In many African countries, mental health issues, including the burden of serious mental illness and trauma, have not been adequately addressed. These essays shed light on the treatment of common and chronic mental disorders, including mental illness and treatment in the current climate of economic and political instability, access to health care, access to medicines, and the impact of HIV-AIDS and other chronic illness on mental health. While problems are rampant and carry real and devastating consequences, this volume promotes an understanding of the African mental health landscape in service of reform.
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About the Author
Emmanuel Akyeampong is Professor of History and of African and African American Studies at Harvard University.
Allan Hill is Andelot Professor of Demography at the Harvard School of Public Health.
Arthur Kleinman is the Esther and Sidney Rabb Professor of Anthropology, Harvard University, and Professor of Medical Anthropology in Global Health and Social Medicine and Professor of Psychiatry at Harvard Medical School.
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The Culture of Mental Illness and Psychiatric Practice in Africa
By Emmanuel Akyeampong, Allan G. Hill, Arthur Kleinman
Indiana University PressCopyright © 2015 Indiana University Press
All rights reserved.
A HISTORICAL OVERVIEW OF PSYCHIATRY IN AFRICA
Mental illness is a phenomenon in all societies. The predominance of preliterate societies in sub-Saharan Africa before the nineteenth century meant fewer written records on medical systems that could enable us to study mental illness in precolonial Africa and the efficacy of traditional African therapeutic systems. Diviners, priests, and healers (including herbalists) have a long tradition of healing in Africa, and their practice certainly predated the colonial encounter. Their skills were particularly indispensable in the case of mental illnesses, which many African societies even in the 1980s ascribed to supernatural causes such as witchcraft or offenses against the gods and ancestors (Odejide, Oyewunmi, and Ohaeri 1989, 709). It is, however, with the colonial encounter that we have our first studies of the African mind, usually by colonial psychiatrists and medical practitioners, and by extension of African healing traditions by curious Western medical men. The racial context of colonialism informed psychiatry, coloring psychiatric observations with racial prejudice and bias. Colonial psychiatry became not just a scientific interrogation of mental illness among Africans, but also an endeavor to explain the African psyche and cultures. Or, to be more precise, "African culture," since key practitioners of colonial psychiatry, such as John Carothers, assumed a common African culture that had produced a generic African individual. Consequently, sweeping statements could be made about the African psyche, such as: "The psychology of the African is essentially the psychology of the African child. The pattern of his mental development is defined by the time he reaches adolescence and little remains to be said" (Carothers 1953, 106).
Perhaps, this should not surprise us. Foucault (1988, chap. 9) reminds us of how the positivism of the nineteenth century, which cloaked psychiatry in the discourse of science, obscured the reality of psychiatry's foundations at the end of the eighteenth century in family and authority, law, and social and moral order. Colonial rule appealed to psychiatry's authoritative predisposition. By the 1980s the psychiatrist and medical anthropologist Arthur Kleinman would critique the strong turn toward biology in psychiatry and the push back against culture, as advances in psychoactive medications in the previous two decades had generated excitement in the field about finding the magic bullet for every psychiatric ailment (Kleinman 1988, 1). Colonial psychiatry in the first half of the twentieth century was caught between these two poles: struggling to account for the interactions between biology and culture, and seeking objective evidence about African psychopathology in racialist science and biology. Given that it was trapped in a European mind-set that assumed the cultural superiority of the European and the naturalness of European rule in Africa, this was not an easy undertaking. The contradictions in these positions would call for a psychological, rather than a sociopolitical, analysis of the Mau Mau movement in Kenya in the 1950s and the strong British denial of its nationalist roots (Carothers 1954). In its preoccupation with social and moral order, colonial psychiatry became a handmaiden of colonial hegemony. Psychiatry's investment in social and moral order has continued into the postcolonial period, leading to intriguing overlaps in lay and psychiatric opinions on major social issues.
