Mental health clinics in violence-prone South Sudan are rare and endangered
'I wanted to take my children and jump in the river,' she said while cradling a baby outside a room with cracked mud walls where she now stays.
But she's made a remarkable recovery months later, thanks to the support of well-wishers and a mental health clinic nearby where she's received counseling since April.
She told The Associated Press that her suicidal thoughts are now gone after months of psycho-social therapy, even though she still struggles to feed her children and can't afford to keep them in school.
The specialized clinic in her hometown of Mundri, in South Sudan' s Western Equatoria state, is a rare and endangered facility in a country desperate for more such services. Now that the program's funding from Italian and Greek sources is about to end, its future is unclear.
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EDITOR'S NOTE — This story includes discussion of suicide. If you or someone you know needs help, the national suicide and crisis lifeline in the U.S. is available by calling or texting 988. There is also an online chat at 988lifeline.org. Internationally, many governments and other organizations offer help and information on how to contact them is available online.
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The clinic is in one of eight locations chosen for a project that aimed to provide mental health services for the first time to over 20,000 people across this East African country. Launched in late 2022, it proved a lifeline for patients like Falatiya in a country where mental health services are almost non-existent in the government-run health system.
Implemented by a group of charities led by Amref Health Africa, the program has partnered with government health centers, Catholic parishes, local radio stations.
Massive displacement
Across South Sudan, there has been massive displacement of people in the civil war that began in 2013 when government troops loyal to President Salva Kiir fought those loyal to Vice President Riek Machar.
The eruption of fighting was a major setback for the world's newest country, which became a major refugee-producing nation just over two years after independence from Sudan. Although a peace deal was reached in 2018, the resumption of hostilities since January led the U.N. to warn of a possible 'relapse into large scale conflict.'
The violence persists even today, with Machar under house arrest and government forces continuing with a campaign to weaken his ability to wage war. And poverty — over 90% of the country's people live on less than $2.15 per day, according to the World Bank — is rampant in many areas, adding to the mental health pressures many people face, according to experts.
In a country heavily dependent on charity to keep the health sector running, access to mental health services lags far behind. The country has the fourth-highest suicide rate in Africa and is ranked thirteenth globally, World Health Organization figures show. Similar challenges in access to mental health services are seen elsewhere in places facing conflict, from eastern Congo to Gaza.
In South Sudan, suicide affects mostly the internally displaced, fueled by confinement and pressures related to poverty, idleness, armed conflict, and gender-based violence, according to the International Organization for Migration.
'Mental health issues are a huge obstacle to the development of South Sudan,' said Jacopo Rovarini, an official with Amref Health Africa.
More than a third of those screened by the Amref project 'show signs of either psychological distress or mental health disorders,' he said. "So the burden for the individuals, their families and their communities is huge in this country, and it has gone quite unaddressed so far.'
Mounting suicide cases
Last month, authorities in Juba raised an alarm after 12 cases of suicide were reported in just a week in the South Sudan capital. There were no more details on those cases.
Dr. Atong Ayuel Longar, one of South Sudan's very few psychiatrists and the leader of the mental health department at the health ministry, said a pervasive sense of 'uncertainty is what affects the population the most" amid the constant threat of war.
'Because you can't plan for tomorrow," she said. 'Do we need to evacuate? People will be like, 'No, no, no, there's no war.' Yet you don't feel that sense of peace around you. Things are getting tough."
In Mundri, the AP visited several mental health facilities in June and spoke to many patients, including women who have recently lost relatives in South Sudan's conflict. In 2015, the Mundri area was ravaged by fighting between opposition forces and government troops, leading to widespread displacement, looting and sexual violence.
Ten years later, many have not recovered from this episode and fear similar fighting could resume there.
'There are many mad people in the villages," said Paul Monday, a local youth leader, using a common derogatory word for those who are mentally unwell. 'It's so common because we lost a lot of things during the war. We had to flee and our properties were looted.'
'In our community here, when you're mad you're abandoned,' Monday said.
NGOs try to bridge the gap
As one of the charities seeking to expand mental health services, the Catholic non-governmental organization Caritas organizes sessions of Self Help Plus, a group-based stress management course launched by WHO in 2021. Attended mostly by women, sessions offer simple exercises they can repeat at home to reduce stress.
Longar, the psychiatrist, said she believes the community must be equipped with tools 'to heal and to help themselves by themselves, and break the cycle of trauma."
But she worries about whether such support can be kept sustainable as funds continue to dwindle, reflecting the retreat by the United States from its once-generous foreign aid program.
The project that may have helped save Falatiya's life, funded until November by the Italian Agency for Development Cooperation and the Athens-based Stavros Niarchos Foundation, will come to an end without additional donor funding. Specialized mental health services provided at health centers such as the Mundri clinic may collapse.
