Family, Religion, and Psychiatry in Ghana

In January 2016, a collaboration between the NYU Department of Psychiatry and the University of Ghana Medical School brought me to Accra in the middle of my PGY-2 year. I spent the month at Accra Psychiatric Hospital, one of the oldest and largest psychiatric hospitals in Ghana.

The hawkers were merchant women in brightly colored wraps, their graceful heads balancing plastic washbasins packed with bottled water and ice sachets; they bobbed through traffic at every intersection. “Sister, sister!”—they called out to me—“buy some water from me!” I was a stranger; notably foreign in every way, but we were family.

These casual greetings spoke of the importance of family in Ghana. In the hospital, an elderly woman was not just your patient—she was your “aunty.” One morning during rounds at Accra Psychiatric Hospital, we saw an elderly woman who was admitted to the ward for bipolar disorder. The patient insisted on speaking outside in the courtyard. Her thin arms trembled as she lifted herself out of the chair and knelt to the ground, pressing her torso into the dirt and gravel of the courtyard floor. The psychiatry resident pleaded with her to get up. “Aunty Eliza,” she repeated, “Aunty Eliza, please let me help you up. I’m the doctor. Do you understand, aunty?”

Family is crucial to psychiatry in Ghana, in a variety of ways. First, it is nearly impossible to hospitalize a patient “involuntarily” in Ghana without a relative agreeing to it. One patient who was brought to Accra Psych by his coworker one night was discharged and told to return in the morning; he could not be admitted without a relative. Family members were crucial in bringing patients to treatment, often by force. One morning, our teaching conference at Accra Psych was interrupted by screaming. A woman outside was being dragged by her arms into the clinic by a group of relatives. It was quite the commotion. When patients themselves did not make it to the hospital, family members frequently presented on their behalf, for follow-up appointments and medication refills. One young man came to Accra Psych for his great-aunt’s risperidone refill, as the family lived miles outside of Accra. The task of squeezing the frail old woman into a hot, precariously overfilled tro-tro (an overpacked minibus, the preferred method of public transportation throughout Ghana) was too physically daunting, not to mention expensive.

Relatives were often able to provide excellent collateral information (as multiple generations and extended families frequently lived under one roof) in addition to much-needed financial support.

Aunty Eliza’s daughter and son-in-law frequented the ward every day; not only to visit Aunty Eliza but to facilitate her entire hospitalization. Her daughter brought her prescriptions to the pharmacy, purchased the medications, and carried the medicines back to the ward to be administered. She paid for the hospital stay. Whereas Aunty Eliza might have utilized Medicare or private health insurance in America, in Ghana her adult children served as her health insurance plan. Nigerian writer Dayo Olapade (1) refers to family and social relationships in African societies as an adaptive and innovative “safety net,” in the absence of reliable alternatives such as government aid or welfare programs.

Signs of a robust and active religious life abound in Accra. Tro-tros and taxi cabs weave through traffic in busy downtown Accra, displaying prominent yellow decals in their rear windows with varying religious messages: “Ask God For Forgiveness,” or “Jesus saves.” (One puzzling taxi simply declared “I’M SORRY” in the rear window.) Roadside shacks selling fried plantains, balls of kenkey (a dumpling made of fermented ground corn) wrapped with banana leaves, and tilapia drying out under the dusty equatorial sun have signs with declarations such as, “God Loves Me.” Billboards announced the upcoming arrival of Pastor Chris, a popular Nigerian pastor who was coming to Accra for a night-long crusade. Car radios blast gospel music interspersed with the shouting of preachers. On Sundays, our quiet neighborhood on the outskirts of Accra was utterly transformed by the rhythm and noise of Sunday church proceedings. For an entire afternoon, the walls and ground shook with the rhythm of the bass emanating from the local church gatherings. Church is the biggest party in town.

Given the importance of religion in Ghana, I frequently encountered patients in whom religion (Christianity as well as African traditional religion) filtered into their delusional constructs or erratic behavior. One young man was brought into clinic by his mother because he had been leaving the house at four or five o’clock every morning to go to the church and “preach.” An elderly gentleman brought his granddaughter to clinic after she started talking to herself in the night; she was convinced that she had inherited the “curse” responsible for her mother’s death. Her grandfather told us he intended to seek spiritual help for his granddaughter, after we made sure there was no medical problem. We reassured him that he had been right to seek medical attention. The girl barely moved during the interview; she appeared catatonic.

Indeed, psychiatric disorders go hand-in-hand with spirituality, religion, and superstition in Ghana. Traditional beliefs regarding mental illness long ago involved ideas of witchcraft or sorcery, with beliefs that psychosis manifests when someone puts a curse on you, or “takes you to juju” (2). These traditional beliefs persist in Ghana, particularly among rural populations and in the northern region of Ghana (3). These ideas may perpetuate the stigma of mental illness, as it further separates the biomedical model from the traditional model. Prior research in Ghana demonstrates widespread views that mental illness is not like any other illness, but rather a consequence of lack of self-discipline or willpower (4). Unfortunately, patients frequently internalize society’s beliefs. Barke et al. (4) described “self-stigmatization” as a process by which psychiatric patients “adopt the stereotypes about people with mental illness prevailing in the society and consequently come to perceive themselves as unacceptable. In Ghana I encountered numerous patients who felt “guilty” and “responsible” for their psychiatric disorders. The stigma of mental illness can further exacerbate the treatment gap for mental disorders in Africa, as stigma often deters the mentally ill from seeking treatment (4). Certainly, the commotion of a patient being physically dragged into Accra Psych was an everyday occurrence. In fact, the World Health Organization estimates that out of the 650,000 in Ghana suffering from severe mental disorders and 2,166,00 suffering from mild-to-moderate mental disorders, only 2% are receiving psychiatric treatment (5).

Perhaps the biggest risk resulting from superstitious and spiritual beliefs about psychiatric disorders is the use of inappropriate or harmful treatment methods. I learned during one teaching conference at Accra Psych that elderly women are sometimes labeled as “witches” when they become demented and manifest neuropsychiatric symptoms. They may be banished from the community and sent to “witch camps” (6). Along a similar vein, a recent article calls to attention “prayer camps” in Ghana, where hundreds of mentally ill are placed, often subject to inhumane conditions (7). The article underscores the relationship between supernatural beliefs about mental illness and abusive treatment of the mentally ill; inhumane practices may be viewed as part of the cultural tradition of “removing the evil spirit” that inhabits them.

Ultimately, our priority as health care providers is to ensure the well-being and safety of our patients. Particularly in psychiatry, where establishing a therapeutic relationship is a priority and a requirement, we cannot dismiss religion or spirituality, particularly in a society such as Ghana where religion plays a central role in our patients’ lives. Like the utility of family relationships, religion serves a unique purpose in Ghana as a “complex form of social solidarity” (1). One resident psychiatrist at Accra Psych tells me that she addresses religion directly with her patients. She tells them, “Listen, it is great that you are religious and believe in God. God is fine with you coming to see me and taking the medicines that I prescribe. God created psychiatrists for a reason, right?”