Interview! So earlier this year (this was in April 2016) I was interviewed by a postgraduate student from Australian National University.
Her name? Jennifer Kabangu, from Congo-Kinshasa, and she’s presently completing a Masters in Culture, Health and Medicine. As part of her research at the time, she was investigating the effects of culture on mental health, and vice versa. She found me online, reached out and got me interested in talking, and when the time came, she was prepared with really good questions. Her questions were so good and so stimulating, in fact, that when we were done, I asked if I could publish the interview and share it with my readers.
So here it is, lightly edited for clarity. (It’s on the long side, by the way, but I think you’ll find it interesting.) 🙂
Her questions are in bold, by the way, and my answers in regular text.
Ms Kabangu: Okay. I shall go straight into it if that’s okay?
Doc Ayomide: Yes it is.
Ms Kabangu: Firstly, the notion of mental health — is it a Western concept?
Doc Ayomide: No it’s not. Traditional African cultures recognised mental illness long before the whites came. We have names for it. We think of it more as spiritual. Or as curses. But there’s a sense in which we have thought of it as treatable. So it’s kind of all together.
Ms Kabangu: So in a way, the way mental illness has been conceptualised in Africa/Nigeria is similar to the Western conception model?
Doc Ayomide: Oh no, I’m not saying it’s similar. I’m saying there are similarities but they’re still different. In a sense how we think of it is closer to how it was thought of historically. But of course Western conception itself has changed over time. And it’s more medical now.
Ms Kabangu: Sorry, perhaps I’m not clear…what I mean is both systems (Western and traditional) recognise that they are illnesses? That is, there is a mind/body distinction?
Doc Ayomide: Oh yes, both recognise them as illness… Mind body distinction though is more a Western concept, coming from the Greco-Roman tradition. Yeah?
Ms Kabangu: Yes. That’s right.
Doc Ayomide: So there’s kind of a distinction. But it’s not as clear-cut. But there’s a conception of it as being not fully physical, except the extra is seen as more spiritual than mental.
Ms Kabangu: Having said that, what do you find in your profession as the most challenging when treating patients with a mental illness in Nigeria?
Doc Ayomide: Hmm. Interesting question… You might expect me to say the spiritualising of illness but it’s interestingly not that at all.
Ms Kabangu: That is interesting.
Doc Ayomide: I’d say it’s more the stigma and the general low level of public knowledge. The stigma really makes mental illness harder to live with for those who have it. And the low knowledge level makes it harder to explain things to people, which makes them harder to reach also. Then I’d say another issue is the language translation issue, by which I mean, not just the actual languages but the sociocultural constructs. Talking to patients you’re speaking the same language as, and yet not actually getting through in the way religious and traditional healers do.
Ms Kabangu: That is sad…but having acknowledged that mental illness is not a foreign concept, what factors do you think contribute to the stigmatisation? Is it, for the lack of a better word, cultural? Or there is a belief driving the stigmatisation?
Doc Ayomide: The stigma comes from our own historical conceptions of mental illness. Mental illness means you’re cursed, or spiritually ill-favoured. There are taboos in some Nigerian ethnic groups against marrying into a family where there’s a history of mental illness.
Ms Kabangu: In that case, do you think they’re maybe a shortfall of adopting a biomedical model of treatment in such an environment?
Doc Ayomide: I wouldn’t say that exactly… I think the medical model itself isn’t the problem. I think the real issue is our failure to translate that into our own cultural constructs in the way Asian cultures seem to have. In that sense, it’s a general healthcare problem, it’s not just in mental health. It’s just maybe more easily seen here but the effects are present everywhere else too.
Ms Kabangu: Okay. That is interesting. Does the lack of translation then suggest that maybe some of the illnesses we want to translate may not necessarily be a reality in our society? I found it interesting that some African languages don’t have a word for depression…
Doc Ayomide: I think it’s not that simple.
Ms Kabangu: And yet depression is very common in the West.
