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Grief and trauma counselling
and psycho-social support :
Perspectives in a changing
society
DAVID M. NDETEI
MBChB (Nrb), DPM (London), MRCPsych. (UK),
FRCPsych. (UK), MD (Nrb), DSc (Nrb), Certificate in Psychotherapy (London)
Professor of Psychiatry, University of Nairobi (UoN)
Founding Director, Africa Mental Health Foundation (AMHF)
Faculty and Collaborator, The Chester M. Pierce, MD Division of
Global Psychiatry, Massachusetts General Hospital, Harvard
Medical School, Boston MA, USA
Chair, African Division of the Royal College of Psychiatrists
Zone 14 Representative, World Psychiatric Association
Website: www.africamentalhealthfoundation.org
Email: [email protected] / [email protected]
PRESENTED DURING:
THE AART OF LIFE
INTERNATIONAL TRAUMA
CONFERENCE
AT THE UNITED STATES INTERNATIONAL
UNIVERSITY
NAIROBI, KENYA
26TH – 27TH AUGUST 2015
INTRODUCTION

Human beings have lived with the threat of violence, injury
and death throughout history.

We expect therefore that there are mechanisms available to
help us adapt to threats that do not destroy us.

When threats are more severe and inescapable, other
mechanisms come into play, including dissociation, and
aggravated psychiatric conditions

Problems linked to trauma are grief and other forms of
reactive distress, depressive and anxiety disorders, and posttraumatic stress disorder (PTSD).
How does trauma occur?







It happened unexpectedly.
You were unprepared for it.
You felt powerless to prevent it.
It happened repeatedly.
Someone was intentionally cruel.
It happened in childhood.
Emotional and psychological trauma can be caused by singleblow, one-time events, such as divorce, a horrible accident, a
natural disaster, rape, or a violent attack. Trauma can also stem
from ongoing, relentless stress, such as living in a crime-ridden
neighbourhood or struggling with cancer.
Commonly overlooked causes
of emotional and psychological
trauma







Falls or sports injuries
Surgery (especially in the first 3 years of life)
The sudden death of someone close
A car accident
The breakup of a significant relationship
A humiliating or deeply disappointing
experience
The discovery of a life-threatening illness or
disabling condition
Risk factors that increase occurrence of trauma (Megan et al 2007)
Group
Increase occurrence
Decrease occurrence
1
Medical personnel,
disaster personnel,
fire fighter, police
men, military
Long exposure during work
hours
Training improves resilience
and self efficacy.
2
General population
Lack of mental health care
services Delayed reporting/
lack of awareness/
stigma/culture (association
with spirits)
Availability of mental health
care services and policies,
prompt reporting/increased
awareness, treatment
options
3
General population
History of PTSD
Improved Psycho-social
support
4
General population
Lack of social support
Improved social support
5
Children (Pine and
Cohen 2001)
Level of exposure
& psychopathology
Improved Psycho-social
support
World statistics of trauma (WHO)
No
Country
Group
Percentage
1
United states
Civilians
7-8 %
2
General
War veterans
30%
3
United states
High school
students
3-6%
4
Pakistan
Women
refugees
86%
5
UK
Female rape
victims
45%
6
Cambodia
civilians
3%
7
Across the world
Refugees
10%
8
Mexico
Earthquake
victims
50%
Trauma and violent conflict in Africa (contd.)

Violent conflict, is perhaps one of the most widespread cause of
enduring trauma on the continent

In Kenya, my home country, we as a nation have been exposed to
trauma as a result of violent conflict from the trauma of World War I
and II where many Kenyans were conscripted to fight, one of them
being my late father, witnessing and participating in the atrocities of war.

Kenya’s struggle for independence – the Mau Mau war in the 1950’s also
left its own enduring mark of trauma among the population. In 2005,
about 45 years after the end of that war, a student of mine did a study
on Mau Mau detention camp survivors, the veterans of that war, and
found that a diagnosis of current Post Traumatic Stress Disorder (PTSD)
was evident in 65.7% of the 181 survivors who participated in the study.
Trauma and violent conflict in Africa

After independence Kenya had other various incidences of armed
conflict such as the Shifta war in North Eastern Kenya and the not
too infrequent tribal clashes.

Most recently, the threat of terrorism has constantly been at our
doorstep. Since the 1998 bombing of the American Embassy and two
years ago, the mass shooting at the Westgate Mall, not to mention
the Garissa University attack.

