Nigeria

As in most LMICs, mental health services in Nigeria are underfunded and poorly resourced, and access to mental health services is difficult for the majority of Nigerians. A needs survey carried out by the WHO found that only 20% of people with SMI in Nigeria had received treatment in the preceding year (Wang et al. 2007). Mental health service provision is largely provided at publicly funded community-based general and teaching hospitals psychiatric units and at stand-alone mental hospitals, but often patients have to pay for services themselves out-of-pocket. Furthermore, service provision is majorly centred on biomedical interventions, whereas formal psychosocial interventions and ancillary professionals such as psychiatric social workers and case managers are often in short supply. Wide intra-country disparity exists in both the distribution of treatment facilities and availability of trained personnel, with most services focused on major cities and administrative centres, and rural areas experiencing the most deficits (WHOAIMS 2006). Mental illness stigma is high, as is caregiver burden (Gureje et al. 2005), a not uncommon finding in other LMICs.

Mental health service provision is not modelled on the consumer-driven mental health recovery model that is now dominant in the USA, UK and other parts of the English-speaking world. Rather, patient care still tends to rely more on the paternalistic “doctor knows best” model of care bequeathed by British colonial psychiatry. Until recently, mental health consumer and advocacy organizations were a rarity, thus, service users have not been directly involved in either the formulation or implementation of mental health policies or legislation at any time (WHOAIMS 2006). As such, patients often have little say in decisions as to choice of treatments and interventions. Treatment practices that undermine individuals’ basic rights, autonomy and human dignity get reported in the media from time to time (Westbrook 2011). For example, in 2013, the Nigerian media published many reports that a state governor had orchestrated the forced detention in a psychiatric facility of his estranged wife who was in the process of initiating divorce proceedings against him, allegedly on grounds of domestic violence (e.g., Akukwe 2013; This Day Live 2013).

It would be reasonable to infer that such a treatment system would lead to worse population-level recovery outcomes. Yet surprisingly, there is indication of better illness and social outcomes of SMI in Nigeria as compared to the developed world. Nigeria is one of the sites of the WHO longitudinal studies of outcomes in SMIs that reported better long-term outcomes for patients (Jablensky et al. 1992; Cohen et al. 2008; Myers 2010), indicating yet-to-be- understood processes operating in the social environment that may influence recovery.

Nigeria’s current mental health act, known as the Lunacy Act (1916), dates back to the colonial period. The Lunacy Act has provisions for an insanity plea, involuntary detention and standards for conditions within an asylum, but makes no mention of treatment. Last revised in 1958, the Lunacy Act has been criticized as outdated and “embodying a custodial approach to care, failing to protect human rights that persons with a mental illness are entitled to, and itself being responsible for certain abuses of human rights” (Westbrook 2011, p. 416).

In 1991, the Government formulated its first national mental health policy (FMOH 1991). Still in force, the national mental health policy covers advocacy, promotion, prevention, treatment and rehabilitation. The highlights include giving persons with a mental illness the same rights to treatment as individuals with physical illnesses, the integration of mental health into general health services at all levels, comprehensive care using primary health care (PHC) as a vehicle, combating stigma and periodic review of mental health legislation. The policy also includes a national mental health strategy centred on integration of mental health into the PHC system. While this policy is quite progressive and its spirit consistent with current dominant Western notions of a recovery orientation, recovery is not specifically mentioned or officially defined in the policy. Implementation of the policy has been impeded by governance issues, which include the absence of a dedicated mental health desk at the ministry of health to oversee implementation and the absence of a clear implementation plan (WHOAIMS 2006).

In addition to biomedical psychiatry, however, mental health care and support is also provided by religious and traditional healers, and although not funded by the state, these alternative providers are more ubiquitous and enjoy sizeable patronage from the populace despite the fact that the financial costs incurred by patients who use them can be significantly high in comparison to hospital care (Makanjuola 2003). In terms of their practice, the traditional and faith healers make use of combinations of the medical approach, traditional approaches such as offering sacrifices to ancestral deities and gods, and religious practices such as prophecy, trance and dream (Agara et al. 2008). Often, alternative providers hold illness explanatory models similar to those held by persons with SMI and their family caregivers, a point that has been held as positive and less stigmatizing. On the other hand, traditional practice is associated with a host of negative practices, including physical beatings and use of physical restraints on patients, practices incommensurate with Western notions of recovery (Makanjuola et al. 2000).

