By Lucinda Pepper, contributing writer

Taking a retrospective look at the work of CVT Ethiopia involves both an experience of celebration and the humbling understanding of continued need. We are proud to be arriving at the ten-year anniversary of providing life-saving and healing care in Ethiopia to people who are survivors of war trauma, sexual and gender-based violence and civil strife. As we mark a decade of helping refugees and internally displaced people (IDPs), we are seeing the ripple effects of our long-term engagements in the region. Bol Buony Nuot, associate psychotherapist/trainer in Gambella said, “When I look at CVT from the beginning it’s like a new born baby. The baby is growing — and when the baby grows it will produce. There are fruits! They will benefit different people.”

CVT operates in two regions of Ethiopia. In the western part of the country we work in the Nguenyyiel refugee camp in Gambella. There are more than 80,000 refugees living there who have fled a variety of interethnic and cross-border conflicts. We also operate in the Tigray region in the north at various sites including the Mai Ayni and Adi Harush refugee camps. Right now in Tigray there are more than 2.6 million IDPs and more than 300,000 others (refugees and asylum seekers).

Click here to read an article by Firew Kefyalew Mekonnen, country director, CVT Ethiopia.

CVT Ethiopia has been a leader in implementing mental health care in all three camps. While other international non-governmental organizations (INGOs) provide some psychiatric care and additional health services, we learned early on there were almost no services in any of these locations to help refugees with their acute and intense symptoms of trauma, including depression, anxiety, insomnia, chronic physical (somatic) pain and dysfunction, nightmares, suicidal thoughts, self-directed rage and anger, and post-traumatic stress disorder.

CVT is everything to me.”

Yonas, former client at CVT Ethiopia-Tigray

People who have fled their homes and are living in refugee camps have multiple traumas piled one atop the other. The acute physical and mental symptoms of trauma can lead to a very low quality of life. That’s where CVT Ethiopia comes in: the team provides tools and services that help people find relief, improve mind and body functions, and gain the internal sense of strength they need to engage in their lives. We have often been the only mental health and psychosocial services (MHPSS) provider available, and the first to respond to the need for mental health support in camp settings.

How CVT Ethiopia is Different

Local host communities where the camps are located have been welcoming. Our staff have been excellent at relationship building with our INGO and government partners in the camps. Following comprehensive conversations, the CVT Ethiopia team has been able to provide our life-saving services alongside psychiatric, health and basic needs providers.

Clinical Program Director Sandra Githaiga (now working in Addis, she formerly worked in Tigray) noted that, “We’ve managed at each point to talk with our partners and see how we’re complementing each other, see how we can provide support. For instance, in Shire specifically [Tigray region], we are the coordinators of the MHPSS program, and we are looking at how we can strengthen coordination between MHPSS [providers] in general.” Bol shared, “CVT was initially constricted to provide psychoeducation and sensitization in only one zone [in Nguenyyiel camp]. Though there were some clans and people who came from other zones, and while we could provide services when they came by themselves, we couldn’t go to their zones and provide services.” This also impacted hiring, as Bol noted, “Also, when we wanted to recruit psychosocial counselors (PSCs) from other zones to work with CVT, we were restricted to only having PSCs from the zone we worked in.”

I have no words to express my appreciation for CVT.”

Former client, CVT Ethiopia

Learning From & Teaching the Communities

CVT staff have conducted multiple assessments within the camps to determine people’s mental health needs. CVT staff, in their green t-shirts, went from door to door and tukul to tukul to talk with people about what they were experiencing. These surveys took a lot of time, energy and determination, and involved learning about needs and providing basic psychoeducation. Staff continuously help people in the camps understand what services CVT can provide and how they might benefit from those services. Maki Katoh, former CVT Ethiopia country director, noted that through the assessments, “The team could now see their services were useful; some of the clients had come and let us know they were really grateful and that really motivated the team to do more.”

The nature of our assessment questions was about trauma. Because of refugees’ traumatic experiences, religious beliefs and other circumstances, we were sometimes met with skepticism. In the region, there is cultural stigma around receiving help, as mental health issues and their associated symptoms are often seen as involving imbalanced spiritual energies. Symptoms are traditionally addressed by spiritual leaders and through the cultural practices of a person’s clan or community.

By providing psychoeducation and sharing about symptoms and coping mechanisms, [people] come to understand that what’s happening is not a curse or supernatural.”

