Therapist Mudahogora on why Rwandans should be more open about mental health

For someone who lived through years of trauma and observing the stigma around mental health conditions, which is common in Rwandan and most African societies, sitting back and doing nothing about it was not an option. Having moved to Canada two decades ago, and furthering her education in psychotherapy there, Chantal Mudahogora understands well the rigours of struggling with mental health conditions and even worse when you live in a society that does not recognise the serious nature of these conditions. Indeed, when Mudahogora moved to the North American country 20 years ago, even the experience and education she had from Rwanda was not recognised, meaning that she had to take up new courses to get the ‘Canadian experience’ before she could practice. That is how serious some countries take mental health issues. Before she left Rwanda, she had a bachelor’s degree in business administration, and had worked with a government ministry as well as different non-governmental organisations, but that was not enough to work in Canada. “When I got there, I found that they don't consider your education credentials and your experience. There's something they call ‘Canadian experience’” Mudahogora, who went on to earn a master’s degree in psychotherapy. As a survivor of the 1994 Genocide against the Tutsi, Mudahogora knew all too well about trauma and the post-genocide mental crisis that unfolded, which explains why it is the area she chose to further her education. “I needed to learn something which would help me to understand myself psychologically, but also to understand my community. So that's how I was interested to go into psychology,” says the mother of three. With her children becoming adults, the youngest aged 25, a few years ago Mudahogora started coming back home more frequently, spending more time in Rwanda than she does in Canada, where she still has a few projects running. Her plan is to fully relocate back home and focus on her business but most importantly contribute her skills and knowledge to improving Rwanda’s mental health sector through psychoeducation. “As you know, we still have a lot of stigma when it comes to mental health, not only in Rwanda but also in Africa and worldwide,” she says, adding that her focus is mainly supporting young people. “I try to focus more on young people, coaching them on how they can read warning signs of any kind of distress, whether it's stress, anxiety, burnout, or even just to get to know themselves,” she adds. It is common knowledge that most African countries do not have support systems for mental health, given the stigma and stereotypes that surround it. Even those which put the services, people just don’t show up to take them up. Many people don’t seek help or counselling, which in most cases leaves young people more vulnerable and exposed. Mudahogora says it is important to mentally support young people, especially when they are growing up in different family systems or dynamics, because it helps them to understand their emotions and thoughts. “That's is where I focus more, to raise awareness because I know the big deal. In 2018 I published research with my colleagues from Israel, on international trauma, specifically within the Rwandan community,” “The research focus on young people, the post-genocide generation. So, actually intergenerational trauma is real. It's not only for survivors but also anyone who has been going through hardship,” Mudahogora explains. How does intergenerational trauma come about? Intergenerational trauma is trauma passed on from ancestors or older relatives who went through a very distressing or oppressive past. Their emotional and behavioural reactions could ripple through the generations of one’s family and the younger generations. A good example Mudahogora gives, is that a child - scientifically speaking, begins to accumulate trauma passed on from parents, especially mothers, when they are still in the womb. “At four months in the womb, a child or a foetus has already started accumulating some of the struggles the parents are going through. If there's a lot of domestic violence, a child may record, because at the time they are not conscious enough to know what is going on in their surroundings but they are consciousness,” “They are aware of what is going on, so they start accumulating information. If there's a lot of yelling, screaming or maybe mom is affected by trauma, especially if they cry a lot, are sad or angry, all those emotions will actually be transferred to the baby in the womb,” she explains. The good news, however, is that it is not only trauma which gets transferred, but also resilience. That's why you can see siblings who grew up in the same family and same dynamics but the outcome is different. Some will be much stronger while others will be more on the nervous side of things. Mudahogora says what makes intergenerational trauma trickier is the fact that even clinicians find it difficult to diagnose because children start asking different questions as they grow up, especially when they become teenagers. “They start having weird behaviours but they don't know why, because they don't know where the behaviours are coming from. Therefore, they conclude that they are not normal and then they start being depressed,” “For example, for me who lived through the genocide as an adult when I have my