We at CIHA Blog have followed representations of mental health in West Africa (for example, see this Track Changes piece published last year). Recently, Brian Goldstone, a 2017 Luce/ACLS Fellow in Religion, Journalism and International Affairs at Emory University, published a haunting and beautifully written piece entitled “A Prayer’s Chance” (Harper’s Magazine, 2017). He highlights not only the stigma of mental illness and challenges of living with it for the individual and family members, but also the broader structural issues of inadequate biomedical and alternative treatment options. In Goldstone’s piece, he highlights that some experts have begun advocating a rapprochement between prayer camps– “secluded places where people struck with madness come to be cleansed of the demonic forces holding them captive”– and Ghana’s formal health system, citing a recent article co-authored by a group of scholars from Yale, Harvard, and the University of Ghana. In this blog post, one of the authors of the cited report, Dr. Angela Ofori-Atta, comments on Goldstone’s piece and expands on some of the key points raised from a practitioner and activist scholar’s perspective.
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By: Angela Ofori-Atta
Brian Goldstone’s article on prayer camps in Ghana leaves me sad and almost weary…almost! His article is for the most part balanced and sadly reflective of the journey for the majority of people living with mental illness and their families. It is also true of people who live with chronic illness who are in search of a cure, rather than management, of illness. On the whole, I find Goldstone’s article realistic, grounded and truthful.
I have practiced as a clinical psychologist in Ghana for 24 years. In that time, I have taught countless numbers of medical students to manage mental illness as they would manage any other chronic illness: to give hope, to help families understand the nature, cause and course of illness, to refer to psychiatry for acute, difficult phases only but to essentially keep their patients at home as long as is possible, living as normally as possible with illness. I have taught clinical psychology and ethics to post-graduate students and supervised over 100 of them through their 500 hours of required practicum training, as well as mentored quite a few young psychologists, doctors and psychiatrists in my 24 years of service to the University of Ghana School of Medicine and Dentistry.
In the 1990s, the department of Psychiatry, in collaboration with the Danish International Development Agency (DANIDA), encouraged the Ghana Health Service to hire Community Psychiatry Nurses (CPNs) for each district in Upper West Region. The result: the chains fell off people with mental illness. Our department provided supervisory support from psychiatrists and psychologists once a quarter. Then we launched community research which revealed how much alcohol was in pito, the local brew, and shockingly, the variety of over-the-counter medication abused in rural communities to manage the aches and pains associated with the hard labor of farming. These medications included codeine, sleeping tablets, amphetamines, anxiolytics, and alcohol, which led to fetal alcohol syndrome in infants, liver disease, and likely increased frequency and severity of seizure disorders.
But returning to Goldstone’s article, in our latest research, we have sought to demonstrate the efficacy of administering medication in a prayer camp, with psychiatry residents and medical officers diagnosing and prescribing treatment, and a community mental health officer administering medication, and reporting any side effects to the prescribing doctors. There are literally tens of these ‘prayer camps’ in each region around Ghana. They may exist as part of a regular Pentecostal prayer center or a traditional healing center that provides a place of healing for people with all manner of illnesses. Usually a relative stays with the sick person to care for them and when healing is complete, the family comes to thank the healer with donations of money and gifts of food. If the sick person gets agitated or violent, the only recourse to contain them is to place them in chains. Two brothers, George and Jonathan came to the camp completely psychotic. They were approximately 17 and 19 years old and their mother had lost hope. As they qualified for the study, they were placed on medication, gradually got better, and were let out of their chains within four weeks. When I first met them, they were jauntily making new friends in the camp and Jesse, the staff member responsible for them, said to me: “when I see George and Jonathan, I believe in the power of medicine to heal this sickness.” It was hard to believe that they had been psychotic and chained.
The hypothesis for the study was that medication would lead to better health outcomes for patients, and ultimately to the removal of chains. As one would expect, medications did lead to better health outcomes and to a trend in the chains coming off. But this was random. Reasons given by the care-givers at the camp for chains not always coming off, even with a lifting of psychosis, was the fear that patients would run away without their relatives ever finding them again; or that they might yield to the strong craving for street drugs (marijuana, cocaine, heroine, tramadol, etc.) which would lead to a return of psychosis; or to avoid incidents of aggression between patients. Basically, as Goldstone rightly asserts, the absence of proper safeguards in the buildings of prayer camps, if there are any buildings at all, makes it impossible to care for patients safely, hence the resort to chains. When we visited Edumfa, they had avoided injury caused by chafing of the chain by having patients wear socks first.
As patients exited the study, they participated in group discussions on mental illness, including how to take care of themselves and the importance of staying on medication. At the start, they could speak of little else but the chaining and the hunger from fasting. To participate in the study, we had come to agreement with the prophet at the camp that participants in the study would not be forced to fast when involved in the study, and when on medication. Gradually, as more and more patients entered the study, exited and remained on medication, the food bill begun to grow and the prayer camp begun to experience difficulty feeding patients. And a fast would be declared from time to time……….! Alas! In our discussions with the care-givers, they would point out to us that this was a spiritual exercise, and the purpose of the camp was to pray. Fasting and prayer was therefore a part of the healing process.
