The boy crouched silently in the rafters, hiding. When the men came, he saw them murder his father and then rape and kill his sister.

It is a horrible story. There are thousands of such stories in Rwanda.

In a country where everyone has lost something or someone, victims and perpetrators live side by side, and the remains of the dead are still being pulled from the ground, how does healing begin?

Several psychologists have been working with the people of Rwanda to try to find an answer to that question.

Genocide and its aftermath

For 100 days during spring and summer of 1994,

Hutu mobs systematically hunted down and killed Tutsis and some moderate Hutus. Government forces and extremist militia groups started the killing after the Hutu president's plane was shot down, but soon ordinary citizens were drawn into the genocide. More than 800,000 people died-most of them Tutsi.

Although the genocide ended when a new Tutsi-controlled government took control, years of conflict in the country and with neighboring Congo and Burundi would follow. Now, Rwanda is relatively peaceful, but the recent 10th anniversary of the genocide and the search for justice in gacacas-traditional courts across the country in which all members of a village participate-keep the past alive.

Treating trauma

Psychologist Karen Froming, PhD, an assistant clinical professor of psychiatry at the University of California, San Francisco, first visited Rwanda in 2004, during the commemoration of the 10th anniversary of the genocide.

"The country is so beautiful, and the people are so warm, gentle and welcoming-it's hard to understand how anything so horrible could have happened there," she says. As she talked to Rwandans, she realized that the genocide had never really gone away-bodies were still being uncovered and everywhere she went people were coping with unimaginable grief.

"My driver's wife lost 17 members of her family," says Froming.

Since psychology is still a nascent field in Rwanda, many of the people she met were fascinated by what she did, and wanted to know how they could get help. Froming couldn't treat them all directly, of course, but it got her thinking about ways she could contribute. After several more visits and contact with the staff at the National University of Rwanda, she came up with a plan. For five days in the summer of 2005, Froming and a team of four other psychologists, including her husband, William Froming, PhD, a social psychology professor at the Pacific Graduate School of Psychology, and three of his graduate students, conducted a workshop with about 60 clinical psychology and social work students at the university.

It was a collaborative effort, says Amanda Gregory, PhD, a private practitioner in San Francisco and one of the participating psychologists. Froming's group put together a draft manual on post-traumatic stress disorder (PTSD) treatment based on the expertise of and trauma research by team member Victoria Beckner, PhD, a research scholar in the psychiatry department at the University of California, San Francisco, and a staff psychologist at the San Francisco Veterans Administration Center.

The team next worked with the students to see what would and wouldn't work in their culture. The Americans had received lessons on Rwandan culture and language, but they wanted to hear how the students would incorporate PTSD techniques with their cultural norms. They talked with the students about the physical and emotional responses to trauma-such as flashbacks, sleep disturbances, anxiety and depression. The Americans demonstrated some self-help techniques the Rwandans could teach to those struggling with trauma, such as relaxation exercises, deep breathing and grounding.

They also discussed how survivors can distract themselves with pleasant activities, says Gregory. For example, the Rwandan students suggested that struggling citizens might benefit from traditional Rwandan practices, including going to church and socializing with friends and neighbors. Many of the students were anxious to share such tips with others.

At the end of the five days, the Froming team hoped it had given the students some tools to incorporate into their cultural traditions. The team also talked about vicarious traumatization and the importance of clinicians taking care of themselves.

"It was a small contribution," says Gregory. "One tiny part of what is needed mental health-wise over there." However, she says, they learned a lot from the students about additional areas they could address together and would like to come back for future collaborations. In fact, Froming has founded a nonprofit organization, the Institute of Restorative Justice, to address issues of mental health and well-being in Rwanda.

Healing and reconciliation

In 1997, Charles Murigande, who was then the president of Rwanda's National University and is now the country's foreign minister, invited psychologists Ervin Staub, PhD, and Laurie Anne Pearlman, PhD, to Rwanda to help the country move on psychologically without further violence. Staub, a psychology professor and the founding director of the PhD concentration in peace psychology and violence prevention at the University of Massachusetts, Amherst, has been studying the origins of genocide for more than 20 years.

In 1999, Staub and Pearlman-president of the Trauma Research, Education and Training Institute in South Windsor, Conn.-went to Rwanda to set up a treatment program. They quickly realized that model wouldn't reach enough people.

"Everyone was affected by the genocide-survivors, perpetrators, bystanders," says Staub. "We could not do it on an individual basis-there were too many people, and Rwanda is a group-oriented society."

Instead, Staub and Pearlman set up a seminar with local nongovernmental organizations (NGOs) and survivors' rights groups, giving them information they could take back to communities. The workshop covered the traumatic impact of violence on people, self-awareness and self-care, and larger issues such as the roots of violence and avenues that can lead to reconciliation. They talked with journalists, national and community leaders and local facilitators about influences that encourage violence and how people can counteract these influences. For instance, based on his previous research, Staub has found that how each group evaluates each other is a core factor: There is a tendency to see the enemy as not human.

"This happened in Rwanda-the Tutsis were demonized on the radio," Staub says. "If journalists, the government, whoever, humanizes a group, violence is less likely," he stresses. He has also found that once a group feels victimized, it is more likely to feel insecure and impelled to defend by violence. Bystanders to conflict also have an important role, he notes: If they speak out early on, they can help stop the violence.

In Rwanda, holding the gacacas is a central part of reconciliation. Although a sense of justice being served is important to healing, stories that come out along the way can lead to retraumatization, say Staub and Pearlman. Staub feared that the process could even lead to more violence.

In 2001, as the government started talking about holding gacacas, Staub, in collaboration with a Dutch NGO, Radio La Benevolencija, began disseminating tactics for preventing violence through radio programs. One monthly program consists of straightforward information on healing and reconciliation presented by local experts. The other, started in 2004, is a more creative approach to promoting reconciliation. It's a twice-weekly drama about two neighboring villages with a fertile territory between them that the authorities arbitrarily assign to just one community. As the story goes on, this leads to violence. The leader of one community attacks the other community. However, the people in the villages have connections that cannot be severed-such as a love story involving a young man from one community and a young woman from the other.

By embedding ideas about healing and information about the roots of violence and how to prevent it in an entertaining format, Staub and Pearlman have been reaching a large portion of the population. Now, the drama also is being broadcast in Burundi; Staub, Pearlman and Radio La Benevolencija are in the process of expanding it to the Congo, where millions of people have died as the result of violence.

Staub and Pearlman have also been running Rwanda workshops focused on minimizing the trauma of the gacacas. For example, they help participants prepare mentally for testimony that may surprise them. They encourage people who have to testify to bring someone with them for support. They also encourage Rwandans to talk to each other about what they hear and see.

Staub and Pearlman realize they cannot heal a whole country, especially when there are no resources for the seriously mentally ill. But what these programs can do is help people reconnect with their own communities, says Pearlman. She sees obstacles to healing, like the country's extreme poverty, high level of unemployment and large number of AIDS cases. However, she does see hope.

"If the reconciliation and justice process continues and poverty is addressed, there is the possibility of a large-scale healing," she says.

Further Reading

To learn more about the Institute of Restorative Justice and the workshops at the National University, e-mail Froming.

For more about Staub and Pearlman's work in Rwanda, visit www.heal-reconcile-rwanda.org or www.ervinstaub.com.