Unfortunately such events are not unique to Kenya alone, but can be
seen in many other African countries and others around the world.
Symptoms of trauma
Emotional and psychological
Shock, denial, or disbelief
 Anger, irritability, mood swings
 Guilt, shame, self-blame
 Feeling sad or hopeless
 Confusion, difficulty concentrating
 Anxiety and fear
 Withdrawing from others
 Feeling disconnected or numb

Symptoms of trauma (Contd.)
Physical
Insomnia or nightmares
 Being startled easily
 Racing heartbeat
 Aches and pains
 Fatigue
 Difficulty concentrating
 Edginess and agitation
 Muscle tension

TRAUMA RELATED WORK
In my work, I have been involved in various efforts for trauma
interventions following armed conflict and violence such as:

The development and execution the Psychotrauma Programme
(module) for the Rwanda Genocide (1995 - 1996)

Development of a training programme for political refugees in Dadaab
Camp in North Eastern Province

Development of a training programme for counsellors following the
terrorist bombing of the American Embassy in Nairobi in 1998

Training and providing counselling and psychiatric services to survivors
of the 1998 bombing of the American Embassy, the 2007/08 postelection violence and even more recently, the students of Garissa
University.
AFRICA MENTAL HEALTH FOUNDATION
(AMHF)

Founded in 2004 to break away from silos of individual
institutions (public and private) and different professions in
order to bring them together under one roof.

AMHF brings together the widest possible spectrum of
professionals with something to contribute to mental health
solutions and enhanced mental health wellbeing – These include:
psychiatrists, clinical and counselling psychologists, social
scientists, economists, human rights activists and people living
with mental disorders all supported by a group of research staff
experienced in research management, proposal writing, grant
management, communication etc.
TRAUMA RESEARCH BY AMHF
AMHF has over the years conducted studies on trauma such
as:
 The psychological effects of the Nairobi US embassy bomb
blast on pregnant women and their children.

A mental health needs assessment of Somali urban refugees
in Eastleigh estate in Nairobi, Kenya.

Traumatic grief in Kenyan bereaved parents following the
Kyanguli School fire tragedy

Traumatic experiences of Kenyan secondary school
students
TRAUMA: EVIDENCE FROM RESEARCH IN
KENYA

I will now take a few moments to share with you some of the findings
of the studies we have done and what these results tell us about
trauma interventions and what we should be looking to.

As I have limited time, I will only give the overview of the conduct of
the studies and the results. Detailed information and data is available
through the various published papers. However, all proper scientific
process and ethical considerations were followed in the conduct of
each study.
THE PSYCHOLOGICAL EFFECTS OF THE NAIROBI US EMBASSY
BOMB BLAST ON PREGNANT WOMEN AND THEIR CHILDREN

We carried out a descriptive study in pregnant women who were
affected by the bomb blast occurring in Nairobi, Kenya on August 7,
1998 and their babies who were in utero at the time of the blast and
contrasted the results to a control sample of similar pregnant women
who had no history of trauma

Both quantitative and qualitative data was collected using their medical
records and a socio-demographic questionnaire, the Impact of Event
Scale – Revised (IES-R) (6), the Childhood Personality Scale (CPS) (7)
and Focus Group Discussions.
THE PSYCHOLOGICAL EFFECTS OF THE NAIROBI
US EMBASSY BOMB BLAST ON PREGNANT
WOMEN AND THEIR CHILDREN (contd.)
SIGNIFICANT RESULTS:

The psychological effects of the disastrous event on exposed
women, as assessed by the IES-R, were severe. There were
significant improvements after three years in hyperarousal and reexperiencing subscales, but the average score on IES-R was still
higher than 29 for the three subscales combined, suggesting that
most of the study group was still suffering from clinical PTSD,
although they reported they had found counseling helpful.

The scores on all CPS subscales were significantly higher in children
of the study group than in controls.

Despite the perceived benefits of interventions limited effects on
the intensity of PTSD were demonstrated in exposed mothers
three years after the event, which emphasizes the need to evaluate
psychological interventions for trauma victims with a view to
making them more effective and culturally appropriate.
A MENTAL HEALTH NEEDS ASSESSMENT OF
SOMALI URBAN REFUGEES IN EASTLEIGH
ESTATE IN NAIROBI, KENYA
The purpose of this study was to highlight the
prevalence of mental illness among Somali refugees in
Nairobi and their ability to access mental health
services.
 The tools used were the Mini International Neuropsychiatric Interview (MINI plus and MINI kid) which
were translated into Somali language.