Doc Ayomide: I think it’s more like we don’t think of them in the way the medical model does. Depression is real. Here as anywhere. For instance, a woman once told me, all the sugar and honey and salt were gone out of her life. I could hardly describe the loss of pleasure depression induces any better. She was elderly, by the way, and totally met the criteria for depression. It’s more like people have the same illnesses here but they describe them different. So when we are talking to them about it they don’t realise we speak of the same thing. Which is why I say it’s a translation problem.
Ms Kabangu: That’s very interesting, especially with her being elderly. So she actually identified it as an illness and not perhaps a social issue?
Doc Ayomide: She didn’t at all. That’s is what I’m saying.
Ms Kabungu: I only ask because I have a friend who was diagnosed with depression and yet no matter how much he tried to explain it to his parents back home — they struggled to see it as a medical condition.
Doc Ayomide: She knew she wasn’t well but didn’t know what with. That’s what I’m saying. So the person with it knows they are very not okay but can’t even put it into words. They don’t have the words for it.
Ms Kabangu: Okay, just to play devil’s advocate, if it is a very common condition, how then do we struggle to identify it as such?
Doc Ayomide: Because we don’t talk about emotions is one reason.
Ms Kabangu: Ah… okay.
Doc Ayomide: We don’t even really have words for emotions. Would that then mean we don’t have emotions? 🙂 Most of our words for emotions are physical words. Which suggests why we somatise emotional illnesses. And even then our emotional vocabulary is far from rich.
Ms Kabangu: Do you think the fact that we are from societies that encourage community versus individualisation may have something to do with it as well?
Doc Ayomide: Oh yes, I think it might. But I don’t fully understand how yet. Just ideas. Times like this I wish I was more versed in my traditional culture. But a link might be that communal living and thinking makes us less introspective and more expressive. But I’m not sure that’s the actual link, it’s just a thought. But I do know we’re less introspective and more expressive. Not emotionally expressive though.
Ms Kabangu: I have shared the same sentiments whilst doing my research. It would be good to know how an issue such as depression would have been treated traditionally.
Doc Ayomide: Traditionally it was treated symptomatically. Most people with depression come with complaints of sleep so that’s what would get focused on. Many even still get medical care for years without getting diagnosed or properly referred, until they get lucky to see a doctor who’s more versed in mental health.
Ms Kabangu: That was actually my next point. If mental illness prevalence is similar back home as in the west, why are there so few psychiatrists? It was a struggle personally to find a psychiatrist or psychologist that has practiced back home over here. On the other hand I could find many general doctors.
Doc Ayomide: Oh, that’s easy to explain. Reason is twofold. One, there’s really not a lot of doctors, period. And very many don’t specialise. Two is that even among doctors there’s stigma toward mental health so it actually takes a degree of bravery to specialise in it. I know no fellow psychiatrist whose family was excited about their choice of speciality. Then I read an article last month in which an American doctor spoke of being told he was wasting his intelligence in choosing psychiatry and realised it was a worldwide thing. Although it is probably still more here.
Ms Kabangu: So despite having being medically educated, stigma will still trump a doctor’s choice of specialisation?
Doc Ayomide: Yes o. When students AND doctors come through rotation almost the entire time is spent combating stigmas they come with.
Ms Kabangu: Interesting… so if even the educated are still prone to the effects of stigma- how then do we combat it?
Doc Ayomide: Exactly the issue. Exposure helps but one can’t force people to come out. Exposure to people with actual illness I mean. To help them get over the wrong ideas from media and culture. Telling better stories too, in our movies.
Ms Kabangu: If I may ask. How long have you been a psychiatrist for? And have you had many patients come through?
Doc Ayomide: Over six years in the field. Can’t say how many patients: hundreds though.
Ms Kabangu: Do you find a distinction in the number of people that come through based on their education/socio-economic status?
Doc Ayomide: Not really. The educated are almost as bad as the less so, where mental illness is concerned.