The psychiatric literature about Africa changed significantly with the continent's independence in the 1950s and 1960s, as trained African and Western psychiatrists began to practice and conduct research in an entirely different political environment. It quickly became evident that psychiatric disorders (both neurotic and psychotic) were as common in Africa as they were in the West across age, gender, and rural-urban divides (Diop et al. 1980; Giel and Van Lujik, 1969; Giel et al. 1981; Leighton et al. 1963). Several comparative studies removed the artificial divide in conceptualizations of mental illness between those in Africa and those in the West. In some newly independent African countries like Ghana, attempts were made to incorporate indigenous healers into the formal health system (Warren et al. 1982), a trend that has been pursued more systematically in southern African countries like Mozambique and Zimbabwe (Luedke and West 2006). Such attempts built on insights from colonial ethnopsychiatrists like Margaret Field in Ghana, who presented a sympathetic evaluation of indigenous therapeutic practices in psychiatric conditions such as depression (Field 1955). Thomas Lambo in Nigeria in the 1950s pioneered community-based psychiatry at the Aro Village system in Abeokuta, housing psychiatric patients and their attending relatives in collaborating villages and partnering with indigenous healers. The wisdom in these initiatives is underscored by Jerome Frank's observations that "part of the efficacy of psychotherapeutic methods lies in the shared belief of participants that these methods will work" and that these methods would vary across historical time and space (1974, 3).
The 1970s and 1980s witnessed foundational works on ethnopsychiatry and the history and culture of Western psychiatry in Africa (Janzen 1978; Sow 1980; Yoder 1982). Some were written by trained psychiatrists, who sought to situate their training in Western psychiatry within African cognitive frameworks and cultural practices (Sow, 1980). Works by historians and anthropologists have examined the social construction of medical knowledge, and how Western medical science in the colonial era framed the production of knowledge about the African (Hunt 1999; Lyons 1992; Vaughan 1991; Wylie 2001). A few works are beginning to provide an African perspective on the encounter with Western medicine during colonial rule (Flint 2008).
The growth in the interest in psychiatry in the last two decades has been obvious, as postmodernism underscored the subjectivity of knowledge and the multiplicity of texts and has placed a premium on African agency and autonomy, even in the colonial period. Foucault has been instrumental to this interest, as his works have shaped our understanding of the technologies of rule through seminal studies on the birth of the asylum, the clinic, and the prison. As a "soft" medical science, psychiatry may have lent itself more than any other discipline to manipulation and contestation in colonial Africa. Colonial psychiatry was not an uncontested field, for the efficiency that germ theory and the discovery of vaccines lent biomedicine in the treatment of physical diseases was absent in the realm of colonial psychiatry (Keller 2007; Sadowsky 1999). The very fact that the definition of mental disorder is conceptual and not empirical (Cooper 2005) strengthened the relevance of alternative paradigms and therapies in Africa, and some Western-trained psychiatrists conceded the viability of African psychotherapeutic practices even during colonialism (Sachs 1937).
The remainder of this chapter will examine the provision of psychiatric institutions and changing therapeutic practices in Africa in the nineteenth and twentieth centuries. It does not claim to be an exhaustive review, as it would be impossible to provide adequate continental coverage. It intends to set out some of the key developments in the thinking and practice of psychiatry in Africa, which will serve as historical context for the essays in this volume and an introduction to readers who may want to read further in this area. It begins with the colonial period and the provision of lunatic asylums to confine the mentally insane. As many studies have emphasized, there was no great confinement of the mentally ill in Africa as happened in nineteenth-century Europe (Foucault 1988), and asylums did not constitute an arm of colonial social control (Sadowsky 1999; Vaughan 1991). In many cases, colonial asylums were designed to remove the insane from public places, since they were more of a nuisance than a danger to the public. The role of the asylums was primarily custodial. The provision of care and a commitment to curing in the 1940s and 1950s due to advances in chemotherapy and a growing resort to electroconvulsive therapy coincided with decolonization and African independence and ushered in a new era of African psychiatry.
