Sanitising the Mental Health space in Nigeria

Issues of Mental Health and Mental Illness have been with humanity from the beginning of time.

Unusual behaviour manifested by a person may be regarded as within acceptable limits and may even be passed off as unique identifying characteristics. However, from early times, people manifesting behaviour which makes it difficult for them to live comfortably in society, or for society to live safely with them, are labelled ‘abnormal’, and generally isolated. Such isolation may be for the purpose of offering them some form of remediation that will return them to what is perceived by others as ‘normal’.

‘Treatment’ of Mental Illness in the early days was rudimentary and often cruel. Physical restraint and harsh measures such as whipping were employed. The mentally ill were ‘aliens’, and the people who looked after them were ‘alienists.’ The early Mental Hospitals were essentially places for keeping these ‘aliens’ out of sight, which was why they were often built on the outskirts of towns. The first such hospitals in Nigeria were built in Calabar, Yaba, and Aro, in that order.

In Western society, the role of ‘alienists’ was taken on from the beginning by psychiatrists – medical doctors who specialised in the care of the mentally ill. In traditional Yoruba society, the same role was played by onisegun (herbalists) and Babalawo (people who used divination and other spiritual means, in addition to herbs, to treat illness).

The general perception of mental illness in the early days reflected a belief that it always involved disturbed thinking and disordered behaviour, with a variable mixture of abnormal perceptions such as seeing things or hearing voices or other sounds that other people could not see or hear. This essentially ‘psychotic’ view of mental illness led to an ‘us’ and ‘them’ understanding among the public. ‘They’ who were ‘mad’ were different from ‘us’, who were not. Widespread stigma was created against the mentally ill, so that even after effective treatments became available, those who recovered were not welcomed back to work and family with open arms.

As understanding improved, it turned out that the ‘psychoses’ represented only a minority of mental illnesses. Most people experiencing mental illness were not ‘psychotic’. They were ordinary citizens experiencing depression, anxiety or related conditions, suffering distress within themselves but often continuing to carry out the rituals of work, family and normal living, although their performance might be impaired.

Mental illness is not rare. One out of every five people will at some point in their lives experience a diagnosable mental illness. Most of those diagnoses will be ‘minor’ Mental Health conditions such as Depression or Anxiety. Most of the people with treatable illnesses in this environment, even now, never get to seek help or see a specialist.

COVID-19 was an eye-opener for Nigerians, and a reality check. For the first time, during the lock-down and prevalent sense of insecurity, many Nigerians experienced and acknowledged mental distress in themselves and, for the first time, were eager to seek professional help.

It led to a massive efflorescence of ‘Therapists’ and ‘Specialists’ offering services both online and in-person, in addition to the previously recognised, mostly hospital-based Psychiatrists and Psychologists. The field of practice as it pertained to ‘Psychotherapy’ for ‘Minor Mental Disorders’ and problems in Work and Relationship lives became an all-comers affair, an ungoverned space. It became a lucrative field where people with all manner dubious qualifications advertised and administered their services online or in-person to the public without filter or regulation.

Formal education in Psychotherapy is part of the professional training of Psychiatrists and Clinical Psychologists. In addition, there are recognised Diploma courses in Counselling – a superficial form of Psychotherapy, and various modalities of Psychotherapy that people in related fields such as Occupational Therapy or Social Work may undergo. Many lay persons also undergo such courses and get certified in them.

In conventional mental hospital practice in Nigeria and many African countries, all patients are first seen by the psychiatrist, who then decides whether to make a referral to a psychologist for input such as psychometric testing or psychotherapy.

Many psychologists nowadays practise autonomously outside the hospital system, offering their services directly to the public. Many are offering Employee Assistance Program (EAP) or providing services for Occupational Health and Human Relations departments in Industry.

Some people are aggrieved at this reality and want to put a stop to any possibility of Psychology being registrable as a profession sui generis. This is akin to closing the stable door after the horse has bolted. Employee Assistance Program (EAP) was started by psychologists in the USA to counter the industrial financial loss from rampant alcohol related problems among employees. It is now a holistic psychological wellness counselling service that is offered by gold standard employers all over the world, including the TELCOS, Oil Majors and Banks of Nigeria, among others. It has its own certification system, and is run by psychiatrists and psychologists, and by appropriately certified persons from related specialties.

There is a pressing need to regulate the Mental Health space in Nigeria, but it cannot be done through an atavistic throwback to the procedural hierarchy of the old mental hospital. Hospitals may continue to function with their accustomed protocols. In general society, psychiatrists and psychologists, as line specialists of psychotherapy practice, would need to learn to live together. Psychologists, not being doctors, cannot prescribe medication or deal with some severe levels of mental disturbance. Such persons should rightly be referred to a psychiatrist. Back and forth referral based on the client’s needs and international protocols is a required element of good practice that should be enforceable, with regulation. With effective dialogue, they can standardise and categorise psychotherapy practice, guiding the Registration and Regulatory agencies in their task of protecting the public from charlatans with dubious qualifications, who inflict unproven, sometimes harmful remedies on citizens.

Such a collaboration is the only way to sanitise the mental healthcare space.

Perhaps it will happen, some day.