A MENTAL HEALTH NEEDS ASSESSMENT OF
SOMALI URBAN REFUGEES IN EASTLEIGH
ESTATE IN NAIROBI, KENYA (contd.)
SIGNIFICANT RESULTS:
•
PTSD was significantly associated with:
• depression (p=0.001),
• bipolar mood disorder (0.021),
• OCD (0.012),
• alcohol abuse (<0.001) and
• khat use (p=0.004).

This was a clear indication that PTSD can occur at the same time
with other mental health and substance use conditions, therefore
the need to identify and address them as well.

This study was followed by another which provided brief
intervention to to 315 somali refugees using Khat who were also
diagnosed with PTSD. There was a 70% success rate in reduction
of khat use among the study participants.
TRAUMATIC GRIEF IN KENYAN BEREAVED PARENTS
FOLLOWING THE KYANGULI SCHOOL FIRE TRAGEDY

Following the death of 67 boys in a fire tragedy at Kyanguli School in
rural Kenya, the level of traumatic grief was assessed in a sample of 164
parents and guardians whose sons died in the fire. The study was crosssectional.

Counseling services were offered to all the bereaved parents soon after
the tragedy. The subjects were interviewed using the Traumatic Grief
Scale.

A group of 92 parents/guardians was interviewed 2 months after the
event, while the other group of 72 was assessed 7 days after the event.

The second group of bereaved parents also completed the Self Rating
Questionnaire (SRQ) and the Ndetei-Othieno-Kathuku scale (NOK).
TRAUMATIC GRIEF IN KENYAN BEREAVED
PARENTS FOLLOWING THE KYANGULI
SCHOOL FIRE TRAGEDY (Contd.)
SIGNIFICANT RESULTS:
 There was no much difference in terms of symptoms
profile or intensity between the two groups. It
appears that the counseling offered had minimal
impact on the levels of distress.
TRAUMATIC EXPERIENCES OF KENYAN
SECONDARY SCHOOL STUDENTS



The objective of this study was to describe the
traumatic experiences of Kenyan high school
students and to determine the levels of Posttraumatic Stress Disorder (PTSD) among them, and
in relation to sociodemographic variables.
The cross-sectional study was conducted among
1,110 students (629 males and 481 females), aged
12 to 26 years,
Data was collected using self-administered
questionnaires, the Trauma Checklist and the Child
PTSD Checklist.
TRAUMATIC EXPERIENCES OF KENYAN
SECONDARY SCHOOL STUDENTS (contd.)
SIGNIFICANT RESULTS:
 Being confronted with bad news was the most common type of
trauma encountered in 66.7% of the subjects, followed by
witnessing a violent crime and domestic violence; 23.2% and 16.5%
of the subjects reported physical abuse and sexual abuse
respectively. PTSD symptoms were common;
 Avoidance and re-experiencing occurred in 75% of the students
and hyperarousal was reported by over 50%. The number of
traumatic events was positively correlated with the occurrence of
PTSD. The prevalence of full PTSD was 50.5%, while partial PTSD
was 34.8%.
 Male and female subjects were equally affected but the boarders
were more affected (p < 0.05) and the differences between the
schools were statistically significant (p = 0.000).
TRAUMA INTERVENTIONS: THE WAY FORWARD

From these examples, it is abundantly clear that:
THERE IS NEED FOR FURTHER RESEARCH AND
INCREASED COLLABORATION BY VARIOUS
DISCIPLINES TO PROVIDE APPROPRIATE AND
EFFECTIVE EVIDENCE-BASED TRAUMA
INTERVENTIONS

However, there have been some advances in provision of effective
interventions and I will now take some time to discuss some of these
advances
COMPREHENSIVE SUPPORT
Effective interventions for trauma need to be
comprehensive taking into consideration the following:
Individual
Family
Friends
Finances
Culture
Religion
community
COMPREHENSIVE SUPPORT (contd.): The Peter
C. Alderman Foundation (PCAF) Psychotrauma
Clinic

PCAF partnered with AMHF to open a psychotrauma clinic in to offer
psychosocial support to victims of the 2007/08 post-election violence
in Kenya. The clinic is based in Nairobi near Kibera, one of the slums
worst affected by the violence.

Since it begun, the clinic has catered to 2400 clients, 70% of these being
women who have suffered sexual abuse. The remaining 30% are men
and children.

