David Winter, Professor Emeritus of Clinical Psychology, University of Hertfordshire
Disclosure statement: David Winter has received funding from Enabling Access to Mental Health Sierra Leone (funded by the European Union), and from the Tropical Health and Education Trust and Unison, via Barnet, Enfield and Haringey Mental Health NHS Trust.
A nation “once again… gripped by grief”. This was how Ernest Bai Koroma, president of Sierra Leone, described the effects of the mudslide that devastated Regent, on the outskirts of the country’s capital, Freetown in the early hours of August 14 2017. At least 400 people were killed, hundreds more are still missing, and thousands have been rendered homeless. The vice president, Victor Foh, said that: “The disaster is so serious that I myself feel broken.”
Few countries can have exceeded Sierra Leone’s share of recent misfortune. In its brutal 11-year civil war, beginning in 1991, tens of thousands of people lost their lives, countless more suffered mutilation or rape and more than a third of the population was displaced.
Then, in 2014, the country was ravaged by the largest ever Ebola epidemic, which killed at least 4,000 people in Sierra Leone. Such peaks of trauma occurred against a backdrop of extreme poverty and high mortality rates, including one of the highest in the world for women during pregnancy or childbirth.
Research I’ve conducted in Sierra Leone over the past few years provides some understanding of how those currently gripped by grief following the mudslide might respond in the longer term, and what help they might need in addition to very practical resources.
One of my recent studies focused upon people affected by the Ebola epidemic, including a group who had courageously volunteered to be burial workers. They exposed themselves to the risks of infection, but also of violence from people prevented from carrying out their normal burial rituals, and of ostracism following the epidemic. Nevertheless, they were able to see themselves as being prepared to “stand very tall to fight for our country”.
Another study concerned former child soldiers. Thousands of boys and girls, in some cases with ages not even in double figures, fought in the civil war. Most were forcibly conscripted, with initiations that often involved having to mutilate or murder family members.
They were typically plied with drugs before battle, and many were used as sex slaves. It might be expected that such experiences would have a severe impact on these young people, but surprisingly those who participated in the research viewed themselves more favourably than did young people who had not fought in the war, and as better people now than ever before. Some of them developed a Community Theatre Agency to help the reintegration of former child soldiers into the community.
Another of my studies concerned a group of people who had lost limbs in the war, mostly as victims of the rebels’ favourite form of terror: amputation. They lost not only their limbs but also their hopes and dreams. However, one of them had an idea:
You guys, never mind we lost our legs, some of us lost our hands, we’re not anything in the sight of God … let’s come together and … play football.
They formed a football team, which paradoxically provided opportunities, for example for foreign travel, which would not have been available had they not suffered amputation. It was clear that football played a major role in the recovery of their self-esteem.
Mental health needs
Following the civil war, a very high prevalence of mental health problems was reported in Sierra Leone, where treatment facilities are very limited. In the country’s one psychiatric hospital, 75% of its patients were kept in chains when I first visited it in 2007 (with a delegation from Barnet, Enfield, and Haringey Mental Health NHS Trust) – and virtually the only treatment consisted of very heavy doses of major tranquillisers.
Interviews with the in-patients indicated most felt they needed practical help, for example involving finance, housing, or employment. When those on one of the wards were asked what they would like, their virtually unanimous request was for music. When music cassettes were duly played, most of them spontaneously started dancing, in many cases while still chained until the staff were persuaded to unchain – and dance with – them. During subsequent visits by the delegation over six years, the number of patients kept in chains reduced to about 20%.
Helping those gripped by grief
These examples demonstrate the considerable resilience of the people of Sierra Leone – and of people in general – when faced with major tragedies. Although such disasters tend to attract armies of international “trauma chasers”, such as experts on post-traumatic stress disorder (PTSD), it should not be forgotten that PTSD is a relatively uncommon response to trauma, as compared to resilience, recovery and growth.
The appropriateness of such Western concepts such as PTSD may also be questioned in a country in which, to quote from the Salonean author Aminata Forna: “You call it a disorder my friend, we call it life.”
Approaches based on listening to, and taking seriously, the views of those affected, or which encourage these people’s own creative initiatives, may be more relevant and effective than Western treatment methods. Some of these, which involve rapid psychological intervention after trauma, have been found to be at best counter-productive, and possibly harmful.