Given the poor state of mental health services in Nigeria, the question remains, what explains the relatively better social and functional outcomes of SMI in Nigeria as compared to the developed world? In other words, what recovery processes are in operation in Nigeria and other LMICs that are yet to be understood? Although the WHO studies used outcome measures deemed invariant across individuals and across a diversity of geographical settings, the critique has been made that the notion of recovery used in the WHO studies fails to fully capture recovery as envisioned in the user-consumer movement (Slade et al. 2008). WHO researchers cited “unexplained cultural factors” as a possible explanation for the better illness outcomes in LMICs (Jablensky et al. 1992). The better outcomes have also been ascribed to the coexistence of traditional care systems alongside biomedical (Western) psychiatric services available to individuals with a mental illness because practices of medical pluralism make it more likely that individuals will find treatments to which they respond (Halliburton 2004).

More recently, researchers have suggested as possible explanation the role of families in LMICs, as more accepting and supportive of individual members who develop SMI (Bresnahan 2003; Nunley 1998; Myers 2010). Crosscultural studies of expressed emotion (EE) within families are a case in point. First used in the UK and the USA in the study of schizophrenia, EE has been used as a construct in understanding the interaction, feelings and emotions, between patients and their family caregivers (Bhugra and Mckenzie 2003). Cross-cultural studies of EE in families of persons with SMI, for example, suggest that in LMIC settings, family interactions with individual members who have SMI may evidence much more warmth and positive regard, with an absence of high levels of hostility and emotional over-involvement, two components of EE predictive of poor outcomes in the developed world (Bhugra and Mckenzie 2003). Families may also facilitate improved patient outcomes in LMICs in other ways. For example, a study at a Nigerian psychiatric hospital found that family involvement in treatment during hospitalization was independently associated with greater post-discharge appointment adherence in individuals with SMI (Adeponle et al. 2009). Bresnahan (2003) has suggested that family involvement, acceptance and support of individual members who develop SMI and community cohesion can be understood as contextually relevant practices and processes that reduce stress or increase resilience. They further argue that it is the stress reduction that families engender that possibly accounts for the better illness outcomes seen in LMICs (Bresnahan 2003).

It is important to recognize that family involvement is not always positive or necessarily geared towards the individual interests of the ill member (Cohen 2004). McGruder (2004) in a study of the lived experience of schizophrenia among patients and their family caregivers in Zanzibar (Tanzania) found that while family involvement is the explanatory link between low EE and better illness outcomes, family involvement was diverse and not always positive, and not uncommonly, families would subjugate goals of apparent personal relevance to family interests. McGruder (2004) concluded by noting that local notions about the nature of self, family and adversity mediate how family support is given. In other words, an individual’s perception of family involvement may just be as important as the actual support.

Importantly, positive family involvement is consistent with aspects of the Western notions of recovery in that it is community based, emphasizes individuals’ pursuit of personally relevant goals and instilling hope, and makes use of natural supports (Nunley 1998; Glynn et al. 2006). Thus, one may surmise that positive family involvement in care of persons with SMI, alongside related contextual factors such as less social exclusion and the availability of socially meaningful roles for persons with an SMI (Nunley 1998), plays a significant role in recovery in SMI in the Nigerian context, albeit in the absence of badly needed, currently absent recovery-focused mental health services.

In sum, it appears that in the Nigerian setting, opportunities for recovery occur in spite of a faltering mental health system. Recovery is realized through everyday practices of individuals with SMIs, their family members and caregivers that guarantee a social space within the larger society for persons with SMI. Importantly, these practices are simultaneously rooted both in “tradition” and in present-day sociocultural realities, a continuity that has relevance for efforts to fashion sustainable models of mental health care applicable across diverse cultural contexts (see Susser et al. 2010). In many ways, the current “new” definition of recovery being championed in Western countries may well be old wine in new bottles from the standpoint of individuals with an SMI in Nigeria, their families and caregivers. That said, undoubtedly the “new” recovery has a lot of good from which mental health service provision in Nigeria can fruitfully benefit. Of special importance is the recovery focus on guaranteeing full citizenship and civil rights for individuals with mental illness, including empowering self-advocacy and support for the fledging service user/consumer movement. In Nigeria, this will entail giving legal and political teeth to the issue of guaranteeing both legal and inalienable rights of persons with SMI, including protection against treatment coercion, rights to comprehensive care, adequate funding of mental health services and support for family caregivers.

 
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