Social Context of Mental Illness Disclosure in Kaduna

Paper Number: ICHUSO-004

Proceedings of 14th International Conference on Humanities and Social Sciences 2018 (IC-HUSO 2018)

22nd-23rd November 2018, Faculty of Humanities and Social Sciences, Khon Kaen University, Thailand

Social Context of Mental Illness Disclosure in Kaduna, North West Nigeria

Suleiman, M.S.

Department of Sociology and Anthropology, Faculty of Humanities and Social Sciences,

Khon Kaen University, Khon Kaen, Thailand

E-mail: [email protected], [email protected],

[email protected]

Abstract

Mental illness is recognized as one of the huge contributors to the universal burden

disease, mentally ill patients receive little attention at global, regional and indigenous levels

compared to other illnesses. This paper examined the social context of mental disclosure in Kaduna,

North West Nigeria. The data for this research work was collected from Federal Neuro-Psychiatric

Hospital, Kaduna and were triangulated in order to enhance the data collected. This research used

observation, the daily activities of the hospital staff, the patients and their relations within the

hospital setting were observed. In addition, medical consultations and diagnostic conversations

between physicians and nurses as well as patients and their relatives were observed and recorded.

In-depth interviews were conducted with hospital staff and patients’ relatives as well as examining

the medical records and prescriptions for the patients. Among others, this study recommended that

moral values should be inculcated among citizens of Nigeria in order to reduce to the barest

minimum the incidence of mental disorders. It further recommends that there is need to promote

indigenous healthcare care for people with mental illness as well as the creation of policies that can

support the indigenous partnership with the mainstream psychotherapeutic hospitals and centres

for sustainable development.

Keywords: Disclosure, Mental Illness, Patients, Psychiatric, Social Context

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Introduction

The World Health Organization (WHO, 2014) describes mental health as a state of

wellbeing in which individuals realize their own abilities, cope with the normal stress of life, work

productively and are able to make a contribution to their own communities. The estimate of WHO

indicates that psychiatric and neurological conditions accounts for 13 percent of the global disease

burden and likely going to 15 percent by the year 2020 and statistics furthermore, revealed that

globally, 59 million people suffer from bipolar disorder while 24 million suffer from schizophrenia

(WHO, 2011; WHO, 2014). Similarly, it can also be observed that from available WHO (2013)

data between 76% and 85% of individuals with mental illnesses receive no treatment for their

condition in low income and middle-income countries.

In a related development, previous studies also revealed that people affected by mental

illness face higher rates of disability and mortality, for instance, individuals with schizophrenia and

major depression have 40% to 60% increased chances of dying prematurely than the general

population and these premature deaths are frequently the result of other physical health illness such

as cardiovascular diseases, cancers, diabetes, HIV infections and suicide (Whiteford et. al., 2013).

Similarly, Eaton, Kakuwa, Wright and Minas (2014) in their view, put forward that mental illness

impact equally or more on life expectancy thus as smoking, diabetes and obesity, while they further

argued that people are challenged with human right violation like chaining and subjected to

treatment without consent, discrimination against and being denied to take part in political activities

and exclusion from social, family life and education.

It can be observed that understanding the mental illness in Nigeria is something that

has to be taken contextually and historically due to the fact that there are existing large

misconception as well as misinformation on the context of mental illness amongst Nigerians. The

social organization of this research is centred on the treatment of the psychiatric situation. This

research adopts a narrative approach that focuses on the lifestyle of the patients in the hospital and

upon treatment as a procedure that takes place over time. This study examines the various phases

involved in shaping the patient lifestyle and identifies the social factors crucial to that process in

Federal Neuro-Psychiatric Hospital, Kaduna, North West Nigeria.

Methods

The data used for this research work was collected from Federal Neuro-Psychiatric

Hospital, Kaduna. The methods of data collections were triangulated in order to enhance the data

collected. This research used observation, the daily activities of the hospital staff, the patients and

their relations within the hospital setting were observed. In addition, medical consultations and

diagnostic conversations between physicians and nurses as well as patients and their relatives were

observed and recorded. In-depth interviews were conducted with hospital staff and patients’

relatives as well as examining the medical records and prescriptions for the patients.

Federal Neuro-Psychiatric Hospital

Federal Neuro-Psychiatric Hospital (FNPH), Kaduna was established in 1995 along

four other new Federal Neuro-Psychiatric Hospitals in accordance with the National Mental Health

Policy of the Federal Government of Nigeria. Over the year Federal Neuro-Psychiatric Hospital,

Kaduna has witnessed the remarkable transformation that has since elevated it to international

standard such as providing quality service delivery, training of mental health professionals and

research in mental health and related fields (Jolly, 2018). Federal Neuro-Psychiatric Hospital

(FNPH), Kaduna is a 100-bed public regional psychiatric hospital with consultant psychiatrists,

general practitioners, nurses, administrative and other supporting personnel.