triggers, I know why I'm being triggered,” citing her own struggle, which is the sound of the whistle. Because whistles were predominantly used during the 1994 Genocide against the Tutsi to mobilise and coordinate killings, the sound of a whistle sends her heart racing, especially when it is blown from behind her. “During the genocide, there were very many whistles all over the place. They [Interahamwe] were using to call the killers whenever they saw someone hiding somewhere,” “The whistle is still a problem for me, although now I'm getting better,” she says, pointing out that it is one of the triggers but for young people for example who were born during the chaotic scenes at the time of the genocide or were in the womb might not be aware of its effects. Later in life, the same children react to noisy or chaotic situations, for example when they go to a club or any other noisy place but they don’t know exactly why they are being triggered. They start shaking, develop anxiety or panic attacks when they get into noisy situations. This, according to Mudahogora, is a result of the trauma they accumulated years ago in the womb. When such happens, even their fellow teenage friends don’t know why their friend is getting a panic attack at a concert or in the nightclub and they start thinking their friend is weird because they also don’t know. “So, at that point this child will end up hating themselves thinking I'm not normal, what's going on with me? What's wrong with me? They start hating themselves and withdrawing, they don’t want to go out in public because they don’t want to be triggered again,” Mudahogora says. From here it spirals and escalates and they start getting anxiety, stress or depression because they feel abnormal and they don't know why. It is a complex situation. A vulnerable generation As a result, many young people find themselves vulnerable given their different backgrounds, which makes some more exposed to mental health challenges than others. Mudahogora says that if one grew up in a family where they did not receive any care, affection or love, especially at a certain age, that is five or six years old, they become more vulnerable to mental health conditions. This is mainly because at that age, a child is in the first phase of self-discovery, especially their genders. A girl or boy becomes more attached to the opposite gender among the parents. Girls get more attached to their dads and boys to their mums to the extent that they even start competing for attention with their other parents. When a gap appears during that phase of growth, either because the parent they are attached to is too busy, unavailable or is also stressed or pushes them away, they immediately start becoming vulnerable. “Trauma is about fragmentation, it's about layers. Your mind, thoughts and emotions get fragmented to the point where when we do therapy, we try to melt those fragmentations so that they can reconcile and even work together,” she says. Therapists try to deal with each of those layers as they come because later in life, a child whose parents were not present or did not show affection starts exhibiting their vulnerability later in life as teenagers, young adults or even when they get married due to that gap. The gap will always be there and the child will always find ways of filling it. “There is a saying in English that ‘we attract our own’. Sometimes your emotional wounds will take you to someone who is also wounded and then the wounds clash,” “Nowadays everybody asks me ‘why do we have so many divorces? Why this? Why is that? That's what it is,” Mudahogora says, pointing out that the same churches teach couples marriage courses, they should also be given counselling to make sure that they are mentally on the same page. A girl whose father was not present will get married hoping that the husband will fill that gap and when it does not happen, the girl continues to live with the gap. In the first place, the marriage is built on a bad foundation because no matter how loving, a husband cannot play a father’s role but rather their own role. This can be a source of conflict already in the marriage. It is a good example of how intergeneration trauma is passed on and Mudahogora says it is more complex than many people think and it is widespread. For a society that went through a genocide where entire families were wiped out, chances of intergenerational trauma are very high, not just for survivors but the population at large. It is exacerbated by other factors such as domestic violence and its consequences including early unwanted pregnancies, sexual abuse, rejection or even poverty and financial distress, all of which are common occurrence in today’s world. How do you know you suffer from intergenerational trauma? According to Mudahogora, a combination of things can point to intergenerational trauma, among them behaviours of people which mimic those of many conditions such as depression, bipolar disorder and schizophrenia, among others. When people go through this kind of trauma, they develop some defence mechanisms and get into survival mode, building things around themselves to protect themselves and in doing so they start hearing and seeing things. This condition which is the same as Post-Traumatic Stress Disorder (PTSD) rears its ugly head in many ways than one, all exhibited in how people behave down to the individual. Most common signs include people appearing