Bourdain and Spade: Incantations and Invocations (Part 2: History)

Previously: A look at the history of mental health care in Nigeria and the development of perceptions. Part 1 of this article can be read [here].

Flashforward

In pre-colonial and colonial times, those suffering from mental illness were stigmatised and became community outcasts. Attitudes towards mental illness have shifted, but not by much; mental illness sufferers may not be untouchable outcasts, but they’re still stigmatised, physically and sexually abused, and treated with disdain, disgust, and fear.

Orthodox psychiatric care remains out of reach for most Nigerians, even though care facilities have increased in number; in addition to the private care centres, many government-run and university teaching hospitals now have psychiatric units, but they’re inadequately staffed, have obsolete equipment, and for many, especially in rural areas, neither easily accessible nor trusted. Many of these hospitals are focused on incarceration rather than treatment.

And where care is accessible and affordable, the stigma of mental illness prevents sufferers and their families from seeking help.

Costs also remain a concern; sometimes, care is so expensive that state governments can’t always settle their bills. In July 2013, when budget issues became prohibitive, Ogun State officials were stopped sending homeless mental illness patients to the pricier government-run psychiatric hospital and started sending them to a traditional healing centre where incantation and invocation were the methods of diagnosis and treatment, respectively. While visiting the centre that October, a Slate.com journalist found two patients chained outside the front of the building.

Despite the cons outweighing the pros, however, such non-orthodox healers are still the way to go for many Nigerians.

Trusted Help

As religion and traditional medicine continue to be primary mental health care options for many Nigerians, they have refined their methods to suit the populations they serve. Some Christian denominations have incorporated traditional practices into their forms of worship and apply their practices to those with mental illness, who they consider possessed by evil spirits. Some Islamic sects still address mental illness in terms of spiritual possession. Devotees of both faiths still patronise traditional healers. For the most part, faith and traditional healers use the same tools of the trade that they’ve always used, although some faith healers now quietly add pharmaceutical antipsychotics, like Largactil, to their holy water prescriptions.

However, religious and traditional healers may not be able to fully or properly diagnose mental illness, as their knowledge is largely based on superficial observation and worldview rather than medical experience using medical training and diagnostic tools. Many of their methods are medically unsound and inhumane. They very often end up doing more damage than good in the short- and long-term.

Despite their problems, however, traditional and faith healers continue to see the bulk of Nigeria’s mental illness sufferers. They’re part of the culture. Again; they’re cheap, they’re trusted, and they’re there. Psychiatrists, therapists, and mental health care facilities aren’t as accessible.

So is it time for conventional medicine to plug into the care network that’s actually getting most low-income patients? Do we need an approach to mental health care that’s more culture-sensitive and treatments that are developed to work within our culture?

Working within the Culture

Because culture affects how people understand, talk about, and express mental illness, psychiatrists around the world have begun to develop treatments that work with the culture within which they operate by identifying cultural nuances and applying them to their hybrid treatments. These practitioners create hybrid treatments that they can get their patients to identify with and accept. They connect with their patients and make them understand that they are understood. In Cambodia, for instance, many psychiatrists, speaking to patients in the native Khmer language, use Buddhist metaphors in treatment sessions. A psychiatrist might describe the effects of an antidepressant by saying it’ll “increase the water in the heart, so it will be like the rice fields after a storm.”

Nigerian psychiatrists could develop similar methods for today’s Nigerian patient and Nigerian culture, creating new treatment options and stepping up efforts to educate the populace about mental health. Intensive education efforts would go a long way towards dispelling the stigma of mental illness. Education, however, would begin with care providers; a 2007 study by Adewuya, Abiodun, Oguntade and Ayotunde found that culturally enshrined beliefs about mental illness and its origins were prevalent among Nigerian doctors, despite their training. The benefit of having such perspectives is that they already have a deep understanding of the culture in which they operate that they can then use to reorient themselves with regard to non-orthodox healers.

According to the Association of Psychiatrists in Nigeria (APN), there are currently only 250 psychiatrists, 200 trainees, and 100 associates in the country. That’s for almost 200 million Nigerians. Clearly, the APN must extend their reach. Patients might benefit from APN members working with traditional and faith healers to educate them, giving them tools to diagnose and treat minor conditions, creating incentives for them to refer more serious cases to them, and treating referred patients at subsidised rates they can afford. (And maybe, while they’re at it, cure the general apathy of Nigerian nurses). Education and training could help replace the damaging practices of some healers with a more informed care that employs counselling and frequent referrals.

Orthodox practitioners could also, like Cambodian psychiatrists, develop more culturally-sensitive language and treatments.

But none of these changes will be effective without government input.

Nigeria’s first mental health policy was published in 1991. Two bills, both named the Mental Health Act, were introduced in 2003 and 2013. Both were ambitious; they would protect the rights of people with mental illness, improve access to treatment and care, work towards reducing stigma and discrimination, set standards for psychiatric practice and accreditation of professionals and facilities, and address law enforcement and judicial issues for people with mental illness. The former was withdrawn in 2009 and the latter is yet to be ratified. The outdated 1991 document is still the governing policy.

Without changes at the government level, making significant progress with care provision will be difficult. Nevertheless, changing the approach to mental health care provision and connecting orthodox practitioners to non-orthodox healers can start the work of erasing the stigma of mental illness, making acknowledgement of it in all its forms easier, and finally bringing orthodox psychiatric treatment to the majority of Nigerians. Federal and state governments can catch up when ready, but progress doesn’t have to wait for them. It can begin now.

Then maybe we can finally start putting a dent in those stats.