In keeping with provision of comprehensive support, the clinic with
funding from the African Women Development Fund (AWDF) has
trained women attending the trauma clinic, in entrepreneurship and
given them capital to start businesses for self sustainability. This project
has ensured that patients with trauma are self reliant thus improving
their overall health outcomes.
CHANGING PERSPECTIVES OF TRAUMA COUNSELLING

Through out history, trauma counselling has always focused on the
individual, but it is now being realised that the complexity of influences
reach far beyond the place where the event occurred. As a result, the
effects go beyond family, community or country, to an extent, continent
ad often the people left behind are equally affected. This is why we
need to focus on:
1.
Socio-cultural perspective:
psychiatry has continued to see mental illness as a disease which
recognizes symptoms regardless of culture in which they occur.
Culture is now considered a variable which interacts with biology and
environment to determine the cause of mental disorder. Behaviour is
culturally related and all mental disorders and therapies should be
culture specific. (Opler, 1959: Kiev,1964)


CHANGING PERSPECTIVES OF TRAUMA COUNSELLING
(CONTD.)
2.
Psychological: which therapy work best in this
community?
3.
Financial: Doing way with the culture of dependence
and ushering self reliance through social funds
4.
Human rights perspectives: How do we make sure
survivors tell their story and get Justice at the same
time?
CHALLENGES FACING SERVICE PROVISION IN TRAUMA
INTERVENTIONS

Psychiatrist to population ratio in many countries in Africa is still is low.

Budgetary allocations for mental health services are less than 0.01% of the
National Health budget in Kenya as in many similar countries.

Training of mental health professionals takes time and resources that are not
easily available.

There are other compounding factors such as lack of financial resources
because of poverty , lack of appropriate policies, lack of mental health
awareness, competing priorities for health resources e.g. for HIV/AIDS and
Malaria and lack of visionary leadership.
Negative attitude and stigma towards Mental Health and patients
 Number of people involved in war or threats to war increase everyday


Therefore, we must be innovative, mobilize and utilize the resources at our
disposal through collaboration.
MULTI-STAKEHOLDER APPROACH TO HARNESS
RESOURCES FOR MENTAL HEALTH
Stakeholders are multiple and include:
1. Mental Health Workers (Psychiatrists, counseling and
clinical psychologists, nurses, psychiatric social workers)
2. Informal (lay) mental health workers – faith and traditional
healers, community based workers, recovering patients
3.
Other disciplines covering the full lifespan from conception to old age
(Social scientists, health economists, Anthropologists, the
media)
MULTI-STAKEHOLDER APPROACH TO HARNESS RESOURCES
FOR MENTAL HEALTH (CONTD.)
4. Other NGOs, Community based organizations, human
rights groups and civil organizations
5. Communities and community leadership including
administrative and political leadership
6. Policy Makers
7. Collaborators, partners and donors
8. Researchers to generate data to inform policy and
practice
9. Above all people with mental illness and their families
USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS HUMAN
RESOURCES FOR MENTAL HEALTH - TASK SHIFTING OF MENTAL HEALTH
SKILLS
The stakeholders in the formal health sector include:

Nurses

Clinical officers

Community Health Extension Workers (CHEWs) – these are
nurses trained on community outreach

Community Health Workers(CHWs) – these are high school
graduates identified by the communities in consultation with
the Ministry of Health and trained by the Ministry of Health

School counsellors
33
USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS
HUMAN RESOURCES FOR MENTAL HEALTH - TASK
SHIFTING OF MENTAL HEALTH SKILLS (CONTD.)
The stakeholders in the informal health sector
include:
 Traditional Healers
 Faith Healers
 Expert Patients
 Self help groups
 Families
34
USING THE MULTI-STAKEHOLDER APPROACH TO HARNESS
HUMAN RESOURCES FOR MENTAL HEALTH - TASK SHIFTING OF
MENTAL HEALTH SKILLS (CONTD.)

We at Africa Mental Health Foundation have had positive
results using task-shifting and have even received further
support from local county governments and other donors
to scale up this innovative approach in the provision of
mental health services.

I urge all of us to consider this approach as well in trauma
interventions.
CONCLUSION

It is possible to effectively address trauma through:

Involvement of all stakeholders to address trauma comprehensively
putting into consideration the individual, family, social relations, religion,
culture and the community.

Task shifting of mental health services through training of lay health
workers to bride the gap in human resources available for mental
health service provision.

Integration of mental health services into primary healthcare facilities
to make services available and accessible to the majority population.

Research to come up appropriate and effective evidence-based
community interventions.

I wish to close my presentation with an invitation to all of you to attend this
conference which provides a unique and exciting avenue for a multidisciplinary exchange of recent advances in trauma interventions and mental
health on the African continent.
You are all welcome.
THANK YOU!
FOR MORE DETAILS VISIT:
www.africamentalhealthfoundation.org