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Symptomatic Identification of the Illness People with all kinds of psychiatric problems from simple to complex stage can be

identified by members of the society in different ways such as manifestations of strange behaviour

or communication patterns. It worth noting that through communication or interaction, individuals

with abnormal behaviours can be figured out.

Similarly, it is obvious that speech disorder is accepted as a manifestation of a mental

problem due to that fact it is generally believed that mental illness can be detected at the initial

stage through problems of speech mostly if the person’s speech is illogical and termed talkative or

when the person refused to talk and remain quiet. It is also worth noting that people with mental

illness can be identified with violence and aggressive behaviours as well as roaming or wondering

about as argued by Jegede (2005) and Nwokocha (2008) that mentally ill persons are mainly found

in the different parts of the cities, especially in the major roads or streets, motor parks and markets

among others with common features of roaming about, self-neglect, self-destruction as signs of

mental illness. Thus, it is worth noting that some of the symptomatic identifications of a person

with mental illness by the public may include wandering about, restlessness, looking dirty and

rough among others.

It is observed that people with mental illness may communicate verbally with people

in order to interact, although the communication sometimes could be illogical, meaningless as well

as incoherent, the person with mental illness sometimes could be taken to his or herself alone or

murmuring. For illustration, a relation of one of the patients narrated to the physician that she spent

days speaking to herself and later started shouting and naked herself, it was then they realized the

symptoms of psychiatric illness in her (Fieldwork, 2017). Similarly, another patient's relative

explained to the doctor that he used abusive words against people speciously and he became violent

by attacking people, he can through any object at people without caring if the object is harmful or

not. (Fieldwork, 2017). Thus, it can be observed that most of the dangerous and severe stage of

mental illness is when the mentally affected person becomes violent by maltreating, abusing as

well as beating people indiscriminately.

Admission into the Hospital and Case History

The patient and his or her relative report to the out-patients department on arrival and

they will be directed to register in the card room where patient’s bio-data is collected and at the

end, a referral card is issued to the patient and that of the diagnosis is kept in the hospital. Then, if

there is any referral letter you submit to the Senior Nursing Officer on duty and if not you explain

the conditions of the patient to the nurse who then takes the case history of the patient or likely

assign a nurse to do so. Similarly, the social welfare office can also make referral and patients are

encouraged to come along with relatives that can serve as a source of getting vital information of

about the patients in order to guide the medical personnel in providing a proper diagnosis. It is also

vital to mention that patients who are violent in nature are injected, isolated and physically

constrained in some cases.

Generally, admission into the hospital is expected to be formal and family members of

the patient play a vital role in the process of bringing and admitting the patient into the hospital.

An assessment of patient file records indicates the majority of the mentally affected persons were

brought to the hospital by their relatives but some of the patients were abandoned by their family

members along the line due to the financial challenges as well as stigma attached to mental illness

in the society. Andersson et.al (2013), Schierenbeck, Johansson, Andersson and Van Rooyen

(2013) and Topper, Van Rooyen, Grobler, Van Rooyen and Andersson (2015) assert that economic

challenges and stigma are parts of barriers to treatment as well as utilization of mental health care

8




services by persons with mental illness owing to the fact that they are mostly abandoned at the

various stages of their treatment by their family members and by implications worsening their

illness and making them rejected and vulnerable. Thus, it is important that people with mental

illness need to be given adequate care and support in order to improve their health conditions; they

should not be subjected to any form of stigma and discrimination.

In a related development to the case history of the patients, the case history of an

individual patient is taking by a nurse in the consultation room or office which the patient’s

relatives or persons who bring him or her to the hospitals are expected to equally participate and

provide vital information on the life history of the patient in order to get a clearer background

information and proper understanding of the patient’s mental health challenges since most of the

patients can hardly provide meaningful answers to the questions raised by the medical personnel.

However, it is noticed also as a challenge, that some of the relatives of the mentally ill persons find

it difficult to give adequate information about the patients due to some factors like they are not

living together, they don't understand the patient's lifestyle, and explained that the patient has

accessed any treatment elsewhere before bringing him or her to the hospital presently. It was

observed that most of the patients have received treatment from the native or religious healers in

the course of the illness. One of the patients’ family members revealed that:

They have to seek native healing process due to the fact that

they have belief in the influence of supernatural forces on

the causes of illness before coming to the hospital (Fieldwork, 2017).

Another relative of a patient also confirmed that:

They have to consult religious healers because they have a belief

in the healing process of the illness that was why they consulted

the religious healers first before seeking medical attention in the

the hospital now (Fieldwork, 2017).

Thus, it is worth noting that the society or family members of the patient’s belief in the

influence of supernatural forces in psychiatric illness are related to the first choice of healer.

Mental State Examination

Mental state examination of the patient is conducted after the completing the case

history as a mental assessment of the patient in order to validate and establish the information

provided by the family members regarding the condition as well as the behaviour of the patient.

