Beni — Amuri Masandi, a major in the Congolese army, was in the forest during an operation against an armed group when he started suffering from insomnia and nightmares, and exhibiting a troubled demeanour. Suspecting he had malaria, his colonel sent him to Goma to be treated at the hospital there. When that didn't work, his wife took him to the Centre for the Protection of the Destitute and Mentally Ill, known by its French acronym CEPIMA, the only mental health clinic in Beni Territory, in North Kivu province. There, Masandi was treated for depression and psychosis with a heavy dose of psychotropic medication and regular counselling sessions, as well as multivitamins for his general well-being.
"I was very aggressive. I came here and wrote pages and pages of things I don't even remember, and then tore them up," Masandi told IRIN. "After two months of treatment, I started to feel better. I eventually went back to work."
Masandi is one of several army officers being treated at CEPIMA for psychological problems. Out of 22 patients from Beni Territory currently at the centre, 12 are being treated for symptoms of trauma, which nurses attribute to their experiences in the ongoing conflict in the North Kivu region. Cases related to drug addiction and unemployment are also common.
According to a 2014 study by Médecins Sans Frontières, "mental health needs run high in the conflict affected areas of North Kivu," with many patients displaying post-traumatic symptoms including "constant fear, flashbacks, insomnia, suicidal thoughts, feelings of despair, heart palpitations and breathing difficulties."
More than 80 percent of 600 respondents in an assessment of the mental health needs of internally displaced people in Bibwe in North Kivu said they were victims of violence, and 90 percent said they had "witnessed an act of violence."
Despite the high needs, provision of mental health services is limited. Less than one percent of the government's health budget goes towards it. There are six mental health hospitals in the entire country and only one mental health outpatient facility, in the capital, Kinshasa. In North Kivu, a province with a population of more than six million inhabitants, the only mental health centre, Tulizo Letu, is situated in the bustling hub of Goma.
Smaller private clinics like CEPIMA struggle to stay afloat, depending on contributions from donors and patients' relatives to survive. The centre provides a welcome refuge for those who have mental health difficulties, but staff are required to administer treatment, including medication, for which they have not been fully trained.
Lack of understanding, training
Masandi, the major, said he was taking seven to eight pills, three times a day. "That seems like a very high dose of medication," said Benoit Ruratotoye, who has a doctorate in clinical psychology and is the managing director of a private training centre, the Goma-based Institute of Higher Education in Mental Health.
"CEPIMA is really doing the best they can, but in fact only psychiatrists should be administering medication and it's not always required," Ruratotoye told IRIN. "Most mental health professionals in the country are trained in general health and don't have in-depth knowledge. When you compare with other countries, the quality of care here is not good."
In addition to the scarcity of service provision, there is also a prevailing social stigma associated with mental health problems. When confronted with symptoms of mental disorders, many believe them to be associated with witchcraft and sorcery and rather than seek medical treatment, they turn to traditional healers.
"Although educated Congolese will laugh if you ask them if they believe in witchcraft, this is the first resource they will go to before coming to the hospital," said Charlotte Sabbah, a mental health supervisor with MSF who worked in South Kivu.
People with mental health illnesses also regularly visit pastors. At CEPIMA, a pastor is part of the regular staff and prays for patients once a week.
Staff at CEPIMA try to spread messages on the radio, in churches, and among state authorities to educate the population about the causes and factors of mental illnesses, including the impact of unemployment and domestic conflict. "We talk about avoiding drugs and alcohol, but also about how to recognise the signs of mental illnesses so that people understand," Moise Muhindo Ighana, a nurse at CEPIMA, told IRIN. "Since then, we've seen many more people coming for consultations."
François Polepole Maheshe, a psychiatrist who returned to Congo after training in Senegal, believes more needs to be done to change attitudes.
"People do understand that the conflict in this area has an impact on mental health. At the same time, paradoxically, there is a lot of stigma," he told IRIN. "As long as they don't understand that mental health problems can affect anyone, the dignity of the mentally ill will not be respected. In Senegal, I would see someone leaving the hospital after treatment and the same day he would get married. The understanding of the population is very different. I would like to see that here."
Maheshe added that effective medical approaches to mental health needed to be more holistic, taking into account socio-cultural factors and involving the families of patients.
Despite the obstacles, those working in the sector are determined to improve the outlook for mental health patients.
Ruratotoye's institute in Goma has developed a programme to train nurses specifically on mental health and offers a diploma in psychosocial counselling and a Bachelors degree in clinical psychology.
In collaboration with an NGO specialising in gender equality, the institute has developed another methodology called Living Peace, which uses group therapy and psychosocial support to address the trauma associated with conflict in North and South Kivu. Ruratotoye said the group therapy approach works well in a place where there are almost no trained counsellors, psychologists, or psychiatrists.
During sessions, facilitators try to address the personal affects of trauma and also bring communities together "in a process of social restoration," with a particular focus on men and boys.
"What we do enables people to express themselves," said Ruratotoye.
Such initiatives, however, are rare and dependent on outside funding. Living Peace, for example, is supported by the Dutch foreign ministry. The nurses at CEPIMA are constantly appealling for support from outside organisations. Given the paltry budget allocated for healthcare across their vast country, they believe they have no other choice.
The psychiatrist, Maheshe, said that if more foreign funding could be secured, mental healthcare could be provided for free.
However, he was quick to point out that this was not a long-term solution. "The state also needs to be [involved]," he said. "We need to write laws for the protection of the mentally ill. In Senegal, the entire ambiance is different because the state is involved in the sector. We need that here too."
Edouard Byenda Bakare, a mental health expert from the Congolese health ministry, agreed. "Having foreign partners is not sustainable," he told IRIN. "They come, put in place their projects, and then leave."
But his admission of the limits of state involvement highlighted the Catch-22 facing efforts to turn mental health in Congo around.
"If the state invested, it would be good," he said. "But the budget is tiny and the difficulties huge. So the only way we can put in place any developments is with foreign partners."
Reporting for this story was supported by the International Women's Media Foundation