Ms Kabangu: Oh wow! That’s an eye opener…
Doc Ayomide: Why so?
Ms Kabangu: I always assumed the more educated you were, the easier it would be to understand criteria for mental illness and therefore the more willingness to accept treatment.
Doc Ayomide: Well…
Ms Kabangu: So how do you come across your patients? Is it via referrals or they walk in the door themselves?
Doc Ayomide: Remember the translation issue I mentioned? The educated still have the old constructs, mental health-wise. Education doesn’t exactly change that since it mostly doesn’t even address it. So there’s no reason for many to change.
Ms Kabangu: Ah…so there is a gap in the education system itself?
Doc Ayomide: I’ve even seen doctors who still think it’s spiritual. How much more educated could one be? It’s not education itself. I’m just saying education itself doesn’t address it, not even in the West. So it won’t change it. General beliefs about mental illness (or anything really) are more about societal ideas and norms than about education, right?
Ms Kabangu: Yes. They are.
Doc Ayomide: So education really won’t change a whole lot, I don’t think.
Ms Kabangu: If education is the anecdotal antidote for stigma, and in this case does not seem to work, is there another underlying issue then that we are not addressing? Is it culture then…? I use that word hesitantly.
Doc Ayomide: Education isn’t as far as I know. Exposure is. Meeting people who actually embody the thing stigmatised. Like with HIV. Stigma started to get beaten when people started to come out.
Ms Kabangu: Ah okay…on that note then, would you say there are not as many people with mental illness back home? If prevalence is the same in the west as it is in say Nigeria, in fact I think WHO has the ratio of mental health patients to psychiatrist as 1:10. Then how is it that people are not as exposed as we think?
Doc Ayomide: Because we don’t talk about it. All the stats show similar rates between here and the West. From research done across Africa I mean. I’ll give an example.
Ms Kabangu: I have my own reservations about the stats as well, but I’m happy for you to elaborate.
Doc Ayomide: Post partum depression. It’s VERY common and again it’s culturally known (it’s got a traditional name in my own language). But most people don’t know about it. Because nobody talks about it — it’s not something nice to talk about. But then, every new person affected thinks they’re alone.
Ms Kabangu: Which is where my reservations kick in. If no one is willing to talk about it, how is WHO getting the stats? How do you identify someone with a condition if they are not willing to disclose it?
Doc Ayomide: Because in the research done they focus on the actual symptoms. Like when I was collecting data for a study on schizophrenia, I wasn’t asking if they had schizophrenia. I asked if they heard voices. And differentiated that from thoughts in their mind, because our language speaks of both similarly but when you ask carefully you can differentiate.
Ms Kabangu: Okay. That makes sense. So where is the line crossed then?
Doc Ayomide: Between?
Ms Kabangu: Because there is also another category of ‘the spiritual,’ be it in the west or not. Especially for schizophrenia.
Doc Ayomide: Not really actually. There’s a clear difference most of the time. One major key is dysfunction. And another is that you don’t make a diagnosis on just one symptom. Third, hardly anyone likes coming to a psychiatric hospital. By the time people bring their loved ones it’s often because they’ve seen definite problems they can’t gloss over. So for instance, people might not bring some one who’s hearing voices, they’d even think it was maybe God or spirits. But when the person starts to neglect self-hygiene and become delusional they can’t ignore that. In practice it’s the severe mental illnesses that show up. Which is a problem because they’re better treated early. But that’s when people can recognise them. So that’s a challenge there.
Ms Kabangu: I guess that is true…
Doc Ayomide: People with schizophrenia aren’t even recognised until they’re really bad. Sometimes for over ten years they’ve been ill. You find out when you take the history. And that’s often after they’ve tried traditional and religious healing. Medical treatment is mostly a last resort.
Ms Kabangu: Okay. How do you as a practitioner then tackle these presentations?
