Introduction – Western Institutions
For a multitude of reasons relating to misinformation, limited resources and instability, national policies designed to meet the demands of the mental health crisis currently crippling Sub-Saharan African (SSA) countries have been lethargic. Likewise, in responding to the substantial material deprivation afflicting the global south at large, international NGOs consistently neglect the importance of addressing psychological needs. The Adjei Foundation seeks to be at the forefront of changing attitudes amongst policy-makers and CEOs who head NGOs in SSA. In this article, we will be taking a look at research from Johns Hopkins University that works against current trends. In particular, we will focus on the non-judgemental sensitivity paid to cultural difference that this western institution demonstrated, working with the domestic country rather than seeing it as a charity case requiring Western knowledge to fix its problems. This approach has been critical to the continuing success of subsequent interventions carried forth by StrongMinds (a social enterprise providing mental health care to women in Uganda and Zambia). Throughout the article, we stress the importance of understanding a culture on its own terms from within – a perspective of amplified importance when dealing with mental (rather than physical) health difficulties due to the influence of culture and subjectivity upon them.
What can Western Institutions do?
In her Ted Talk entitled ‘The Danger of a Single Story’, Nigerian novelist Chimamanda Ngozi Adichie stresses how “power structures tend to make a single perspective the most definitive way of understanding a concept”. In understanding the concept of mental health in SSA countries from a western perspective and telling our story about it (what we are doing here!), it is paramount to recognise our own biases, whilst being open to the plurality of understandings and stories told about mental health by local people in specific regions and cultures. Toronto-based First Nation psychologist Dr Suzanne L. Stewart derides the treatment of mental illness in indigenous populations from a western perspective as a subtle form of colonial oppression, one that does not “legitimise [indigenous people’s] world views or treat their cosmologies as valid in their own right”. Thus, the question becomes: How do we draw on the wealth of resources, research and experience in the field of western psychological therapy without committing ethnocentric myopia when operating in the global south? How do we avoid the ‘dangers of the single story’ told about mental health?
To address this question, we turn to an outstanding piece of research led by Johns Hopkins University in 2003. The project sought to uncover an effective and scalable psychological intervention to address the depression epidemic in rural parts of South-Western Uganda. From the outset, the paper’s disarmament of sanctimonious attitudes was apparent. In the absence of epidemiological information on clinically significant depressive symptoms in the sample population, a hybrid of approaches were taken to gauge the severity and extent of depression: The Hopkins Symptom Checklist was used in tandem with a locally developed assessment, and these datasets were corroborated with separate interviews informed by ethnographic research and conducted by local healthcare workers. In understanding the story told about depression in this part of the world, the researchers identified two key concepts: ‘Okwekubaziga’ (which roughly translates as ‘self-pity’) and ‘Okwetchawa’ (self-loathing). The latter was significantly present in those deemed clinically depressed by the researchers, and local traditional healers declared an inability to treat it. As gauged by these heterogeneous measures, depressive symptomatology was found in 24% of the population – a stark finding, considered high by western and regional standards. Let us remind ourselves that, globally, depression is ranked second only to heart disease as a leading cause of disability-adjusted life years (i.e. years burdened and lost to ill health). Depression is a serious killer – such a statistic ought to empower us to act in the same way images of famine, flood, and war do.
Following Wilfred Mlay, the African Regional Ambassador to the WHO – who has been notably instructive in blending mental health into efforts to realise the millennium development goals – the researchers sought to develop a culturally appropriate, evidence-based intervention that could be integrated into local mental health services. When selecting a therapeutic technique, the researchers opted for interpersonal therapy (IPT). IPT emphasises the context that surrounds the individual’s depression; it locates the disorder as existing in the relation between the individual and the environment and attempts to examine how people relate to those around them. IPT was selected over cognitive behavioural therapy (CBT), the more conventional therapy used in the west, which locates depression within the individual and seeks to mitigate symptoms by bringing a reflective awareness to individual thought and action. The choice was made with respect to collectivist characteristics in Ugandan culture and society, where people tend to see themselves as part of a family or community unit before they see themselves as individuals; CBT was deemed too ‘alien’ and unworkable within such a cultural context. To make the therapy scalable, available and accessible, the use of relatively expensive antidepressants was bypassed, and interpersonal group therapy (IPT-G) was deemed a necessary adaptation. It seems that the researchers heavily involved the local community health workers in developing a culturally-adjusted IPT-G that they themselves would go on to deliver to their communities.
In addition to these deliberations, the researchers recognised that further and “considerable flexibility had to be built into the structure [of the therapy] to make the project realistic”. We will consider here how remodelling three of IPT’s categories of interpersonal crises – grief, disputes and role transitions – helped to achieve this. The psychological distress that accompanies the death of someone close to us is a human universal. Nonetheless, how we reflect upon and handle grief can shift with cultural custom. In Uganda, it was noted that any projection of negative emotion in the wake of death is scorned upon due to a belief that ‘the dead live among us’. Accordingly, therapy focused on finding positive avenues through which negative emotions could be sublimated. A mother’s grief after losing a child was met with an emphasis on finding a new maternal role in the community, for example, as an elder providing guidance to young girls.