The context was then set for the first Western-trained African psychiatrists to turn the practice of psychiatry in Africa in new directions. Pioneers included Tigani El Mahi in the Sudan (the first Western-trained African psychiatrist) and Lambo of Nigeria, two psychiatrists who were keenly aware of how social contexts and relations framed both the experience of mental illness and its treatment. Through the Aro Village system, later attached to the University of Ibadan, Lambo sought to provide a conducive and familiar African environment for the treatment of mental illness. Thus in Africa a precedent was set for community care in mental health before this direction became evident in the West. Another important site of innovation was the Dakar school at Fann Hospital, led by Henri Collomb, which took a multidisciplinary approach to the study of mental illness in Senegal and was commited to understanding local representations of mental disorder, as well as indigenous forms of control and socialization (Collignon 1995-96, and this volume).
The focus of this chapter is more on Western psychiatry as introduced in the colonial era and practiced in the postcolonial period, though some reference is made to African, Muslim, and Christian healing practices. I examine the introduction of psychiatric institutions in the colonial era, the rationale for their creation and their place within technologies of colonial rule, the initial custodial nature of psychiatric institutions, and the gradual shift to effective therapy and cure beginning in the 1950s, which coincidentally was also the period of African nationalism and independence. New drugs and a new mind-set would underpin a new practice of psychiatry in independent Africa, where some of the most innovative developments in psychiatry occurred until the economic and political challenges of the 1970s and 1980s undermined the infrastructure of psychiatric practice, ironically just when the need for psychiatry was increasing. The review ends with the 1990s and the birth of the new millennium, when civil wars ravaged Africa and created waves of traumatized refugees, and soaring rates of HIV/ AIDS led to depression among sick adults. The impact of mental illness on AIDS orphans, the growing ranks of destitute youth, and teenager-headed households has yet to be studied in any detail. In line with the earlier statement about psychiatry's preoccupation with social and moral order in the colonial period, a short case study on cannabis and madness in postcolonial West Africa ends this chapter, to underscore the overlap of lay and psychiatric opinions and the fact that—as Kleinman recently put it—psychiatric diagnosis is "an interpretation of an interpretation" (personal communication, February 2, 2011). Kleinman observes that "culture and profession contribute significantly, if more or less tacitly, to the construction of mental illness" (Kleinman 1988, 73).
The imposition of colonial rule was accompanied by the establishment of asylums, not necessarily as an instrument of social control, as I have mentioned above, but as part of the infrastructure of colonial rule. In this regard, asylums—together with hospitals, public works, and censuses—were part of the making of the colonial order. The earliest asylum in sub-Saharan Africa was opened by the British in Freetown, Sierra Leone, one of West Africa's oldest colonies. This was the Kissy Lunatic Asylum, a facility that was used for all types of dependent people, including the mentally and physically ill, starting in the 1820s. It was designated a colonial hospital in 1844 (Bell 1991, 44). In the nineteenth century it received mental patients from the Gambia, the Gold Coast, and Nigeria, other British territories in West Africa (ibid., 16). In colonial Nigeria specialist asylums for the mentally insane were built in Lagos in 1903 (Yaba Asylum) and in southeastern Nigeria in 1904 (Calabar Asylum) (Sadowsky 1999). The Gold Coast gained its first asylum in Victoriaborg in 1888, and a new asylum was opened in Accra in 1907 (Forster 1962), which is the site of the Accra Psychiatric Hospital today, in a suburb now known as Asylum Down. In 1868 the government of the Colony of Natal passed southern Africa's first legislation authorizing the detention of the "dangerously insane" or those "of unsound mind" (Parle 2007, 4). Natal Government Asylum became the first asylum in the subregion to be constructed specifically for the insane. In Southern Rhodesia (now Zimbabwe) Ingutsheni Hospital was opened in 1908. Zomba Asylum was built in Nyasaland in 1910, and in the same year Mathari Mental Hospital was constructed in Kenya. Femi Oyebode points out correctly that "many of these asylums were extensions of the local prisons and often complemented other designated areas in prisons and annexes that functioned as prisons" (2006, 321). The objective was to remove the disorderly, the destitute, and the dangerous from public view. The impetus for the establishment of asylums was more complicated in settler colonies with their more conspicuous politics of racial superiority, and more elaborate psychiatry services characterized areas where European populations were largest (Keller 2007; Parle 2007; Swartz 1998).
