'What shall I tell my child?'

Jemma, I'm visiting Rwanda for the first time and it's an incredible experience. How did you come to be in Rwanda?

Rwanda is an amazing country and has come so far in the 21 years since the genocide. I trained as a Clinical Psychologist at University College London, and initially came to Rwanda with the intention of being here for six months. Rwanda has made a great impression on me - I've now been living here for five years!

It's inspiring to see what psychology has to offer in the aftermath of terrible events such as the Rwandan genocide. Thank you for letting me visit Survivors Fund (SURF). Can you tell me more about SURF?

It's a charity established by Mary Kayitesi Blewitt, OBE. Mary is a British woman of Rwandan origin, who lost 50 members of her family during the genocide. She set up the organisation to support survivors, offering a range of services from education to employment, legal rights to income generation, healthcare to housing.

Like many people, my perceptions of the country have been shaped by lasting images of the 1994 genocide. Can you explain the scale of what happened?

The ethnic killing of Tutsis was on an unimaginable scale, and it's estimated that between 800,000 – 1,000,000 people died in 100 days. The violence was widespread and intimate - neighbours attacked and killed their neighbours. Rape was also a feature of the genocide and it's estimated that 250,000 to 500,000 women were raped as a way to further destroy communities, cause maximum psychological damage and deliberately infect women with HIV. Many became pregnant as a result of the rape. The numbers of children born due to rape is thought to be between 10,000 and 25,000 but no-one knows the exact figures because of under-reporting.

Many women felt unable to speak about what happened to them because of shame and social stigma. The impact of rape is multiplied if a woman becomes pregnant, and the destruction of the social fabric here robbed many of the support they needed to rebuild their lives; many people lost relatives, friends and other sources of support.

Whilst there's a human rights and legal literature around gender based violence and rape in war, there's less about the psychological impacts upon women. And even less about the impact on children of rape survivors. It was the work of Jonathan Torgovnik, a photojournalist, who really started the conversation about this hidden issue in Rwanda.

What are the effects of these experiences on women?

There is a literature that shows rape survivors can face unwanted pregnancy, gynaecological injuries, sexually transmitted infections, post-traumatic stress disorder and other psychological problems, including suicidality. The trauma can continue for years. Pregnancy as the result of rape has been described as a 'living reminder' of trauma. Understandably, it can really harm the bond between the child and mother. We know that some women died by suicide; some had terminations; some carried the children to term, but gave the children away. Others decided to keep the children.

Many women who kept their babies had lost many or all of their relatives. Others have struggled to keep positive relationships with their families because of keeping the child. There are instances of women being disowned by family because they chose to keep 'a child of the killers'.

The child may be the only thing that they had left, and Rwandan culture holds children in high esteem; for these women, there seems to have been some psychological reframing which helped them keep their babies. Faith and hope are important aspects of Rwandan society, and this may have been a factor for those women. I believe we need more research to better understand the psychological responses that women experience to what has happened.

How does it affect the children?

There's an even smaller literature on mother-child experiences for rape survivors. There's evidence that children born of wartime rape have increased vulnerability to poverty, social rejection, poor mental health and identity problems. They are at risk of infanticide, neglect, physical and emotional abuse, stigmatisation, social exclusion or abandonment. And yet, there's been little follow up of these children, probably due to social taboo and shame.

How has SURF tried to support these women?

SURF initially offered practical help. It's striking that many have had to continue living in communities alongside the men who raped them. They've had to raise their child in the same community where they were victimised. The issues are huge, but initially the help requested by the women was practical – they wanted financial assistance so their children could go to school.

This support gave women hope that their child could find work in the future, and care for themselves and their mothers into old age. For women who had remained married, or had wed later, the cultural assumption is that husbands will not usually financially support or recognise children who are not their biological offspring. There are some step-fathers who've been very supportive of children who aren't biologically theirs. However, many children have faced family conflict and were growing up with no access to schooling, often taking a servile role within the family.

What does your work with survivors involve?

Part of my role involves a specific project helping women who had babies conceived through rape. These babies are now young adults.

It became apparent that some women were facing additional difficulties. Their needs were changing as their children grew up, and it was a struggle. Many started asking for help about what to tell their children about their origins. Of course, adolescence is a crucial time in identity formation and these mothers were now facing questions from their sons and daughters about who their fathers are. Many women had told stories to protect their child from the truth, or because it was still too painful to talk about traumatic events, particularly as many are still living alongside men who attacked them.

In Rwanda, children also have to get a national ID card when they turn 18 years old. This requires them to register parental names.

It became clear that many of the mothers had never disclosed their experiences to anyone, even during previous counselling so we decided to use to use a community group counselling approach. This helped provide a safe and supportive space for women to share their stories, meet others with similar experiences and increase their social support.

So could you give me an overview of the programme?

As you'll know, with such complex trauma, clinicians are often working at the margins of the current evidence base. And survivor struggles are often accompanied by severe poverty, hunger and housing issues. Women's basic needs are often not met and so it can be hard to engage in therapy effectively for this reason. So we have to be flexible, but the programme runs fortnightly for six months, a total of 12 sessions. A maximum of 10 women are accepted per group, all living in a similar area. The group is closed and run by two trained counsellors. We cover a range of topics with disclosure issues discussed towards the end of the programme, after careful scaffolding. The earlier topics pave the way for discussions about more difficult material.

What topics or themes do you cover in the group work?

We offer psychoeducation on a number of topics. We talk about symptoms of trauma and understanding triggers to traumatic memories. Many women were experiencing highly disturbing memories and flashbacks, and were struggling to make sense of this. Explaining what was going on helped women gain more control over what was happening, and we explore ways to manage symptoms.

