the better after they had witchcraft.’ After receiving training, nurses received support and had recovered.

269 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

Issue six: alcohol and substance abuse health, but understanding the actual relationship of the con£ict to mental illness ‘In 2009,I discovered he is a cocaine and mar- has been challenging. Additionally, there is ijuana addict, intoxicating himself.That your considerable debate about the relationship son, who you have educated to college level, is between armed con£ict and mental health, doing such harmful acts is really frustrating.’ even in the global literature (Miller & (Father) Rasmussen, 2010; Summer¢eld, 1999). In 2002, one year after the end of hostilities, Substance abuse appears to be of great the WHO’s pilot epidemiological survey concern, with many community members found that Sierra Leone corresponded to citing it as the number one cause of mental the expected rate of mental illness, (approxi- illness. Media reports by television and radio mately 3% of the population) and that this journalists appear to have heightened did not appear connected to the war (Jensen, communityawarenessaboutsubstanceabuse. 2002; World Health Organization, 2012a). The growing problemof illicit drugs, particu- When asked what they believed caused men- larly marijuana (djamba), and alcohol were tal illness, only three out of 28 clients and cited by community members, families, families interviewed thought their problems police, the former psychiatrist, and other were linked to the con£ict. The remainder agencies as a major cause of mental illness. said their illness started after 2003, with the Both traditional healers and PHU health majority citing 2007 ^ 2011. Most, including workers estimated that alcohol, marijuana, community members, attributed the causes and poly substance abuse disorders occur at of mental illness to drugs,‘evil spirits’, fetishes, least twice the rate as other mental disorders ‘frustration or disappointment’, family problems withinthecommunity.Aboutathirdofclients and poverty. Because of the signi¢cance at one counselling centre had substance of this issue, one of the supplementary abuse noted in their records. However, there questions for interviewers was to ask about appeared to be confusion about the relation- the impact of the war, if interviewees did ship between substance use and other not spontaneously mention it. This did not disorders. Many of the centre clients were result in signi¢cant a⁄rmative responses. diagnosed with‘drug induced psychosis,’although In the review of 270 counselling centre itisunlikelythatthecounsellorsdistinguished records, only 5% of patients reported having drug intoxication from psychosis. war related trauma. The clinicians at the Illegal drugs are more available and easily counselling centre were not only trained accessible sincethewar,and interviewees said in trauma related issues, but also had peer pressure and frustration due to unem- signi¢cant personal tragedies related to the ploymentwereleadingtoincreaseduse.These war. It is unlikely that they would have issues warrant further study to ascertain to minimised war related mental illness. what extent drug abuse is actually leading to Finally, in the morbidity survey, post- mental illness and what e¡ective treatments traumatic stress disorder was the lowest esti- and interventions might be applied. mated disorder, both in the community and in treatment by traditional healers and Issue seven: the war and mental illness community health workers. Numerous NGO reports on Sierra Leone Doubtless, there is much continued su¡ering recite the impact of the war on mental as a consequence of the con£ict in the

