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Cordaid NL
Health care Democratic Republic of the Congo

How traumatic is trauma counselling in eastern Congo?  “They can’t afford a burnout, they just carry on.”

Taking good care of survivors of sexual violence is crucial. It is also burdensome. Especially in Eastern Congo. How do caregivers deal with that? Who takes care of them? We asked clinical psychologist Jitske Rullmann, who trained caregivers in Bukavu. “You need a mental fire suit to protect yourself,” she says.

Before we hear from Rullmann, let’s first dive into the situation in the eastern provinces of the Democratic Republic of Congo (DRC). The situation has been alarming for decades. Dozens of armed groups commit atrocities against the population. Millions of people end up being displaced. In most cases, those in need of care often do not find it. Those who have been wronged see impunity. And the UN peacekeeping mission Monusco is failing to curb the violence.

Tip of the iceberg

In this humanitarian crisis, people, particularly women and girls, face sexual and gender-based violence. Despite efforts by the Congolese government to map SGBV, no one really knows how big this crisis within a crisis is. Collecting data is challenging in conflict zones that are barely digitised and difficult to access. Moreover, stigma and shame often prevent survivors from reporting incidents or from seeking care at a health centre, if there is one.

“The data collected from the Ministry of Health are only the tip of the iceberg,” says Christina de Vries, health expert at Cordaid. “In the eastern Congolese provinces like North and South Kivu, we think the rate of sexual violence is about 10 times more than officially recorded.”

“People are exposed to many traumatic experiences. Some are conflict-related, some aren’ts.”

That estimate is based on Cordaid’s years of collaboration with Congolese hospitals and care centres, both in urban and rural areas. Improving and digitalising health information systems is an important part of that collaboration. Only with a strong health information system can we really get an idea of the true scale of sexual and gender-based violence.

One-stop centers for survivors of sexual violence

The Kivu provinces, which lie on the border with Burundi and Rwanda, are an epicenter of gender-based violence. This is also reflected in the government’s SGBV figures. When it comes to the number of SGBV survivors using health services in 2022, those two provinces have rates well above the 24 other provinces.

It is in this epicentre that Cordaid, together with HEAL Africa, is funding and training eight district hospitals in setting up and managing so-called One-Stop Centres. We also supply emergency medicines to survivors of gender-based violence. And work in collaboration with hospitals and health centres to strengthen and digitalise health information.

Survivors of sexual and gender-based violence can go to One-Stop centres for much more than medical help. “A team of psychologists, nurses, social assistants and legal aid workers provide professional care there, all under one roof. There is medical and psychological care. They can also help survivors find a place in a safe house. Those unsure about reporting to the police are guided in doing so. Those who can no longer make ends meet get help in finding a source of income,” de Vries explains.

These ‘all under one roof’ centres work together with some 24 smaller health centres in the region. Together, these health and One-Stop centres cover an area inhabited by one and a half million people.

Care for the caregivers

Another partner Cordaid works with is ARQ Nationaal Psychotrauma Centrum in the Netherlands, where Jitske Rullmann works as a team leader of the Sexual Violence and Exploitation team. She went three times to Bukavu, the provincial capital of South Kivu. There, she gave trainings and workshops to psychologists, nurses, and social workers working with survivors of sexual and gender-based violence.

Working in conflict zones is not new to Rullmann. She previously worked for Médecins Sans Frontières in the DRC and the Central African Republic. In the Netherlands, she works with survivors of human trafficking as well as refugees and asylum seekers who suffer from trauma.

Jitske, what are the traumatic events people are most confronted with in eastern Congo?

People are exposed to many traumatic experiences. Some are not directly conflict-related, such as domestic violence, or road accidents. Robberies, looting, murder, having to flee – these are conflict-related incidents. There is a constant sense of insecurity. Who is your friend, who is your enemy? And, not insignificantly, there is a large active volcano. All these events and circumstances cause trauma.

In rural areas, the risks are even higher than in cities, where there is still a degree of protection. Especially when it comes to sexual violence.

What kinds of sexual violence?

First, there is a lot of sexual violence within relationships. In terms of gender equality, there is a lot of work to be done. Sexual violence is also a consequence of poverty and the instability that has been going on for decades. Poverty and social unrest cause feelings of powerlessness and insecurity and frustration.

Street scene in Bukavu
Street in Bukavu. Image: Jitske Rullmann

Sexual violence is also used as a weapon of war, deliberately deployed to disrupt whole families and communities, and to sideline women.

What professional help is available to those affected?