Bol Buony Nuot, associate psychotherapist/trainer, CVT Ethiopia-Gambella

Bol said, “If they don’t know that this is a mental health problem, they might think it is a curse or link it to traditional, religious issues – anything that is not known is connected with supernatural powers, whether it is negative or positive. Anything that is a mystery or that is poorly understood is considered to be supernatural.” Bol also noted that power dynamics in the communities play into this. He said, “By providing psychoeducation and sharing about symptoms and coping mechanisms, [people] come to understand that what’s happening is not a curse or supernatural. When [people] come to us and see how we are doing the services, sometimes they look at it as another way of praying. They say, wow, this is what we do when we go to the forest and collect firewood and feel tired, so we rest and breathe. This is the same as what you do!”

Expanding our Reach

In western Ethiopia where Gambella borders South Sudan, we used data from our 2019 assessment to customize our approach in the Nguenyyiel refugee camp. Because of conflict between the three largest clans in the border region there is a general aura of fear among people, where incidents have often resulted in the abduction and selling of children, the burning of homes and armed conflict. Famine conditions and resource competition add kindling to these ongoing tensions, which erupt in violent conflagrations many times a year and have been ongoing for more than a decade. Initially, CVT was limited in our reach inside of the camp, allowed only to work within one zone. Nearly two years after setting up, we had provided services to almost every eligible individual within the zone, so we continued to press for an opportunity to expand. Our efforts at times were hampered by the conflicts in the region getting worse, and temporary stoppages of the flow of new refugees. The people we had helped were urging for our expansion so we could help others.

Our staff never became discouraged even though mental health is not on the top of the priority list for camp communities, especially during times of extreme strife. As Girmalew Teklu, operations and finance manager in Tigray, said, “Mental health is not as visible as water, food, sanitation and shelter construction,” but it is just as essential. Part of CVT’s unique approach is to provide psychoeducation and sensitization to the people living in refugee camps, and by extension that includes staff of partner INGOs and governmental agencies.

As Girmalew Teklu, operations and finance manager in Tigray, said, ‘Mental health is not as visible as water, food, sanitation and shelter construction,’ but it is just as essential.”

Monthly, we provide psychoeducation and sensitization, and host gatherings within the camps. We provide capacity-building training for religious leaders, camp leaders and incentive workers in different INGOs. We train other workers to be aware of trauma symptoms so they can refer people to CVT for assistance, and know when they are experiencing secondary trauma. Clients who have come in for initial sessions talk to others in the camp communities about what they have experienced. Clients who have benefitted from our services write and share songs and poems about their healing.

We also work together with partner agencies to provide programs of commemoration for days of importance to people living in the camps: International Day in Support of Victims of Torture, World Refugee Day, World Mental Health Day, days against sexual and gender-based violence and World Suicide Prevention Day. Through those events very important issues are brought into the light, and people are encouraged to share their experiences of struggle, and of healing and hope.

All of the hard work of the assessments, psychoeducation, sensitization and the persistence of our staff in working to expand programming in both the north and west of Ethiopia has been worth it. Sandra shared, “Even right now, in Gambella…the clients are talking about the amazing help they’ve received from CVT, and that’s really mostly due to the program.” In Tigray, CVT has repeatedly been asked to expand its services as the needs have increased. “The result of the expansion within Tigray and now to Shire, and planned for Selekleka, Axum and Sheraroo (mobile teams), and to the Amhara region is tremendous,” noted Girmalew. Through those expansions CVT can reach many more people in need of stabilizing support for their mental health, even during times of uncertainty.

An Upside-Down Life for Refugees

Outside of the Tigray region it can be difficult to imagine the horror of armed conflict breaking out around refugee camps where people who have already fled persecution and violence are living. But that’s what happened in November 2020. For six weeks after the crisis in Tigray began, CVT’s headquarters staff were unable to reach the field staff working in the camps. There was no way to confirm if staff, their families or our clients were alive or if they had the resources they needed to continue to stay alive in a hostile environment. Maki stated, “During the conflict the roads were blocked to the camp. The refugees were left on their own. There was no cell phone access. Refugee staff took it upon themselves to reach out to clients and would try to go to extremes to reach the counselors and to check on clients. This was helpful for them to do because they could see themselves as useful. In spite of everything that happened they were able to keep going.”

Outside of the Tigray region it can be difficult to imagine the horror of armed conflict breaking out around refugee camps where people who have already fled persecution and violence are living. But that’s what happened in November 2020.”

Staff in Tigray have continued to be first-line responders during this crisis. They immediately saw how the influx of IDPs created a need for skilled trauma response. Our well-trained team decided to do what was necessary to help people find some stability by providing psychological first aid and using other trauma-informed crisis stabilization tools.

