Resilience-oriented therapy, a promising approach to addressing mental health

On November 21, I attended the National Policy Dialogue on Mental Health that brought together experts, policymakers, and practitioners in mental health to explore strategies for advancing mental health care in Rwanda. The discussions were engaging and promising. A standout topic was Resilience-oriented Therapy, a group-based psychological intervention designed to address mental health challenges and foster resilience. Jointly tested by the Rwanda Biomedical Centre (RBC) and Interpeace through Randomized Control Trials (RCT), the therapy has proven highly effective in treating Post-Traumatic Stress Disorder (PTSD), depression, anxiety, and borderline personality disorders. It equips individuals with resilience-enhancing socioemotional competencies, self-management, and collaboration skills, promoting emotional well-being and capacity to adapt to changes, and effectively navigate life challenges. Considering Rwanda’s significant mental health needs, this therapy offers a promising solution. It is currently being implemented in 32 health centers and seven district hospitals across five districts: Nyagatare, Ngoma, Musanze, Nyabihu, and Nyamagabe, where its positive community impact is notable. On October 15, I witnessed this therapy in practice at Rukira Health Centre in Ngoma District. After getting their permission, I briefly attended a session where 10 participants engaged in healing dialogues, facilitated by a psychologist. Their stories reflect remarkable journeys of recovery and resilience. Mugeni (not real name), a survivor of the 1994 Genocide against the Tutsi, suffered from PTSD for 29 years. Although the genocide ended three decades ago, in her mind, it was still ongoing. She continuously relived the terrifying scenes of screaming, running, hiding, and killings she had witnessed during the 100 days of horror. Before attending Resilience-oriented therapy sessions, she was unable to sleep, terrified of being alone. She stayed awake, hyper-alert throughout the night, running to hide at the slightest sound or whenever she heard people walking near her house, believing the perpetrators were coming for her and her children. The therapy has since helped her overcome her trauma, allowing her to sleep peacefully after years of fear and hypervigilance. Another participant, Uwimana (not real name), attempted suicide twice due to depression following mistreatment by her husband who later abandoned her with a four-month pregnancy and three other children. Alcohol had been her coping mechanism. Now, she has quit alcohol and testifies to have found inner peace. She has healed and is proudly caring for her four children. All group members agree that being part of a group has been tremendously beneficial, allowing them to share their life stories, experiences, and daily challenges while finding collective strength to overcome their distress. The group-based approach has empowered participants with a renewed sense of purpose, leading to transformed lives. Given its effectiveness to enhance psychological well-being and being a culturally adapted therapy, it is well-suited to addressing many of the mental health challenges Rwanda has been facing. Allow me to mention a few but most pressing ones. High prevalence vs one-on-one therapy approach - the 2018 Rwanda Mental Health Survey revealed a mental disorder prevalence of 20.49%, far exceeding the global average. Major depression is the most prevalent, affecting 12% of the population. In 2023, the Rwanda Biomedical Centre (RBC) reported that one in five Rwandans face mental health challenges, with 2,879 suicide attempts recorded by the Health Management Information System (HMIS). As of June 2024, HMIS identified schizophrenia and other psychotic disorders (18%), depression (10%), bipolar disorder (2%), and PTSD (2%) as common diagnoses. Globally, it is projected that by 2030, mental health disorders—particularly depression—will ranknumber one in the global burden of disease. Furthermore, intergenerational trauma from the genocide threatens the mental well-being of future generations. Despite this high prevalence, one-on-one therapy remains the predominant treatment approach. This individualized model limits the number of people that mental health professionals can reach. In Rwanda's collectivist society, group-based activities resonate more culturally and are less hindered by stigma. One-on-one therapy can be less effective due to these cultural and social barriers. Group therapy such as ROT, which can be implemented in communities and health centers, offers a more scalable and culturally attuned solution. It allows mental health professionals to serve 10–12 individuals at a time with the possibility to facilitate two to three groups a week. Limited number of available mental health professionals Rwanda has made significant investments in training mental health professionals, but the current demand far exceeds the available resources. The country has only 16 psychiatrics (1 for 862,400 persons), 441 certified clinical psychologists (1 for 31,289 persons) and 202 mental health nurses (1 for 68,400 persons) working in public facilities. Additionally, there are just seven private clinics or hospitals offering mental health services. These facilities often face challenges, including inadequate infrastructure, lack of appropriate context-informed tools, and limited understanding of mental health systems among the heads of health centers and hospitals. Limited funding As a low-income country, Rwanda faces financial constraints in addressing various development needs, including health. The budget allocated to mental health remains disproportionately low compared to the scale of the problem. The annual spending on mental health makes up 7% of the total budget allocated to the health sector in 2024, according to the fourth Health Sector Strategic Plan 2018-2024. However, there is a very significant increase as in 2018 the same budget represented only 1.4%. Given these limitations, Resilience-oriented Therapy offers a more cost-effective solution than traditional one-on-one therapy, which is time-consuming and less efficient. This group-based approach can be implemented in both community settings and health centers, enabling broader access to mental health support without significantly increasing costs. Medication vs psychotherapy In absence of a well-established mental health healthcare system and workforce, hospitals and health centers in Rwanda often prioritise medication over psychotherapy for mental health conditions. However, psychiatric medications are costly and require a substantial budget. Research suggests that while medication can provide short-term stabilisation, psychotherapy—especially group-based approaches—offers more effective long-term recovery and resilience-building. Integrating group-based psychotherapies, such as Resilience-oriented Therapy, can alleviate the financial burden by reducing dependency on expensive medications. For this integration to be successful, all stakeholders must collaborate to create conducive conditions by ensuring the following: Institutionalise Resilience-oriented Therapy: full integration of Resilience-oriented Therapy into policies and practices by relevant institutions, professionals, and practitioners is essential. This therapy should be included among the approved mental health interventions in Rwanda and should be integrated into university and higher education curricula to promote its understanding and application within academic circles. Prioritise mental health services and increase funding Mental health care is often overlooked in health centers and hospitals, where mental health professionals are frequently redirected to support other services, hence reducing their time and attention dedicated to clients. For better service delivery, responsibilities of mental health professionals should be clearly defined, and they should be provided with necessary logistics and support to exercise their duties. Though the government has made commendable efforts, there is a pressing need for increased financial support at all levels to adequately address mental health challenges in Rwanda. Enhanced funding will also support training, research, infrastructure, and Resilience-oriented therapy implementation. Expand training for mental health professionals More professionals need to be trained to implement Resilience-oriented Therapy at the community, health center, and hospital levels. Additionally, roles and responsibilities of mental health professionals must be clearly defined to address misunderstandings of their functions, thereby enhancing service delivery. Mental health awareness campaigns Mental health care uptake remains low (5.3%) due to limited awareness, stigma, and barriers to accessing services. Nationwide campaigns are necessary to improve understanding, reduce stigma, and encourage more people to seek mental health support. Establish a Strong Coordination and Referral System: a robust coordination and referral system between health centers, hospitals, and other community-based actors is vital. This will facilitate the smooth transfer of cases that require specialised care and ensure that individuals receive the appropriate support at every level of care. A referral and coordination system will also help to ensure the provision of a comprehensive service package in a more holistic and multisectoral system. The Author is a Communications Professional and Peacebuilder.

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Resilience-oriented therapy, a promising approach to addressing mental health