northern region (Mughal, 2012), with the this was the case in Sierra Leone, and other death of loved ones, displacement, and the research does not indicate a correlation destruction of property, but this evaluation between mental illness and committing adds to an increasing amount of evidence crime or becoming involved in con£ict. from other studies to suggest that war does Programme goals and outcomes were not not necessarily lead to an increase in mental always clear or achievable, and the authors illness. In addition, issues of truth and felt that future programmes would bene¢t reconciliation, and rebuilding community from clearer strategic goals with realistic, cohesion may be more e¡ective than coun- concrete and measurable objectivities that selling programmes in addressing the re£ected the mental health needs of the impact of war (Betancourt & Williams, communities being served. 2008). Fambul Tok (‘Family Talk’; Terry, At the administrative level, there were 2011)is another interesting example of recon- tensions between some of the ¢ve partner ciliation implemented by Sierra Leoneans organisations and the authority of the ‘lead’ themselves. agency was not always respected.There were also sta¡ tensions within the individual Issue eight: programme management organisations and managing sta¡ behaviour Our ¢ndings indicated that program became di⁄cult. Numerous accusations management and administration had a of discrimination, corruption, favouritism, signi¢cant impact on aspects of the mental misappropriation of funds, and other health programme. Despite the large num- misconduct were made.The veracity of these ber of NGOs that worked in Sierra Leone accusations was often impossible to ascer- and employed host country nationals, tain, but the damage was evident. At one numerous problems related to day-to-day agency, only one person remained working management and record keeping were after two years. Cursory e¡orts to improve observed. The likelihood of ¢nding person- employee and management relations were nel who had previous employment history attempted, such as creating activity and ¢eld in development organisations was good, report forms and conducting weekly sta¡ but often found that sta¡ lacked skills to meetings, but they were not maintained. perform some tasks, such as writing reports, Little monitoring or evaluation was done by liaising with other agencies or representing any of the partner organisations. Annual the programme at a senior level. No sta¡ reports submitted to funding agencies member indicated an interest in document- often times simply repeated information in ing nor contributing to a paper setting the original proposal, without updating out the programme achievements, their progress made on desired outcomes or com- views or lessons to be learned from their municating current needs and priorities. experiences. Key documents were lost, including the At the proposal level, the authors noted training course curricula, making attempts unfounded assumptions about humanbehav- to cross check information and employ iour, rather than formal evidence, guided triangulation methods di⁄cult. Documents the programme objectives. For example, that did exist were di⁄cult to ¢nd when one stated project goal was ‘to reduce criminality preparing our evaluation. and con£ict caused by those with mental health Nurses, traditional healers, and other problems’. No evidence existed to support stakeholders were rarely contacted after the

271 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

workshops, despite expressing interest. of important records and data. Sta¡ skills This would have reinforced learning and should be more closely audited and shortfalls helped newly trained personnel with the should be addressed by providing the considerable ongoing challenges of the work. necessary supervision, training, and mentor- These included situations where clients ing to assure that support sta¡ succeed in were di⁄cult to manage, time consuming, their own chosen profession. reluctant to comply with taking medication or had no family support, the high relapse Strengths and achievements of rate, ‘the di⁄culty to convince them of the cause of the programme mental health problems, for them to accept that it ‘Before, people pointed fingers at me because is not caused by witchcraft or evil spirits and is I was not well. Now I want them to point curable’, and the lack of adequate facilities fingers at me because I am well and I hope to and medication. Almost all said they needed be a good example to them, showing that you follow-up support and that it had been can recover.’ (Male client, aged 20 years) promised, but was not forthcoming: ‘since it’s been a long time without UNIMAK getting back to us, we want to know if you are not interested in Despite the di⁄culties we saw at the us any longer?’ organisational level, these issues are not Any research that was done was not uncommon in similar studies in Africa incorporated into programme planning or (Hanlon, Wondimagegn & Alem, 2010) and evaluation. For example, a morbidity survey it was clear that most stakeholders bene¢ted to determine estimates of mental disorders from the various activities. The family in the northern provinces was conducted at member of one client stated: ‘he is now feeling the beginning of the project. Approximately better...it has helped him to cope up and improve a dozen personnel were trained in the on his health and behaviour.’ Another said: ‘we administration of a questionnaire and trans- hoped treatment would bringback his and our pride: ported to 90 PHUs to survey community this was achieved 80% positive’. Two clients health workers and traditional healers. who had received treatment and recovered The results of this study were never used, said: ‘now I can sleep peacefully without any com- nor did the sta¡ members attach any plaint and no more cold infection. Fantastic!’ and importance to the ¢ndings. ‘it changed my thoughts and ways of doing things.’ In LMICs that do not possess su⁄ciently The strengths we saw came in the trained mental health service providers, it deliverables, especially in e¡orts to provide is important for NGOs to determine the level support/counselling and sometimes medi- of skills for local host candidates to work cation to those who needed it, reaching out as senior administrators and managers, and raising awareness in the community which are specialist positions in their own through radio messages and o¡ering train- right. Similar projects should anticipate its ing workshops to nurses, traditional healers, major sponsors providing greater oversight, police and prison sta¡: guidance and support of personnel to assure smooth operations. A realistic, work- ‘Youlearn how to refer them and encourage able and acceptable system of documen- them to attend clinic, to be attentive to them, to tation and communication is also needed, take care of them when they are in distress. plus a method for duplication and back-up Specifically I learnt how to communicate with