Doc Ayomide: Like any doctor. Take a history, examine, make a diagnosis, explain it all and start treatment, admitting if necessary.
Ms Kabangu: Do you find this being very effective, given the underlying beliefs of mental illness in the population?
Doc Ayomide: Oh yes, largely. At that point it’s easy to explain because the symptoms are obvious and because they’ve tried everything else anyway. It’s the many others who one doesn’t see I worry about. Of course there’s the problem of continuing treatment after they get well: many return to the traditional and religious approaches again. But many stay with medical too. At that point, education does make a difference.
Ms Kabangu: Okay…so its easier in the case of manic illnesses?
Doc Ayomide: Oh no, everything. Once it’s severe enough, doesn’t matter if it’s psychotic, or mood or anxiety disorders.
Ms Kabangu: Okay. Seeing as traditional healers are valued, do you think then they need to be incorporated into the treatment model?
Doc Ayomide: Very big question, that. On the face of it, it makes sense to. In practice, though, it’s proven very difficult.
Ms Kabangu: How so?
Doc Ayomide: Okay, so that’s been successfully done with obstetrics, right? Traditional midwives and the rest. So you’d reasonably expect the model could be easily imported into mental health. But it’s quite different here. For one, with midwives one is dealing with a physical process. Anyone can see what’s going on. And two it’s a process both parties mostly agree on.
Ms Kabangu: Yes.
Doc Ayomide: Both factors don’t play out in mental healthcare. It’s hard to determine a common ground and in the end we come up against the translation issue all over again. It’s not like in obstetrics where there’s a common language already in place. So it’s not worked out well so far.
Ms Kabangu: In your opinion is it something that will ever work?
Doc Ayomide: It can. But I feel like there isn’t yet a will to really work on it. At least in a general widespread sense. On the disconnect I mean. And like I said in that sense it’s a problem that permeates healthcare as a whole but more so in mental health. Also we need to communicate with them in a way that doesn’t sound competitive or denigrating. Which is something I’m not sure we’ve done well for the most part. See them as potential partners, I mean.
Ms Kabangu: Is that a shared notion on both sides? Some of the readings I came across seem to suggest the biomedical model subverts western psychiatric ‘power’ if you will and thus traditional healers are not really seen as relevant or respected for their role.
Doc Ayomide: You just said what I was saying, lol. But yeah. You can’t work WITH someone you’re not prepared to see or at least treat as an equal.
Ms Kabangu: So perhaps work needs to be done more on the side of Western psychiatry?
Doc Ayomide: Yes definitely. If we think we know more than the responsibility is on us, isn’t it?
Ms Kabangu: In essence there are beliefs on both sides that present a challenge to both healing systems?
Doc Ayomide: Yes.
Ms Kabangu: Okay. And as a biomedical practitioner practising in a landscape filled with traditional medicine, are you open to treating traditional healers as equals?
Doc Ayomide: Yes, but not in an unqualified, anything goes, sense. More in the sense of accepting that we can’t be enough doctors anytime soon and perhaps if we work together we can learn from each other and better help our people. A helpful model would be what’s been done so successfully by the Chinese who’ve been able to integrate their healthcare models with modern medicine (acupuncture, yoga etc).
Ms Kabangu: That is true.
Doc Ayomide: Would you mind my publishing this interview by the way? I quite enjoyed it, and I hope you did too.
Ms Kabangu: Not at all. 🙂 Its been very interesting for me as well. One more question. Do you believe there is an aspect of spirituality in the healing of mental illness?
Doc Ayomide: Yes and no. I’d like to know though, are you religious yourself? You don’t have to reply if you don’t want to. I’m just curious.
Ms Kabangu: Yes. I am a Christian.
Doc Ayomide: Oh okay. I too. So in a sense I believe it’s either all things are spiritual or nothing is. If there’s spirituality then it permeates all things. I don’t think it’s an either or sort of thing. So as I understand it, my spirituality does not preclude orthodox healthcare. But rather goes hand in hand with it. With patients therefore I engage them at the level of spirituality they are willing to engage at, and not at all if it’s not their thing.
