In 1998, during Liberia’s civil war, teenage rebels surrounded a family and, at gunpoint, ordered the husband and wife to dig a pit. Clawing at the hard ground, the couple eventually managed a waist-high hole. The fighters became furious, threatening to kill the husband if the wife didn’t work faster, and she began digging more frantically. Without warning, the rebels shot her husband dead. Then they ordered her and the four children to cover him up. Before they could finish, rebels shot the two boys. Terrified for her two daughters, the mother fought back against the armed men, but was overcome and beaten until she fell unconscious. When she woke hours later, she was alone, and the pit covered.

“And up to today,” Winifred C. Naleatue continues somberly, “she doesn’t know if the two daughters were taken or buried.” Naleatue holds a rare job in Liberia: she works in mental health. A coordinator with the Archdiocesan Training Councilors and Practitioners (ATCP), an organization based in the capital city of Monrovia, Naleatue and her small staff of counsellors have listened to hundreds of similar stories about the fourteen-year civil war that gripped the country from 1989 to 2003. Stories of cruelty that defy comprehension; stories that Naleatue can repeat in strong, professional tones, but not without her voice cracking.

The civil war flipped Liberian society upside down. It cut across tribal, political, economic and religious boundaries, leaving 250,000 people dead, at least another three hundred thousand injured or maimed and more than a million displaced. Seventy-five percent of the female population suffered sexual violence: rape, gang rape. The rape of children—later used as sex slaves—is also well-documented.

Especially harrowing were the forced recruitments. Competing forces (of which there were many) moved around the country indiscriminately, pulling civilians into causes to which they had no real affiliation. The line between civilian and fighter blurred regularly, and made the threat of violence from any direction a constant fear. People—including children—could be forced to switch allegiances depending on who controlled their area. Many would break away and attempt to melt back into society, only to be re-recruited days later.

Some Liberians survived all this with remarkably few psychological side effects. Naleatue’s patient—who waited eleven years before she could even begin to speak about what she endured—is a more typical example: traumatized and in need of guidance to move beyond the past. Liberia, however, is a country where need outraces means. With only one practicing psychiatrist, a handful of support staff and a mental health budget last year of roughly $25,000 for a country of 3.5 million people, treatment remains out of reach to most.

“We still have a lot of people suffering,” explains Sando Mulbah, a counsellor and field coordinator for the Liberian Association of Psychological Services (LAPS). “Especially those that lived in refugee camps. Those that witnessed atrocity—that witnessed the death of their relatives, and have come back to Liberia—they are still having flashbacks.”

The memories are as bizarre as they are horrific: child soldiers dwarfed by the AK-47s they cradle; the Butt Naked Brigade storming into battle, doped-up, wearing nothing but boots; ragtag units roaming in fright wigs, makeup and frilly dresses; cannibalism; chainsaw-wielding units; checkpoints marked with human heads and intestines strung across the road.

Today, such episodes are recalled casually in Liberia, often with deflecting laughter. Innumerable civilians were exposed to a level of brutality above and beyond that of your average war. Its lasting effect on the minds of the population remains largely uncharted territory.

Liberia has been a focal point of international aid ever since a peace deal, backed by West African peacekeepers and United States forces, brought the civil war to an official end in 2003. United Nations’ signature white trucks are everywhere, as are the barricaded checkpoints that mark the entrance to major towns. Non-governmental organizations (NGOs) strategize inside walled, razor-wired compounds. Bombed, shelled and burned-out areas remain, but shiny new buildings—adorned with corporate logos—are popping up. Despite the economic downturn, international investment hasn’t slowed; physical progress is impossible to miss.

Sister Barbara Brilliant, an American nun active in the country for thirty-four years, cautions that Liberia’s infrastructure development won’t do much to heal psychological wounds. “Because a society has built back the infrastructure, and the economy is moving up, does not tell you someone’s psyche’s okay, or if they still hate their neighbour, and want revenge.”