And yet, when we attempted a discharge plan to ease the congestion, camp staff were not supportive and showed little interest. We realized that even though they had soon come to accept that medication made their work easier and their patients better, they would often not inform the Chief Mental Health Officer (CMHO) about patients whose relatives were ready to take them back home and so relatives were not informed about the need to continue with medication, often believing that patients were better because of prayer alone. Patients soon suffered a relapse and a return to the camp and possibly to chains if it was deemed necessary by the camp staff. Even when families knew that patients had improved on medication, there was little access to medication outside of the camp due to a crippling shortage; the government of the National Democratic Party had not imported psychoactive medication into the Government’s Central Stores for close to three years!
Unlike busy Edumfa, the camp we worked in did not do much in the way of teaching the Bible or prayer to the patients. Thus, this part was sorely lacking and patients were clearly bored. Patients saw the prophet once a week for prayer and joined in the mid- week and Sunday services of the prayer camp, but they had little one-on-one instruction.
We had workshops for the staff, teaching them the psychosocial model of illness, proper boundaries, sanitation, side effects of medication, and so on. These workshops prompted interesting discussions. And a year later, we returned to the camp, and saw that there are only tiny glimpses that we had been there; the camp pays for a CMHO to ensure patients take their medication daily after they have been diagnosed by a Community Psychiatric Nurse (CPN) or medical officer. Little else has changed, sadly. We would have wished to see patients regularly discharged home with medication, group scriptural classes and regular prayer sessions, and most importantly, no chaining of patients.
We are not done, however. We believe that the study allowed us a foothold into the camp; a chance to build a relationship of trust between two different worlds; the secular and the religious. Now we are at an impasse. We would like to do more but we need to insist that our partners from the religious side meet us halfway and commit to a camp without chains. We think of our study as the carrot. Now we need the stick; the implementation of the Mental Health Law which Brian Goldstone wrote about. In that law, a person cannot be held for longer than 72 hours against his or her will, and must either be sent to a hospital or handed over to the police. We think that prayer camps ought to send people with mental illness to hospitals for assessment and treatment. There are three psychiatric hospitals in southern Ghana and six smaller psychiatric units attached to regional/district hospitals around the country. Then recuperating patients may return to prayer camps to recuperate and to be cared for according to their beliefs, without the human rights abuses reported in recent times. When they come with their sanity restored, and of their own free will, the camps then provide the peaceful havens and prayer support these believers need.
The implementers of the Mental Health Law ought to be the Mental Health Authority and all district health management teams which ought to have a mental health coordinator who leads the charge on prayer camps, bringing to bear, the full authority of the law as well as partnership for mental health care. In this way, prayer camps will not be allowed to accept patients who cannot stay without being shackled. Camps should then evolve into true sanctuaries for people with mental illness on treatment from mental health professionals and who are thus able to access healing and teaching in prayer camps. Prayer camps which keep patients in chains will therefore have to answer to the law.
Why not close them down all together? Because, as my friend and fellow researcher Betsy says, it is the belief of 97% of people with mental illness, those who fall into the treatment gap, that they will receive their miracle from a prayer camp. This belief must not translate into abuse or negligence, but can be actively mobilized for healing. Besides, there are not enough hospital beds to accommodate all who need care. Moreover, we think our psychiatric hospitals ought to be used for brief assessments and the beginning of medical treatment prior to referral to places of convalescence such as safe prayer camps without chains.
But we dream of even more. In the last five years, our departments of Psychiatry and Psychology in collaboration with Yale University, convinced the Ghana Health Service to place lay counselors alongside CPNs in districts. These lay counselors are psychology graduates doing their mandatory national service providing psycho-education, psychological first aid and documentation of harmful practices in mental health across the country. We called them “Psych Corps” and each year there were close to 100 graduates who received an orientation for relevant lay counseling skills to work within communities. We have received favorable responses from the communities within which they work and from the CPNs whose work is made easier by their presence. The next step is to train them in implementing cognitive behavioral interventions through group work with patients. We have strong evidence from a pilot that this format works very well in Ghana where we built resilience among participants over a three-month-long weekly intervention of teaching people to listen to their thoughts, identify and label distortions, challenge them and replace them. We also had modules for interpersonal conflict resolution, healthy living, anger management and planning for the future. Our Psych Corps members will begin to provide this at outpatient clinics of mental health institutions with manuals and supervision from clinical psychologists.
We believe that the prayer camps are not to be shunned by health professionals simply because the ethics of working in these places are so difficult to get right. 97% of those who need care have very few choices in our country. We need to be where they are to bring about change and to offer care, healing and comfort. We ask ourselves:
- Will we make a difference by being there even for the short while?
- Could we teach what we learn to the next generation of doctors and psychologists?
- Will this reduce fear and stigma?
- Could we do more to take away the chains?
And we think the answer to all of these questions is yes! And so we will persevere! We dream of prayer centers with no chains, no forced fasts, simply places of prayer and compassion. We dream of a health service which is assertive enough to insist on these and is ready to partner with indigenous systems of care for the good of the patient. We dream of a country where people with mental illness are granted their human rights as a matter of course.