It follows, then, that the process of committing a mentally insane person was political (Akyeampong 2006), as chiefs and colonial officials mediated the diagnosis of insanity. At a time when asylums were largely custodial and not curative, trained psychiatrists were rare in colonial Africa, and physicians doubled as psychiatrists when needed. In the 1930s Yaba Asylum shifted from its strictly custodial role and began to provide treatment for its patients, a pattern that become noticeable all over colonial Africa (Oyebode 2006). The 1930s had seen the introduction of electroconvulsive therapy, and a better understanding of neurology had created some optimism that intervention in mental illness was possible. This shift was underpinned in Britain by the passage of the Mental Treatment Act of 1930, which sought to "encourage voluntary treatment and to promote psychiatry as a curative rather than a custodial discipline" (McCulloch 1995, 9). Prior to this a pamphlet written in 1928 by the secretary for the British National Council for Mental Hygiene, J. R. Lord, had proposed measures that would encourage voluntary admission and advocated a change of name from "asylum" to "mental hospital" and from "lunatic" to "mentally ill person." Lord stressed the need for medical personnel with psychiatric experience in mental hospitals, underscoring a transition from a custodial to a therapeutic agenda (Bell 1991, 58).
An important landmark in the history of psychiatry in sub-Saharan Africa was a survey conducted on psychiatric care in colonial Nigeria by Robert Cunynham Brown, a doctor, in 1936. He found much that was commendable about the care traditional healers provided for the insane, and he assessed their role in a very sympathetic light. However, he found many government asylums in Nigeria to be inadequate, with prisons often doubling as asylums, and he recommended the use of a village system of care that would combine a familiar social environment with modern medical care (Asuni 1967; McCulloch 1995, chap. 3). This challenge would be taken up in the 1950s, when Lambo returned to Nigeria from England in 1953 to work at the Neuropsychiatric Hospital in Aro, Abeokuta and established the Aro Village system.
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Table of Contents
Introduction: Culture, Mental Illness and Psychiatric Practice in Africa
Emmanuel Akyeampong, Allan Hill and Arthur Kleinman
1. Historical Overview of Psychiatry in Africa
2. Common Mental Disorders in Sub-Saharan Africa: The Triad of Depression, Anxiety, and Somatization
Vikram Patel and Dan Stein
3. Schizophrenia and Psychosis in West Africa
Ursula M. Read, Victor Doku, and Ama de-Graft Aikins
4. Mental Illness and Destitution in Ghana: A Social Psychological Perspective
Ama de-Graft Aikins
5. Children and Adolescent Mental Health in South Africa
Alan Flisher, Andrew Dawes, Zuhayr Kafaar, Crick Lund, Katherine Sorsdahl, Bronwyn Myers, Rita Thom, and Soraya Seedat
6. Some Aspects of Mental Illness in French-Speaking West Africa
7. Local Interpretations of Global Constructs: Women’s Reports on Mental Illness in Africa
Allan G. Hill and Victoria Demenil
8. One Thing Leads to Another: Sex, AIDS, and Mental Health Reform in South Africa
Pamela Y. Collins
9. Health Care Professional Mental Health and Well-Being in the Era of HIV/AIDS: Perspectives from Sub-Saharan Africa
10. The Role of The Traditional Healers in Mental Health in Africa
ElialiliaOkello and SegganeMusisi
11. Improving Access to Psychiatric Medicines in Africa
Shoba Raja, Sarah Kippen and Michael Reich
12. Child Solders and Community Reconciliation in Post-War Sierra Leone: African Psychiatry in the 21st Century
13. Using Mixed Methods to Plan and Evaluate Mental Health Programs for War-Affected Children in Sub-Saharan Africa
What People are Saying About This
Cultural, historical, and mental health perspectives on the sub-Saharan African context come together in these distinctive studies while also providing a sense of where the field of psychiatry stands in terms of African practices today.