Partly due to Nobel laureate Denis Mukwege, sexual violence in eastern Congo is getting a lot of international attention. There are also many organisations supporting healthcare providers, from small infirmaries to larger hospitals. There are reference pathways, to ensure that survivors are referred and find their way to that care, even in remote areas. More and more people are finding their way to care. But the reality is still that most are not getting the help they need. Not even psychological help.

Why is that?

Because of the huge stigma attached to being a survivor of sexual and gender-based violence. That makes it so difficult to step out and seek help. Nobody supports them because people often blame the victims for what happened to them.

“‘Just deal with it and move on’, that is how many medics talk about symptoms of mental distress.”

In addition, you see that survivors often don’t realise they have symptoms of mental distress. So why would they ask for mental health care? If they go to a hospital, it is for medical complaints, for headaches or back pain, or if they are pregnant. Research by Cordaid, Health Africa, and ARQ International shows that most survivors did not initially report feeling gloomy or anxious. But after being helped at a One-Stop Centre, they found that they had benefited especially from psychosocial support, such as explanations of grief and anxiety. Only then do they recognise and acknowledge the mental burden they carry and also know that it is something you can ask help for.

Could it also be that people in eastern Congo process shocking experiences differently from, say, the Netherlands?

They do. In our Western way of thinking about and treating trauma, we quickly turn to the DSM [diagnostic and statistical manual of mental disorders] classification system and immediately offer post-traumatic stress treatment for people who show symptoms of PTSD. In crisis areas in the Central African Republic, DRC, Rwanda, and Uganda, I have seen that there are also very different ways to move on and look to the future again. Such as being well-embedded in the community, feeling useful, and being able to earn a living.

We observe that people in Eastern Congo who experience shocking things often think ‘let’s not dwell too much on the painful past’. In the West, we are quick to call that ‘avoidance’, and label it as something that is part of a post-traumatic stress disorder. But in the reality of the countries I mentioned, this ‘avoidance’ is sometimes a coping mechanism that works.

With ARQ International, you and your colleague Linda Verhaak have been training caregivers who themselves trained staff at the One-Stop Centres for survivors of sexual and gender-based violence in North and South Kivu. How did that work?

Because we wanted to do something sustainable, we have trained doctors, psychologists, and social workers in the care of survivors of sexual violence, who are themselves trainers and in turn pass on their knowledge to the teams they supervise. This is how that knowledge transfer goes from the larger to the smaller care institutions. And we provided training on how to stay healthy as a caregiver.

What was the biggest need the participants had?

Above all, they wanted more systematic guidelines across all One-Stop Centres. There are protocols from the Ministry of Health, but they are pretty basic and not focused on dealing with trauma-related symptoms.

How do you recognise a patient with PTSD? How can you still ‘read’ someone that wishes not to express her- or himself? Which complaints can you address in a smaller centre, for instance as a psychosocial worker, and when should you refer? The degree of suicidality and dissociation play a role in this, for instance. To get a good handle on this, we developed questionnaires together with our Congolese counterparts. These were also translated into Kiswahili.

“Caregivers go through shocking experiences themselves, and are simultaneously helping others to cope with shocking events.”

It is important to know that the most specialised mental health care, psychiatric help, is virtually non-existent in eastern Congo. There are no psychiatrists. In their absence, medical doctors prescribe psychopharmaceuticals, if there are any.

Are those the biggest gaps in the mental health system in eastern Congo: specialised care and drugs?

That and stigma. Because of stigma, those in need of care do not even find their way to professional help. In addition, the whole healthcare system is unstable because there are no permanent contracts. Staff retention is a big problem. Sometimes at follow-up trainings, we see that most staff have already left.

Within this fragile healthcare system, mental health care is very much neglected. For most, mental health care is an appendix to medical care.

So, mental health is looked down upon, not only among the general population but also within the healthcare system?

Definitely. ‘Just deal with it and move on’ is still how many medics talk about symptoms of mental distress. At staff meetings in hospitals, psychologists are often skipped. You also see this in Dutch hospitals by the way.

‘How to take good care of yourself’,  was another theme of your training sessions. Why is this so important?

People who help others to cope with trauma often don’t think about themselves. Meanwhile, all day long, they are dealing with the kind of gruesome realities any other person prefers to avoid. Without handling that burden well, you collapse, and you can’t help others. This is true for trauma caregivers anywhere in the world.

people in a room
Jitske Rullmann during a training session with caregivers in Bukavu. “Here, I am explaining the ‘window of tolerance’, the ideal tensity level within which one functions best. If you exceed the top level (stress), then you are too tense and you can’t reason well, if you’re below the bottom line (falling asleep, drug use) you can’t function well either.” Image: ARQ International

But in eastern DRC, the challenges are particularly big. Conflicts in society cause ethnic divides. This trickles through in all aspects of life, also in health facilities. It causes mutual friction and distrust among staff. In addition, like everyone else, staff face looting and armed violence. Because they, unlike many others, have a job and an income, they run more risks. On top of that, most of them work far away from their families, which is also a huge stressor. And they too live near the Nyiragongo volcano, which could erupt at any moment.