The natural human instincts to care for each other are already functioning in overdrive in times of disaster, and despite all of the stress and trauma our staff was experiencing daily, they knew that providing support for others in need would be helpful for everyone. Maki said, “I was worried for their lives, I was worried for their safety, but I was never worried that they would do something unprofessional. They were very flexible and creative; they did their own outreach and their own negotiations with the local government . . . and they were amazing.”

Our Resilient Staff

In a region full of conflicts, the only steady cycles are those of nature: the sun and moon still rise and set, seasons turn. Even the earth and its plants, trees and creatures going about their business of growth, life, reproduction, birth, and death are deeply impacted by violent conflict. Despite the disruption, the staff at CVT Ethiopia are optimistic, hopeful, resilient and full of deep care. They understand how to best approach clients’ health and healing needs.

When violence erupted in Tigray again in August after a five-month ceasefire, new worries surfaced about the retraumatization staff and clients would experience. Sandra said, “I developed a brochure [for staff] with four tips on how to cope in times of uncertainty, and I am trying to put a plan in place for remote support. It is definitely something that really worries me. I do have supports in place for myself but right now my focus is on them. The Tigray team is really amazing; they get into the mode of helping others and their resilience rubs off on me.”

From the early days of our work in the country, CVT has trained Ethiopian national staff and refugee staff who have backgrounds in mental health care. Maki noted how this has helped our work improve, saying, “That helped us to understand the needs of the local population and the refugee populations. They helped us review and change the model, and we started to see some positive results.” Despite encountering numerous challenges due to the environment and constantly shifting dynamics in and around the camps, staff go through intensive, in-depth training to understand CVT’s tri-phasic clinical model, trauma, responding to clients in crisis, clinical assessment tools and more. Training takes place in the camps and in Addis Ababa.

Every training module includes an aspect of self-care, so staff can gain supportive tools for themselves while working in an atmosphere permeated with trauma. Many staff cite the close relationships they’ve developed with their teams as a major source of self-care: “The team in Tigray is so strong, they live away from their families and have such a strong connection so they’re always checking up on each other and sharing with each other. When things are good and not so good, they’re able to support each other from that aspect. In Gambella the team…often supports each other by checking on each other, being together in the evenings sometimes though they are living with their families, and have various activities (staff lunch, New Years, staff retreats),” shared Sandra.

Maki explained some specific elements that have come together to make the teams stronger. In recent years, team leadership traveled to Kenya to visit CVT’s urban program in Nairobi and to CVT’s Uganda program. Through these travels staff became exposed to a variety of different clinical cases and approaches and they learned new procedures. They returned to Ethiopia with a willingness to apply new knowledge and skills. These trips also allowed staff to meet with experts of other backgrounds, and to understand that how they were working in the camps was indeed special, so they’ve gained significantly in positive self-regard. All of these conditions have been essential to helping staff reach their potential.

What Will the Future Hold?

All of us at CVT are hoping for peace to hold in Tigray, Gambella, and the country at large. During a lecture she gave on Nelson Mandela’s birthday in 2005, Nobel Laureate Wangari Maathai gave a fuller picture of the actions that create hope: “Education will help, peace and security are important, and sustainable management of resources is essential. But the people must be allowed to gain confidence, dignity and a sense of self-worth. Ultimately, they must also be empowered with knowledge, skills and tools to take action.” We know that each person we help to find their own dignity, healing and inner peace will become a skilled peacemaker in action.

Our staff in Ethiopia shared their visions for how their actions and CVT’s reach might grow as the future unfolds. Describing his vision of growth in Gambella, Bol used his metaphor of the fruits newly born through CVT, saying, “Now the first people that are eating the fruit are in the camp. The host community will still benefit because CVT will collaborate with universities and regional education, because there are students studying psychology in universities. This organization will be one of the biggest in Gambella and university students will come to practice, do their internships. Hospitals can also benefit from CVT; we can provide our self-care training to their staff and they will benefit because they also see that trauma. This is all direct benefit to the host community. Gambella will benefit, and other people who are not employed by CVT will still benefit from CVT.”

Maki said, “I really think that they are able to grow a lot more, we just need to support them. I don’t mean expand [just] because we can expand and get bigger, but that there are many needs there and they can help. I know they’re trying to do something more sustainable: more capacity building, more partnering with educational institutions. These people who are trained are an enormous resource and I really hope that we can support them, so that even after CVT is no longer there they can be of benefit to their communities.”

Sandra added, “CVT has been able to build the skills of national psychologists to be competent to work with trauma survivors, and the staff take pride in that. We’re building Ethiopian skilled community to work with survivors. That’s what’s sustainable.”