For that you need individualized care, resources and, of course, patience. All of which are in short supply since the civil war ended. When you’re left with a country missing basic political, social and economic systems, it makes sense that reconstruction groups (and their donors), would prefer waste-no-time goals that can be quickly met and easily measured. Mental health, however, doesn’t fit into such a procrustean platform. The UN-led Disarmament, Demobilization, Reintegration and Rehabilitation (DDRR) process, for example, was fairly effective from 2003 to 2005 at getting weapons out of the hands of fighters, but it did precious little to ease the lingering psychosocial needs of those ex-combatants.

“Some of them underwent detraumatization programs that often lasted only a few weeks, and that is just not enough time,” says Immanuel Ballah, the psychiatric administrator at E.S. Grant Mental Hospital. Reintegration essentially meant trading in your weapons for cash, then trying to make amends with the people you just spent years killing, maiming, raping and terrorizing.

This type of quick-fix approach overlooks the fact that inadequate counselling in post-conflict societies can significantly hinder reconstruction efforts. A population with high numbers of severely depressed, stressed-out, suicidal individuals is, after all, implicitly unstable and unproductive.

Today, while streets are largely safe and friendly, anxiety simmers just beneath the surface. A backfiring car can send a sidewalk of shoppers ducking for cover. Cries of “rogue, rogue!” can cause any suspected thief to be chased down by a mob and beaten to death. This type of behaviour, explains Dr. Benjamin Harris—the country’s lone psychiatrist—was conditioned into Liberians through many years of war. “Liberia is a very angry society. It is important people understand that,” Harris argues. “People are still very tense. These are things we need to recognize in order to understand certain behaviours.”

Sister Brilliant believes the war left Liberia with traits anathema to the natural empathy of the culture she experienced through the seventies and eighties. “People in this country are extremely compassionate,” she says. “We have a lot of work to do to get back to those true values.”

Just how much work is anyone’s guess. Liberia’s Ministry of Health claims it has no statistics on mental illness for the country and refuses to disclose the results of recent studies done to buttress a new mental health policy currently being written. However, some general statistics can help to infer just how immense the problem really is.

“In any population in the world,” explains Simone van der Kaaden, a clinician and trainer in Liberia with the NGO Centre for Victims of Torture, “about 5 to 10 percent are suffering from long term mental illnesses. In societies where conflict or natural disasters have a huge impact, this number will be much higher, sometimes as high as 15 to 20 percent.”

Harris cites a recent study that surveyed 1,600 Liberian households. The study “showed that 43 percent of the population met diagnostic criteria for post-traumatic stress disorder (PTSD), and up to 40 percent meet the diagnostic criteria for major depressive illnesses.” Apply this number to 3.5 million people, and the amount in need of treatment is staggering.

Waiting to treat patients in Monrovia Central Prison, Immanuel Ballah points out that the challenge lies not just in the numbers, but in how different each case can be: “People went through a lot of stress during the war, and they now exhibit PTSD in many different ways.”

It’s a problem Atwan Kamara understands intimately. Kamara (not his real name) seldom sees his brother, and when he does, it’s a crapshoot as to what to expect. Weeks can go by between run-ins, and rumours about him trickle back to Kamara: he is addicted to PCP; he lives under the Old Bridge; he is eating his own feces; he is engaged in criminal activity. Recently his brother appeared as Kamara spoke with friends on a street corner in downtown Monrovia. He was wearing tattered women’s clothing, filthy from days on the street, and speaking gibberish. It was a tough conversation.  “All he wanted to do was speak about the past, like when we were kids,” Kamara recalled.  “When he sees me, it’s like that’s all he knows to talk about.”

The chances of people like Kamara’s brother ever getting treatment are made worse by poverty. “Mental ill-health and poverty interact in a negative cycle,” writes Dr. Ala Alwan in a 2008 World Health Organization report. “Mental ill-health impedes people’s ability to learn and to engage  productively in their economies,” Alwan argues, “and poverty in turn increases the risk for developing mental disorders, and reduces people’s ability to gain access to health services.”