them, now I am not afraid of them.’ (Police Although we do not wish to minimise the officer) impact of the war, programmes need to now go beyond the often quoted ‘trauma Through the training, nurses became related issues pertaining to the war’as a rationale more aware of the pressures on family for providing mental health services. Mental members andtheir need, too, for encourage- health problems are far wider reaching. ment and support. Examples of how they Our ¢ndings indicate that future pro- incorporated training into their work grammes and services need a greater included giving family members ‘words of emphasis on reducing stigma, providing encouragement, condolence and hope,’ ‘telling education and information about mental ill- families it’s not their fault,’ ‘not be harsh with the ness, and focusing on culturally appropriate ill person because they are not with their normal community and social support for those senses’ and ‘o¡ering advice on how to manage su¡ering from mental illness, and their their stress and problems.’ The authors found families. These programmes need to be all these examples were con¢rmed in inter- guided by, and contribute to, government views with family members and were much policy and address the needs of all those appreciated. su¡ering from the wide diversity of mental At the national level, the mental health health problems. programme raised the pro¢le of mental The ¢nal words come from a client who health concerns by becoming a partner at received support from the mental health national strategic level, contributing to the programme: government mental health strategic plan andthe mental health policy.It was an active ‘Iam feeling better, and I hope medication, member of the Mental Health Coalition, counselling, love, encouragement, and income an important lobbying and advocacy group. will help me stay better.Thanks a lot to the It also organised and co-ordinated activities mental health organisation, and its donors annually for World Mental Health Day, the and workers. And alsoto community members.’ last of which commemorated the adoption of the national policy. The programme was also successful in becoming a principal part- References ner in future mental health capacity projects Abdullah, I. (1998). Bush path to destruction: through its role in Enabling Access to the origin and character of the Revolutionary Mental Health. Finally, successful training of United Front/Sierra Leone. The Journal of 22 psychiatric nurses illustrated a long term Modern African Studies, 36(2), 203-235. impact of the CAFOD project that was never originally planned. Asare, J. & Jones, L. (2005). Tackling mental health in Sierra Leone. British MedicalJournal, Conclusion 331, 720 http://dx.doi.org/dx.doi.org/10.1136/ bmj.331.7519.720 -b. ‘We are glad that you and your organisation have started visiting, you are warmly and Betancourt, T. S. & Williams, T. (2008). Building happily welcome as we believe, with time, an evidence base on mental health interven- yourorganisation will work in this community tions for children a¡ected by armed con£ict. and other communities.’ (Family member) Intervention, 6,39-56.

273 Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Mental health capacity building in northern Sierra Leone: lessons learned and issues raised Intervention 2013, Volume 11, Number 3, Page 261 - 275

Betancourt,T.S., Brennan, R.T., Rubin-Smith, J., Lancet Global Mental Health Group (2007). Fitzmaurice, G. M. & Gilman, S. E. (2010). Scale up services for mental disorders: a call Sierra Leone’s former child soldiers: a for action.The Lancet, 370,1241-1252. longitudinal study of risk, protective factors, and mental health. Journal of the Leedy,P.D.&Ormrod,J.E.(2005).Practical AmericanAcademyofChild&AdolescentPsychiatry, research: Planning and Design (8th ed.). Upper 203,49. River Saddle, NJ: Pearson Prentice Hall.