to live in excessive fear, always knee-jerked and unsettled, suffer from sleep disturbances, show signs of anger, aggressiveness, show mistrust and suffer from anger issues. All these and more are signs people bypass but in actual sense they exhibit signs of something underlying. Some will live a long time dealing with issues of anxiety, lack of concentration, drug abuse and many other signs. These, if not dealt with, can become a major challenge to society in the not so far future. They must be tackled head on because in Mudahogora’s words, “there is no health without mental health.” “Any mental health disorder is a disease like any other disease. If you have any disease, say high blood pressure, diabetes or kidney problems and you don't attend to them, they we'll get worse,” “Same thing, with mental health disorders, whether it's PTSD, depression, anxiety, whatever, if you don't attend to them, they will get worse,” she says. For young people, the common signs might include drug abuse, self-harm, suicidal thoughts and much more, all of which might be tied the past family dynamics. Regarding the concern of alcohol and drug abuse among young people, Mudahogora says there is a good opportunity to rein those in because they are preventable and can be controlled. While addiction is a major challenge, Mudahogora believes it can be tamed if the society comes together to do the right thing, creating sensitisation and awareness on the dangers of alcohol and drug abuse, leveraging available platforms such as social media. It is important to tie these symptoms to mental health, if they have to be addressed. Because of the stigma that comes with mental health, many people live in denial and keep these symptoms to themselves, turning to self-medication and reliance on painkillers to subdue pain. What most people in Rwanda and Africa in general do is to treat the physical pain such as headaches and migraines and ignore the psychological pain. All these and more could be a time bomb. Other anxiety signs might include sadness, chest tightness, palpitations, hallucinations, panic attacks and other traits, all of which might point to emotional pain, but treatment focuses on physical pain. Today, young people find themselves overthinking, become self-sabotaging, worry too much about the future, suffer from impostor syndrome, always finding themselves failing to live the present because they are preoccupied by the future. “When you cannot control your thoughts, and when your emotions become too overwhelming, you start taking something to relax because your nervous system is so hyper,” Mudahogora says, explaining why young people end up taking alcohol and drugs and taking a lot of risks. In the end it affects their brain growth and functional ability, surviving on high energy to cope. In trying to ease emotional pain, they ended up getting addicted to whatever substance they are using to silence their minds. This is something even many adults are grappling with according to Mudahagora. What starts as socializing becomes addition. For a country that traditionally and culturally glorifies alcohol, sometimes it happens and people normalize it and brush it off. The consequences can be dire. Take out stigma, Mudahogora says all mental health conditions are treatable but it starts with people acknowledging that it is ok not to be ok and there is nothing wrong in seeking treatment or support. She says the perceptions and stereotypes around seeking mental health treatment must be done away with. It should not be seen as ‘going to Ndera’ or ‘gusara’ (running mad) yet most of these conditions can be controlled early. People tend to treat mental health conditions as psychosis, the condition which sends people to psychiatric hospitals but that is not the case. However, all these conditions are silent killers when they go unaddressed and can have a heavy toll on society. When people exist with these conditions which they have little control on, it can be very exhausting and they become even less productive at work and addiction increases. Similarly, when these conditions are not treated, they can lead to psychosis, yet in reality it can be prevented, especially if all people become ambassadors of mental health. Mudahogora says that as they say that it takes a village to raise a child, it is the same with mental health. It takes everyone to deal with mental health challenges, and it can’t be the work of the government alone. “The support is there, the Ministry of Health has centralised these services but people don’t take advantage of them because of stigma or fear of being judged,” Mudahogora says. The other challenge is the approach used to deal with mental health conditions, which is more brutalizing and victimizing than helping those who need help. “We have to be brother's and sister’s keepers. As I said, it takes the whole village to care for someone who is struggling, but we need to educate ourselves, seek information,” she says, adding that naturally Rwandans are raised to be strong. People resort to crying, hiding pain and suppressing emotions and that is even more dangerous. One cannot sit back and look when they know someone struggling with mental health issues. The sooner people get help, the better the society can deal with mental health challenges.

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Therapist Mudahogora on why Rwandans should be more open about mental health