It’s actually part of psychiatry to do that: it’s become realised more and more that spirituality is part of who people are and shouldn’t be ignored as was previously thought. Even non-religious psychiatrists learn to do it.
Ms Kabangu: Sorry, when you say engage with them if they are willing to, is it in relation to any particular spiritual belief or all across the board? That is an eye-opener for me.
Doc Ayomide: Well for my personal integrity I engage to the degree I’m personally able to agree with, but then as a Christian, I find that happens to be a lot indeed. What part is an eye-opener?
Ms Kabangu: The engagement of spirituality…
Doc Ayomide: What about it?
Ms Kabangu: In a way it is progress, but how and what reference faith is used during such an engagement will be an interesting topic to address — and if such engagement is being incorporated into the biomedical model. Perhaps it is also further evidence that the biomedical model is not the be all and end all of psychiatry. Those that disqualify traditional methods of healing should therefore not be so quick to do so.
Doc Ayomide: Oh the biomedical model is DEFINITELY not the be all and end all. It’s just a model, a very good one, I think, but a model still. I do think it might be one of the best we’ve got in fact. But that still doesn’t preclude it from enrichment by other models. It’s like a language, in a sense: no matter how good it is, it can always be enriched. And a good place to start is precisely with those who simply don’t get it as it is. In this case, our own people. And it’s we who understand both languages who can do it: who know our culture as well as the Western biomedical constructs. Yeah?
Ms Kabangu: I agree with you… Yes I do agree…but for the reasons we have discussed, it’s not as easy in practice as it is in theory.
Doc Ayomide: I’ve not discouraged you, have I? I feel like I might have. 🙂
Ms Kabangu: No not at all.
Doc Ayomide: Oh it’s totally not as easy in practice. I do believe it’s possible, though.
Ms Kabangu: My intention is not to push for any one view but to unpack the structural realities and violences underpinning each view. Simply attributing the differences to culture is not a realistic argument. There is more.
Doc Ayomide: Do you feel that “simply attributing the differences to culture” is what I have done?
Ms Kabangu: Not at all…I’m thinking about the literature I have read in the topic.
Doc Ayomide: I’d like to know what you learned from them. (Were they African by the way?)
Ms Kabangu: As is with most research on Africa, we haven’t done our own research prior to colonisation — most are done by Westerners. Some suggest that because of our culture, we are unable to be treated effectively using the biomedical model, but in reality, it’s not culture — culture is such a loosely and sometimes wrongly used concept. There are definitely different power plays at hand. While literature from Nigeria, South Africa and even Ghana suggest locals prefer to visit traditional healers as a first point of call, there’s still a strong push to adopt the biomedical model of psychiatry while discrediting traditional systems. My argument there is that its simply not a cultural issue. There are many issues at play: socioeconomic and historical issues. It’s as you said before, someone wanting to venture into psychiatry will have opposition from their family. And yet learning the ways of a healer would have been something admired pre-colonial times. Culture is transient and ever-changing.
Doc Ayomide: Yes, it is. And being a doctor is still admired (although the financial implications are making even that less so, at least in Nigeria).
Ms Kabangu: Yes, and that is another things as well, financial appeal also plays a role in one’s choice of career.
Doc Ayomide: Understandably, no?
Ms Kabangu: Yes definitely understandably. It’s a very broad topic with many factors at play, but anyways I really appreciate you taking the time to chat with me, Dr Ayomide. I acknowledge that I have taken a large chunk of your time. Thank you very much.
Doc Ayomide: Thank you too. You asked very good questions, too, and I enjoyed answering them.
Ms Kabangu: I’m glad. I will keep an eye out for more of your publications. It’s a bold endeavour you are undertaking. Thank you. I hope you have a happy weekend. Regards!
Doc Ayomide: Thank you, and you too.