Bolten, C. E. (2008).‘‘The place is so backward’’: McKay,S.,Veale, A., Worthen, M. & Wessells, M. Durable morality and creative development (2011). Building meaningful participation in in northern Sierra Leone (Doctoral dis- reintegration among war-a¡ected young sertation). Retrieved from http://deepblue.lib. mothers in Liberia, SierraLeoneandnorthern umich.edu/bitstream/handle/2027.42/58384/ Uganda. Intervention, 9,108-124. cbolten_1.pdf. Miller, K. E. & Rasmussen, A. (2010). Mental health and armed con£ict: The importance of Braun, V. & Clarke, V. (2006). Using thematic distinguishing between war exposure and analysis in psychology. Qualitative Research in other sources of adversity: A response to Psychology, 3, 77-101. Neuner. SocialScienceandMedicine,71,1385-1389.

Burman, M. E. & McKay,S. (2007).Marginaliza- Ministry of Health and Sanitation. (2009a). tion of girl mothers returning from ¢ghting Mental health policy. Freetown, Sierra Leone: forces in Sierra Leone. International Nursing Government of Sierra Leone. Review, 54,316-323. Ministry of Health and Sanitation. (2009b). Denov, M., Doucet, D. & Kamara, A. (2012). National health sector strategic plan, 2010^2015. Engaging war a¡ected youth through Freetown, Sierra Leone: Governmentof Sierra photography: Photovoice with former child Leone. soldiers in Sierra Leone. Intervention, 10,117-133. Mughal, U. (2012). Rehabilitation of post- Hanlon, C., Wondimagegn, D. & Alem, A. (2010). traumatic stress disorder patients through Lessons learned in developing community the Mental Health, Behavioural Change, and mental health care in Africa. World Psychiatry, Social Inclusion Programme in Sierra Leone 9,185-189. (Unpublished master’s thesis). University of Sussex, Sussex, United Kingdom. Harris, D. A. (2007). Pathways to embodied empathy and reconciliation after atrocity: Pe¤rez-Sales, P., Fe¤rnandez-Liria, A., Baingana, F. Former boy soldiers in a dance/movement & Ventevogel, P. (2011). Integrating mental therapy group in Sierra Leone. Intervention, health into existing systems of care during 5(3), 203-231. and after complex humanitarian emergencies: rethinking the experience. Intervention, 9,345- Jensen,S.B.(2002).Mental health and substanceabuse 358. in post con£ict Sierra Leone. Freetown, Sierra Leone: World Health Organization-Sierra Stark, L., Alastair,A., Wessells, M. & Boothby,N. Leone. (2009). Developing culturally relevant

indicators of reintegration for girls, formerly use disorders in non-specialized health associated with armed groups, in Sierra Leone settings. Retrieved from http://www.who.int/ using a participative ranking methodology. mental_ health/evidence/mhGAP_intervention_ Intervention, 7,4-16. guide/en/index.html.

Summer¢eld, D. (1999). A critique of seven World Health Organization (2012a). WHO assumptions behind psychological trauma proMIND: pro¢les on mental health in programmes in war-a¡ected areas. Social development: Sierra Leone. Retrieved from Science & Medicine, 48,1449-1462. http://www.who.int/mental_health/policy/ country/sierra_leone_country_summary_2012. Terry, S. (Director) (2011). Fambul Tok [Motion pdf. picture]. USA: Catalyst for Peace. World Health Organization (2012b). Zero United Nations Development Programme (2007). draft global mental health action plan 2013- Human Development Report 2007/2008. 2020. Retrieved from http://www.who.int/ Fighting climate change: human solidarity mental_health/mhgap/mental_health_action_ in a divided world. Retrieved from http:// plan_EN_27_08_12.pdf. hdr.undp.org/en/media/HDR_20072008_EN_ Complete.pdf. Jane Shackman, BA is a social worker, based in Swindon, United Kingdom. She works as a WorldHealthOrganization(2008).WHOcountry trainer and consultant in trauma, crisis and cooperation strategy 2008^2013, Sierra Leone. victim support. Retrieved from http://www.who.int/country- email: [email protected] focus/cooperation_strategy/ccs_sle_en.pdf. Brian Price, PhD, is with the Department of Counseling of the Adler School of Professional World Health Organization (2010). Intervention Psychology in Chicago (IL), United States of guide for mental, neurological and substance America.