IPT encourages directness and openness when matters of disagreement arise. However, such an approach would not be conducive to common Ugandan social practice. For example, tension in a marriage may manifest as the wife cooking poor quality food for the husband rather than direct verbal expression. Avoiding any value judgements, the researchers considered what would be workable within this context, such as seeking console from friends in a safe and open space, where qualms about the relationship could be vented. Here, the therapy permits negative emotion to find its expression, preventing an internal backlog of repressed emotions that could bring about intense outbursts or further health complications.
The third category – role transitions, or life changes – was distinctly marked by factors external to the families and small communities involved in the research project, such as the effects of war, tyrannical regimes, public health crises (at the time, notably, the aids and HIV pandemic) and the global economy. The onslaught of these oppressive forces often combined to undermine the autonomy and dignity of the average Ugandan in ways significant for physical and emotional well-being. The authors highlighted the example of a man in his 40s whose small business was sabotaged by the global economy’s effect on Ugandan coffee prices. The two years that followed the business’s closure saw the individual spiral into depression, where symptoms manifested as insomnia and psychomotor deficits. Whilst recognising the injustice that underscored such conditions, the researchers remained pragmatic. Borrowing from CBT, the individual was encouraged to recognise and label the effect that the depression had in dovetailing with this genuine loss of autonomy and, further, to identify factors still within the individual’s control. As a result of this technique, and via the opportunity to share and listen to similar accounts from others within the community in a safe space, symptoms began to ease. The individual went on to find the courage and mental clarity to make contact with former colleagues, eventually setting up a new business in a nearby town that he reported as tending to contently and symptom-free.
The example presented above provides us with a clear insight into how material resources that support dignity and autonomy for communities such as those in South-Western Uganda are restricted by preventable global inequalities. We do not seek to obfuscate such injustices by refocusing on cheap, temporary psychological fixes (i.e.“Your livelihood has been uprooted by western business interests in the region? Hmm, have you tried CBT?”). The Adjei Foundation strives to promote an understanding of well-being in SSA that includes mental health, and support efforts to build effective systems that address issues around mental health alongside issues of material injustice. We are firm in our belief that recognising both material and psychological needs will provide the most efficient route towards prosperity and well-being in SSA.
So, in this Johns Hopkins-led randomised clinical trial – a methodology considered the gold standard in psychological research – with a sample size of 224 men and women, the culturally-adjusted IPT-G proved to be a clinically relevant therapeutic approach to treat depression in this SSA context. Despite initial barriers, the local population accepted the notion of an intervention for depression. Subsequent attendance for the IPT group was high, the drop-out rate was much lower than in the control group, and post-therapy assessments found a strong effect for the intervention group. A lasting effect was also evidenced in follow-up reports, whereby the IPT group members continued to support one another after the clinical trial had finished. In sum, the intervention was a success, and this research has gone on to inform mental health provision in SSA since (via organisations such as StrongMinds).
So what should we take away from this? Despite the difficulties inherent in providing psychological intervention cross-culturally, it appears that, at its core, the creation of safe and open spaces to express weighty psychic baggage to receptive listeners may be an underlying mechanism that can provide mental and emotional solace to people, irrespective of cultural background. Conversely, a deep understanding of the culture from within, and on its own terms, is of the highest necessity if interventions are to be successful. And despite touching on some universality in mental-health treatment here, the contouring and delivery of this provision must inevitably be culturally appropriate. Insights from thoughtful research such as these can help to specify the roles that well-meaning western institutions can play in SSA when collaborating with efforts to broaden and strengthen mental health services.
BIBLIOGRAPHY:
Akomolafe, A. C. (2012). Decolonizing the notion of mental illness and healing in Nigeria, West Africa. Annual Review of Critical Psychology, 10, 726-740.
Mlay, W. (2010) NGO Perspectives on Mental Health and Development [Speech transcript]. WHO Panel discussion: An Emerging Development Issue: Integrating Mental Health into efforts to realize MDGs and Beyond. https://www.un.org/disabilities/documents/mlay.doc
Stewart, S. L. (2008). Promoting indigenous mental health: Cultural perspectives on healing from Native counsellors in Canada. International Journal of Health Promotion & Education, 46(2), 12-19.
Verdeli, H., Clougherty, K., Bolton, P., Speelman, L., Ndogoni., Bass, J., Neugebauer, R. & Weissman, M. (2003). Adapting group interpersonal psychotherapy for a developing country: experience in rural Uganda. World Psychiatry, 2:2, 114-120.
WEBSITES AND LINKS:
Chimamanda Ngozi Adichie Ted Talk, ‘The Danger of a Single Story’: https://www.ted.com/talks/chimamanda_ngozi_adichie_the_danger_of_a_single_story?language=en
StrongMinds: https://strongminds.org/