The hierarchy of needs, in other words, greatly affects people’s ability to seek care.  When people can’t put food on the table, find adequate shelter or clothing, and lack access to even basic health care, they are unlikely to have the presence of mind to recognize signs of mental illness in a friend or relative.  In a country where most live on less than $2 per day, it’s not hard for individual symptoms, and the overall mental health crisis, to escalate unnoticed.

The challenge extends beyond quantifiable factors. As in much of Africa, symptoms of mental illness carry deep cultural stigmas that compound the efforts of health care workers. “Most people [in Liberia] regard mental illness as ‘psychoticness,’ and even then, the individual is blamed,” says Harris. “There is a general conception that if you are psychotic, it is because you have used drugs, or that you’ve been exposed to witchcraft or something.”

Regine Hemmeter, a nurse at the E.S. Grant Mental Hospital, the country’s only psychiatric facility, describes mental health as a young field in Liberia. “At first, people didn’t accept such thing as mental illness,” she explains. “It’s going slow, slow, slow, but changing.”

“The community often tries to reject the patients. They don’t want to be around mentally ill patients,” explains Joseph Kobba, the hospital’s head nurse. “So the relatives bring the patients here, and they don’t want to come back and visit them. They don’t always want to take them back.”

Run by Cap Anamur, a German non-profit medical aid group, E.S. Grant Mental Hospital has received high marks. For just over $5 us, eighty patients can be treated for six weeks at a time. But the demand is too great for one facility. To fill the void, private caregiving services have emerged. These range from compassionate faith-based counselling to extreme methods reminiscent of rural Liberia’s history of chaining the mentally ill to logs. Holy Ghost Mental Home, run by a nurse out of a Monrovian suburb, was repeatedly forced to close in 2008 after health officials found patients shackled in cramped, dirty rooms.

 “She had a little home. She would chain these people to beds, to posts,” explains Nateatue. “Some of them in some way got better, others got worse. It was kind of brutal.”

Another choice is visiting the “sick bush” or tribal healer, whose treatments run from herbal potions to violent ceremonies designed to “free” the patient of demons. “They’ll say, ‘He’s possessed,’ and sometimes they just beat the fire out them,” Naleatue says with a resigned smile, noting that sometimes families settle on the easiest option: leaving the person outside to die. Such practices, although increasingly rare, are still prevalent enough to attract concern. Tackling them—and demonstrating to skeptical Liberians that proper treatment can actually heal patients—will be a major challenge for mental health reform.

Liberia is in the final stages of developing a comprehensive mental health policy. “The mission is to ensure mental health programs exist that will address the well-being of all people through affordable, accessible and available services,” explains Nmah Bropleh, an assistant minister at the Ministry of Health, and the head of the mental health committee.

The committee’s main objective is to provide local clinics, hospitals and caregivers with basic psychiatric training. Treatment and counseling will occur locally for smaller problems; more serious conditions will be referred. Community organizations and local NGOs such as LAPS, that provide psycho-social counselling, will receive better direction and training.

All of this, says Lyn Westham, mental health program administrator for Mercy Ship, “will better equip health care workers to learn about mental, emotional, social and spiritual issues as well, so that the person can be treated more effectively to decrease recidivism.” 

If implemented, Liberia’s mental health plan will be the first of its kind in a post-conflict country, and something Bropleh and others hope will serve as a model. The plan won’t alter poor living conditions, high unemployment, an ineffective justice system and freely available drugs—all of which exacerbate Liberia’s mental health crisis. It might, however, ease those issues by helping thousands return to more productive lives, and demonstrate that a better mental health policy should be a core component of any post-war recovery strategy.

See the rest of Issue 34 (Winter 2009).

Related on maisonneuve.org:

—Soldier's Heart: Mental Health in the Canadian Military
—Iraq's Walking Dead: Torture Tourism in Kurdistan
—Why Afghanistan is Canada's Next Korea

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