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Delivery of mental health training to nurses overseas: Mary-Jo Doyle reflects on the problems and rewards of teaching mental health nursing to students in Somaliland, a poor country emerging from civil war

Delivery of mental health training to nurses overseas: Mary-Jo Doyle reflects on the problems and rewards of teaching mental health nursing to students in Somaliland, a poor country emerging from civil war

Author(s): Mary-Jo Doyle
Source: Mental Health Practice. 15.4 (Dec. 2011): p34.
Document Type: Report

Full Text:


The author undertook a teaching trip to Somaliland, an autonomous region of Somalia, East Africa, where she gave a course of lectures about mental health nursing to a group of fourth-year nursing students. She found the preparation of teaching materials difficult, but after listening to students' views about mental health, she was able to make the course work culturally sensitive. The course included two visits to local public mental health wards and by the second visit, students had become more confident and had developed a rapport with the patients. By the end of the course, the author had become impressed by the dedication in difficult conditions of Somaliland's nursing staff.


IN 1991, after the overthrow of the Somali government, the enclave of Somaliland declared itself an independent state. This independence is yet to receive formal recognition by most of the international community and, like many countries emerging from war, Somaliland faces daunting problems in reconstructing its infrastructure and economy. It is one of the least-developed countries in the world. Many of its health workers died or fled during the war, and most of its medical facilities were destroyed. As a result, few people in this poor nation have access to healthcare services.

The Tropical Health and Education Trust (THET) and King's College, both in London, have formed the King's THET Somaliland Partnership (KTSP) to establish links with educational institutions and help train healthcare workers in the country.

Under the auspices of the KTSP, I travelled in May this year to Somaliland to provide mental health nursing training to fourth year BSc nursing students at Amoud University, Boroma. I travelled with KTSP mental health lead Dr Susannah Whitwell, who was to teach medical students at the university and to help provide mental health services.

The two-week course took place in the school of nursing and the general hospital in Hargeisa, the Somaliland capital, and the students had to travel from Boroma, which is situated about 100km north west of the capital, to attend classes.


The KTSP had asked me to provide introductory training in mental health disorders, nursing assessment and care covering 14 topics altogether. This meant I had to prepare teaching materials, which proved to be difficult for several reasons:

* Somaliland is extremely poor and has few mental health care facilities. Some of the forms of assessment and treatment recommended in the UK, therefore, are unavailable there.

* Somaliland is recovering from a recent civil war, which had affected the population's mental health significantly.

* Delivering lectures and arranging appropriate activities is difficult in a country with intermittent electricity supplies and little technical equipment. On my flight to Somaliland, I had been restricted to 13kg of luggage and had been unable to take much equipment with me.

* The student's concepts and beliefs about mental health are different from mine.

* Few of the students were fluent in English, which is the second language of most people in Somaliland.

In preparing teaching materials I found Vikram Patel's book, Where there Is No Psychiatrist (Patel 2003), Indispensable. This book was written for use specifically In developing countries, where access to specialist mental health services is limited, and was particularly helpful In conveying difficult concepts in a culturally sensitive way.

On my first day I met my class of ten women and six men. At first, I found it nerve-racking to stand in front of them and talk, but the students were warm and friendly, and soon made me feel welcome.

During the introductory lecture it emerged that the students regarded mental health problems to be caused by 'distressing memories of the war' or 'too much thinking'. They thought that such 'over thinking' is due to use of the drug khat, which can prevent sleep. Hearing such views helped me to modify the course to ensure it covered the students' specific problems.

The first few lectures covered mood and anxiety problems and it was interesting to hear the students' views on polygamy, khat use, post-traumatic stress disorder and self-harm by burning with petrol, which is common in Somaliland. By learning how mental distress presents itself In the country, I could develop more culturally sensitive care plans and risk-assessment exercises.

There is a social stigma attached to severe mental health problems in Somaliland, which made my lectures on psychosis potentially problematic. However, by introducing practical exercises on 'hearing voices', I was able to help the students understand why people experiencing psychosis may be unable to concentrate or may become extremely distressed.


Discussion of my experiences as a nurse helped the students understand their own experiences of treating patients during clinical placements at Boroma hospital, while discussion of the experiences of a group of mental health nurses, who joined us for a few lectures, helped to make the practical exercises easier to understand.

I delivered further lectures on dementia and delirium, personality disorders, autism and talking therapies during the two-week course. I was encouraged to see that the students related the content of the course to their own experience of nursing. While preparing a care plan for a patient with dementia, for example, they noted that the nurse may have to provide and set up a mosquito net for the patient, an aspect of the nurse's role that had not occurred to me.

The course included two visits to the public mental health ward in Hargeisa. We were accompanied by a Somali doctor, who was also the mental health representative for the KTSP mental health group. The doctor knew the patients and identified those who would enjoy a visit from the students. Before the first visit to the ward the students were nervous and unsure of what to expect. On arrival, they were split into small groups to talk to the patients about their experiences and had soon developed a rapport with them.

Before the second visit, the students were more relaxed, a change of attitude toward people with mental health problems that I found encouraging. As a result, they were able to complete structured assessments of the patients' mental health problems and prepare care plans for some of them.


There are many problems ahead for mental health services in Somaliland. The resources needed for improvement remain scarce. There is a limited supply of psychotropic medication, and severe shortages of trained staff and basic supplies, such as food and water.

Nevertheless, there have been recent improvements, including a reduction in the number of patients on the mental health ward who are kept in chains, after a World Health Organization initiative had criticised the practice. I was also impressed by the dedication of many of the nursing staff, who must work in extremely difficult conditions.

The nursing students I taught were receptive to new ideas and caring, and some expressed an interest in working in mental health services. One student said that learning about mental health nursing had 'shown me something hidden' and that, during future trips to Hargeisa, she planned to visit patients on the mental health ward.

Overall, the teaching trip had been an incredible experience. The Somali people I met are friendly and enthusiastic, and have a genuine desire to help their fellow citizens and to contribute to the development of Somaliland.

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Patel V (2003) Where there is No Psychiatrist: A Mental Healthcare Manual. Gaskell, Glasgow.

Mary-Jo Doyle was, at time of writing, a clinical nurse specialist in the behavioural genetics clinic, and is now a clinical studies officer in the mental health research network, at South London and Maudsley NHS Foundation Trust

Source Citation
Doyle, Mary-Jo. "Delivery of mental health training to nurses overseas: Mary-Jo Doyle reflects on the problems and rewards of teaching mental health nursing to students in Somaliland, a poor country emerging from civil war." Mental Health Practice Dec. 2011: 34+. Expanded Academic ASAP. Web. 21 Apr. 2012.

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