We've also covered psychoeducation around parenting, particularly looking at the responsibilities of parenting and the rights of children. We've talked about child development, especially adolescence, as it is an emerging concept here. We've also discussed normal adolescent behaviour as mothers were often misattributing adolescent behaviour as catastrophic sign of their child being 'no good', because of their origins. We've explored family conflict and how to manage it. One important theme has been helping some mothers to distinguish between the perpetrator and their growing sons, who may physically resemble the man who attacked them.

Health issues have been incredibly important too: it's estimated 60 per cent of women who were raped were deliberately infected with HIV. Many women showing symptoms misattributed this to their own 'badness', not realising that they were physically ill. One woman in the group plucked up the courage to get tested. She found out she was HIV positive, but it meant that she then got proper medical treatment. It was moving to see her then encourage other women to go for testing too.

So, it's only once these earlier topics are covered that the counsellor introduces the topic of disclosing the past to their children. However, we often find that the topic has already started to come up naturally in other sessions. The women begin by talking together about their fears of disclosing. This is incredibly difficult. How can you explain to your child what happened, when you've never had the chance to talk about it to anyone or think about your own trauma?  We discuss why disclosure might be important or necessary but we're clear with the mothers that it's their choice whether to tell their child. We help to explore the advantages and disadvantages of speaking out. The majority of the mothers want their child to know the truth, but often don't know how to begin that conversation, what to say and worry about the child's reaction. Disclosure is a process rather than a one-off event, and it often involves a number of conversations over time.

It is remarkable what ground is covered in the groups – does it feel like there's enough time? And what are the results /impact of the group?

The programme is compact and there's never enough time! But the impact of the groups is significant and as the mothers meet in their own communities, they do stay in touch with each other, giving each other support and friendship beyond the end of the programme. There's also the option of individual therapy sessions, if needed.

The model is community psychology based - it works via community leaders and women who become advocates after the group. So we know the work continues, and that it reaches into remote rural areas. I offer supervision and training to the counsellors.

We're aiming to reach 800 women within the current funding limit. We've already reached 360, and we've developed culturally adapted ways to evaluate the programme. This involves looking at what outcomes that matter to the women - life satisfaction, hope, relationship with their children, social connectedness and of course, symptoms and coping.

I've visited some of the women who've used the programme, and spoken with one of the counsellors. They said that the group had helped them to feel accepted, cared for and connected to each other. The warmth, care and compassion were palpable. They also shared beliefs related to rape that appear universal: shame and stigma; social isolation; feeling low self-esteem. There's a debate about the appropriateness of Western psychology in other cultural contexts. What's your experience of working across cultures?

Yes, there are challenges around applying Western models unthinkingly, I agree. But there are some issues that are universal across cultures. Language, customs, cultural beliefs, means of presenting information - all this needs thinking about.

It's really important to understand trauma within a cultural context and to pay attention to cultural meanings of marriage and having children as a rite of passage; in Rwandan society, a girl transitions into womanhood once she's become sexually active and had children. Some of the girls were as young as 13 years old when they were raped. Not only were they traumatised, but they were left confused about their cultural identity and their place in society.

Cultural and social considerations are also another reason we chose a community psychology approach, getting out there and working with people in their local communities, and trying to build up social support.

It's also been interesting to hear the comments from the young people themselves – they seem optimistic and have high aspirations for the future, particularly their desire for education and future careers. I'm sure they must face challenges too - what support is available to them?

Ideally, SURF would like to run groups for the children of rape survivors. But at present, our focus is on supporting mothers within our funding limits. We hope that the vital work with young people will follow later. There'll need to be careful thinking around youth work, as some of the young people will be at different stages of awareness about the past, and inevitably, will have different needs and wishes.

Some young people will face issues such as realising that what they've been told about their fathers was untrue or concealed. They face the realisation that their father committed murder and rape. Whilst Rwanda is working hard to create a common Rwandan identity, for these young people, there needs to be sense-making about their heritage. Some children may want to know who their father is, some may not. Some can never find out who their father was because their mother was raped multiple times.

Finding out the truth may also help young people make sense of their mother's behaviour, particularly if there has been a lot of tension in the relationship. And these young people face financial challenges too – many won't get land or a house through their father's inheritance, and will have to provide for themselves.

So, the issues for these young people are huge. They have their own vulnerabilities. But it is also important to acknowledge how much resilience people have in the face of adversity. As you say, there are challenges for young people; Rwanda is a young country, over 50% of the population is 18 years or younger. But there is also a sense of wanting to move forward towards a brighter future.

I am really struck by how you're working in the messy everyday of real life intervention. What message would you really like to convey about this work?

We must pay attention to the needs of women who have suffered wartime rape, and for children born of rape. This work can protect them from ongoing vulnerability and to ensure that they are healthy, supported and integrated in their communities.

Useful links to resources:

AEGIS Trust 

Foundation Rwanda 

SURF

Movement for Global Mental Health 

References

Hogwood, J., Auerbach, C., Munderere, S. & Kambibi, E. (2014). Rebuilding the social fabric: community counselling groups for Rwandan women with children born as a result of genocide rape. Intervention, 12, (3), pp.393–404.

Torgovnik, J. (2009). Intended Consequences: Rwandan children born of rape. NewYork: Aperture Foundation. See website: http://www.torgovnik.com/pages/storyDetail/39

Acknowledgements

Khadj is deeply grateful to Françoise Lemagnen (CEO, SURF), Emmeline Skinner (Department for International Development), Samuel Munderere (Director of Operations, SURF), Beata Mukarubuga (Counsellor, Solace Ministries) and the women who gave their time, and for the comments of young people to Yasmin Gilders.