In short, caregivers go through shocking experiences themselves, and are simultaneously helping others to cope with shocking events. They also need to provide support to colleagues who risk collapsing. If mental distress prevents me from doing my job in the Netherlands, I go to another psychologist at another institution. If needed, I take sick leave for a while. In eastern Congo, in terms of professional help, you can only fall back on your own team, which is already overstretched. Taking a break because you have burnout is out of the question. They can’t afford that, there isn’t any safety net. They just carry on.

Do they clench their teeth and just move on, even if they have burnout symptoms?

They stretch their limits a lot further than we are used to in the Netherlands. Some, especially medics and nurses, certainly do have symptoms, but they refrain from labelling them as a problem. Think of insomnia, becoming emotional quickly, feeling numb. If you have that, you can no longer function optimally as a caregiver. It is an ethical duty as a caregiver to also take good care of yourself.

And how do you help them do that?

For instance, with tips on how to protect yourself in conversations with patients. Empathic people, which caregivers often are, often mirror the behaviour and language of the person sitting in front of them. In doing so, they also internalise the story, its fears, and grief. A tip is to be aware of this and to distance yourself. To listen very carefully, but not to frown when the patient frowns, for instance. Just like a fireman puts on a protective suit to fight a fire, we can learn to wear a psychological fire suit to protect ourselves.

Two white psychologists from a wealthy and stable country training Congolese experts in crisis zones, isn’t that a bit weird?

When you put it that way, yes. And there are uncomfortable sides to it. We mainly want to show participants how we, in the Netherlands, deal with trauma and PTSD for people who come from other countries, often from conflict areas. It is an exchange. We are not going to tell Congolese caregivers how things should be done in eastern Congo; they have that expertise themselves, not us.

Let’s turn it around then. What did you learn from Congolese aid workers?

To look even more at the context a ‘survivor’ is in or comes from. Here in the Netherlands, we look at how complaints fit into the DSM and provide the treatment that goes with it. In Eastern Congo, they don’t look at the DSM, they look at the context of why someone feels bad and what factors they can influence to make someone feel better.

“Community support is much less well-developed in the Netherlands than in the DRC. We can learn a lot from that in the Dutch healthcare system.”

Participants of the ‘how to stay healthy yourself’ training developed questionnaires to properly answer the question ‘how healthy do I feel?’. It showed they attach much more importance to things that we sometimes overlook. For example, whether someone can still smile. They use that as a sign of mental health, of resilience. Or they would look at the state of someone’s yard, to find out more about that person’s mental health. I don’t see a psychologist or psychiatrist in the Netherlands doing that easily. The value of human and social contact plays a bigger role in healthcare than in ours.

I learn from their incredible resilience. I focused a lot on the insecurities and risks they face. Not only perceived but real ones, like shootings or volcanic eruptions. They just shrugged their shoulders and said ‘well, that’s part of life’.

I learn from them that we are sometimes overprotective in our Dutch approach. A person can bear more than we tend to think.

Why couldn’t we invite Congolese caregivers from the One-Stop Centres to give training courses in the Netherlands?

We should and I hope they come. Especially to teach us the value of community-based mental health care. In the Netherlands, care is very formalised, and much emphasis is placed on specialised second- and third-line care. Community support is much less well-developed in the Netherlands than in the DRC. We can learn a lot from that. Also to better link community care to our formal healthcare system.

To conclude, what about your own ‘mental load’?

That’s a wicked question. The suffering of patients, the painful details, I have learned to deal with that well. But as a team leader at ARQ, I have a fragmented job with a mailbox you’d rather avoid. That weighs heavily at times.

What also weighs on me is the injustice I see in the Netherlands. I work with asylum seekers and victims of human trafficking. Seeing patients suddenly being transferred, yet again, to some godforsaken place, or when someone who clearly qualifies for asylum is not granted it, can really demoralise me.

And you can’t really go to a doctor or psychologist to address a bad case of injustice, can you? But that’s a whole different story. Thank you for this conversation!


Cordaid’s support to the One-Stop Centres in North and South Kivu is part of a programme that is financed by the Dutch ministry of Foreign Affairs.