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Commit and act in Sierra Leone

Corinna Stewart, Beate Ebert, and Hannah Bockarie

Sierra Leone: Current Issues and the Legacy of the Civil War

Sierra Leone is located in West Africa and has a population of six million composed of approximately 16 different ethnic groups. While English is the official language of the country, the most widely spoken language is Krio (although other languages such as Mende and Temne are spoken within different regions). It is one of the poorest countries in the world, ranking 183rd out of 187 countries in the Human Development Index (United Nations Development Programme 2014). The life expectancy is 45 years for men and 46 for women (WHO 2012). Health expenditure is low. In 2012, the sum of public and private health expenditure per capita in Sierra Leone was 95.7 US dollars (17.5% public expenditure) compared to 8895.1 (47% public) in the United States and 3647.5 (84% public) in the UK (World Bank 2015). Neuropsychiatric disorders are estimated to contribute to 4.1% of the global burden of disease in Sierra Leone; however,

C. Stewart

National University of Ireland, Galway, Ireland B. Ebert

Aschaffenburg, Germany H. Bockarie

Sierra Leone, West Africa © The Author(s) 2017

R.G. White et al. (eds.), The Palgrave Handbook of Sociocultural Perspectives on Global Mental Health, DOI 10.1057/978-1-137-39510-8_31

there is very limited data on the current prevalence rates of mental health issues in the country (WHO 2011). It is estimated that less than 1% of people with mental health difficulties are treated within psychiatric services and the rate of relapse is high (Sierra Leone Ministry of Health and Sanitation 2012).

Sierra Leone has also endured a turbulent recent history. The country was devastated by a civil war between 1991 and 2002, in which 40,000-50,000 people were killed and 500,000 civilians fled the country (Dufka 1999). The war was characterized by brutal atrocities against civilians, including widespread execution, amputation of limbs, and rape (UN Development Programme 2006). The mental health of the population has been affected greatly by the civil war. Findings from an assessment of traumatic stress in the capital, Freetown, toward the end of the civil war by Medecins Sans Frontieres (MSF) indicated that 99% of respondents demonstrated very high levels of disturbances on the Impact of Events Scale, which assesses two central dimensions of coping with extreme life events: intrusion and avoidance (de Jong et al. 2000). During the war, approximately 22,000 children were abducted, forced to watch and carry out violent acts and suffered physical and sexual abuse (Denov 2010). Sexual violence was also used a weapon of war during the conflict. Physicians for Human Rights (2002) reported that internally displaced girls and women within Sierra Leone were subjected to an extraordinary level of rape, sexual violence and other human rights violations. Of the women and girls who participated in their survey, over half of those who came into contact with the Revolutionary United Front reported sexual assault. Longitudinal research has indicated that individuals who wounded or killed others during the war demonstrated increases in hostility and that youth who survived rape exhibited higher levels of anxiety and hostility across time (Betancourt et al. 2010). MSF concluded that the high levels of traumatic stress observed indicate an urgent need for psychosocial interventions to address the needs of the survivors of violence and that Sierra Leoneans must be involved in the development and delivery of these interventions (de Jong et al. 2000).

In addition to war-related trauma, the country has also been faced with a number of other issues, including poverty, unemployment, stigma (e.g., child soldiers, victims of sexual violence, mental illness etc.), domestic- and gender-based violence, as well as poor infrastructure and a lack of resources. Gender-based violence continues to be a widespread problem across the country and evidence suggests that domestic violence against women and children is common (Denney and Ibrahim 2012). For instance, Coker and Richeter (1998) found that approximately 70% of urban women interviewed for a survey on AIDS revealed that they had been beaten by an intimate male partner and over 50% reported being forced to have sexual intercourse. Current prevalence rates of domestic violence and rape are difficult to clarify as these crimes are greatly underreported, police are reluctant to intervene in domestic disputes, and complaints are often withdrawn due to social stigma, fear of retaliation or acceptance of payment in lieu of pressing charges (U.S. Department of State 2013a). More recently, the Ebola Virus Disease (EVD) epidemic has had a devastating impact on the already vulnerable and unstable country. Sierra Leone was among the worst affected countries, with 12,371 suspected, probable, and confirmed cases and 3899 deaths due to EVD reported by April 2015 (Centers for Disease Control and Prevention 2015). This has been attributed in part to the inadequacy of the health care systems in the country.

There is also a serious lack of mental health services and community care, and the few available services are limited in scope and trained personnel (Song et al. 2013). The country has only one psychiatric hospital, which is grossly understaffed and under-resourced, as evidenced by the fact that there are only two trained psychiatric nurses tasked with the responsibility of managing the 400-bed hospital. There is also only one psychiatrist in the country, and he is retired from active government service. Following a recent situational analysis, the Ministry of Health and Sanitation (2012) has outlined the shortcomings of the current mental health system, proposed strategies for its improvement and identified key groups that require particular attention in future design, planning and implementation of mental health services. Within this report, the Ministry has recognized the need to shift the emphasis of treatment to community-based psychosocial programs to improve access to mental health care, reduce the stigma associated with attending mental health services, lessen burden on individuals, families and communities, and ensure smoother social integration and better chances of recovery. Recent efforts have been made to foster collaboration between different sectors, including beyond the health sector (e.g., traditional healers, religious leaders), and to promote research to monitor, evaluate and inform services and to ensure that they are evidence-based.

commit and act

commit and act is a German-based NGO that provides training and continuing supervision in Acceptance and Commitment Therapy (Hayes et al. 1999) in low-income countries (LICs) and has a local partner in Sierra Leone

(White and Ebert 2014). commit and act works with a variety of different professions (e.g., social workers, teachers, religious leaders, prison officers etc.), as well as non-specialized workers, NGO staff and established local groups (e.g., women’s groups). Their international team includes psychotherapists and other mental health practitioners, ACT trainers, researchers and individuals with various skill sets (e.g., finance etc.), linked by a shared vision of connecting with others, caring for others’ well-being and personal growth, and creating contexts that empower people to realize their own vision, goals and ambitions, as reflected by their motto: ‘connecting, caring, creating’.

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