'What happened to me in the past was very dangerous, but the thought of bad things can be removed,' Falatiya said, surveying a garden she cultivates outside her small home where a local man has allowed her to stay after taking pity on her.
She said that she hopes the clinic will still be around if and when her 'bad thoughts' return.
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For more on Africa and development: https://apnews.com/hub/africa-pulse
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The Associated Press receives financial support for global health and development coverage in Africa from the Gates Foundation. The AP is solely responsible for all content. Find AP's standards for working with philanthropies, a list of supporters and funded coverage areas at AP.org.
Florence Miettaux, The Associated Press
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Many therapists are already willy-nilly entering data about clients and patients into off-the-shelf publicly available LLMs. The problem is that there is almost no guarantee of data privacy with these AIs, and you could readily be violating confidentiality and HIPAA provisions. You might also need to certify consent from the client or patient, depending on various factors at play. For more, see my discussion at the link here and the link here. Make sure to consult with your attorney on these serious matters. One approach is to stridently anonymize the data so that the client or patient is unrecognizable via the data you have entered. It would be as though you are simply creating a generic persona from scratch. Whether that will pass a legal test is something your legal counsel can advise you on. Another approach is to set up a secure private version of an LLM, but that, too, can have legal wrinkles. More On Personas As Digital Twins Yet another approach is to merely and shallowly describe the persona based on your overall semblance of the person. This is somewhat similar to my earlier point that you can use personas by simply entering a prompt that the devised persona is supposed to represent a person with depression. That's a vague indication and would seem untethered to a specific person. The downside, of course, is that the surface-level persona might not be of much help to you. What are you going to do with whatever persona you craft? You could try to figure out the emotional triggers of the person, as represented via the persona. What kind of coping style do they have? How does their coping mechanism react to the therapy you have in mind? All sorts of therapy-oriented strategies and tactics can be explored and assessed. In essence, you are trying out different interventions on the persona, i.e., the digital twin. Maybe you are mulling over variations of CBT techniques and want to land on a particular approach. Perhaps you often use exposure therapy and are unsure of how that will go over with the client or patients. This provides a no-risk means of determining your therapy in a simulated environment and prepares you for sessions with the actual person. Don't Fall For The Persona I trust and hope that any therapist or mental health professional going the route of using a persona as a digital twin is going to keep their wits about themselves. Ordinary users of AI who use personas can readily go off the deep end and believe that the persona is real. Do not let that same fate befall you. The persona is merely the persona. Period, end of story. You cannot assume that the persona is giving you an accurate reading of the person. The AI could be completely afield in terms of how the person will actually respond and react. Expect that the AI will almost certainly overrepresent some traits, underrepresent other traits, and be convincing as it does so. Convincingness is the trick involved. Contemporary generative AI is so seemingly fluent that you are drawn into a mental trap of believability. Inside your head, you might hear this internal voice: 'It must be showing me the true inner psyche of my client or patient! The AI is working miracles at modeling the person. Wow, AI is utterly amazing.' You must resist the urge to become over-reliant on the digital twin. Over-reliance is a likely possibility. Here's how. You use the persona. After doing so, you later meet with the client or patient. Everything the AI indicated as to responses and reactions appears to mirror what the person says and does during the session. Awesome. You decide to keep using the persona. Over and over, you use the persona. Voila, you are hooked. The persona has led you down a primrose path. The seemingly uncanny portrayal has been spot-on. The problem is that when the client or patient diverges from the persona, you are going to have your mind turned backward. The person must be wrong, because the persona was always right. In other words, the person is supposed to be acting as the persona does. The world has gone topsy-turvy. But it's you, because you have forsaken your therapist mindset and allowed AI to capture and defeat your real-world acuity. That's bad news. Do not let that happen. Additional Twists And Turns There is a lot more to consider when using AI as a digital twin in a mental health context. I'll be covering more in a series of postings. Be on the watch. One quick point to get your mental juices flowing is this. Suppose that you have gotten written consent from the client or patient, and they know that you are using AI to depict a persona of them. The person comes to one of your later sessions and starts to suspect that you are proceeding as if it is based on what the AI told you. They worry that the AI is portraying them in some unpleasant fashion. Furthermore, they now insist that you let them access the persona. They want to see how it represents them. Mull that over and think about how you would contend with that potential nightmare scenario. It's a doozy. It could arise. A final thought for now. Albert Einstein famously made this remark: 'My mind is my laboratory.' Yes, that's abundantly true. In the case of mental health therapy, besides your mind being your laboratory, it turns out that AI can be your laboratory too. Proceed with aplomb.