The comparison is made between the patient’s case history and mental assessment which after then

a report on the patient is compiled and necessary recommendations are made to the consultant who

is expected to conduct the final diagnosis before the final decision to admit the patient or not is

taken. Thus, the recommendations put forward by the nurses help the psychiatrist in making a

decision despite there are other vital factors to be considered before concluding whether the patient

is to be admitted or not.

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Factors that Influences In-patient Status

It is worth noting that there are many factors that influence the in-patient status of a

person with mental illness ranging from the availability of space for admission in the hospital and

willingness of the patient to cooperate with the hospital personnel. Previous research work indicates

that the global median number of facilities per 100,000 population to mental hospital is 0.04; there

are 7.04 psychiatric beds per 100,000 population in mental hospitals; and 1.4 psychiatric beds per

100,000 population in general hospitals and in Africa, the rate of psychiatrists per 100,000

population is 1(Fournier, 2011; WHO, 2011; Morris, Lora, Mcbain, Sexena, 2012).

In addition, Bird, Omar, Doku, Lund, Nsereko, and Mwanza, (2010) and Nwokocha

(2013) assert that indeed, the situation is more severe in low-income countries where insignificant

proportions of budgets are allocated to the health sector generally. Thus, the impact of poor funding

of the health sector cannot be overstated. It has been observed that most people with a mental, a

neurological and substance-use disorder in less developed countries were not receiving treatment

or care for their conditions and a condition that has remained largely unchanged in most places,

mental healthcare delivery is undermined by inadequate facilities, lopsidedness, and financial

constraint. Similarly, the proximity of the patient’s residence is sometimes taken into account

before admission due to difficulties some of the relatives from far places encountered due to socio-

economic factors of regular visits, provision of regular food, pocket money, drugs to the patient

among others.

Duties of the Hospital Social Welfare Unit The social welfare unit of the hospital plays a critical role in helping patients and their

family members address the impact of mental illness and treatment. Martin and Jo (1995) assert

that social workers in the hospitals necessarily work alongside other healthcare professionals and

the perspectives on social work held by doctors and senior nurses are relevant both to their

relationship with social workers and to the smooth running of the hospital. Thus, the social welfare

unit as part of the healthcare team provides assessment and appropriate interventions to aid the

patient in achieving optimum recovery, rehabilitation, and quality of life. Similarly, the social

welfare unit also renders service of admitting those patients who wander about on the streets or

public places especially the violent patients and those who resist coming to the hospital to seek

medical attention. Thus, the social welfare unit through its officers provides all the necessary care

and support for people with mental illness. Although, there is a decline in the services of the social

welfare unit in taking care of the people with mental illness wandering around the streets or public

places due to lack of adequate resources and the economic hardship the nation is facing.

The social workers reported that lack of adequate resources has turned them to be less

responsive and effective; it has incapacitated them and they find it very difficult to discharge their

responsibilities effectively and efficiently (Fieldwork, 2017). Hence, there is need to adequately

provide the social welfare unit with needed resources in order to make them more effective and

efficient in delivering their services to humanity that is cardinal to the sustainable development of

the nation. Mental illness remains one of the controversial illnesses with prejudice and stereotype.

People with mental illness are unnoticed by the policymakers due to the poor public health policies,

financial and human resources challenges making people with mental illness remain neglected and

marginalized strata of the society, therefore, their potential to contribute to the community remains

undermined and untapped.

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Discussion

Most of the people with mental illness, their relatives as well as caregivers experience

the consequences of vulnerability on daily basis. While most of the people with mental illness are

poor and unable to receive the necessary treatment and care they require making them be a

marginalized group in the society. The above assertion is also observed by World Health

Organization from available data that between 76% and 85% of individuals with mental illnesses

receive no treatment for their condition in low income and middle-income countries (WHO, 2013).

One of the main perspectives of the symbolic interactionism is interaction, in this case,

the interaction between the medical personnel and patients as well as their family members in order

to provide understanding for a proper diagnosis as a social process while symptoms as social

objects. Mental illness is seen as a process that shaped in through social interaction. However, it

is imperative to note that diagnosing and symptomatic identification of mental illness as a social

construction is not in competition with any medical models but this study is sociological in nature.

Cockerham (1990) put forward a model of becoming mentally ill comprising seven separate

chronological phases in which a mentally ill patient passes through and acquires different

experiences of becoming mentally ill at each of the stages in the transition from normality to

madness.

Meanwhile, mental illness diagnosis is a socially constructed phenomenon as asserts

by Symbolic Interactionism which can be understood from the process of attending or admitting

the mentally ill patient into the hospital and it is vital to point out that illness is positioned within a

wider cultural and normative framework which has bearing on disclosure process. It is believe that

speech disorder is accepted as a manifestation of a mental problem due to that fact it is generally

believed that mental illness can be detected at the initial stage through problems of speech mostly

if the person’s speech is illogical and termed talkative or when the person refused to talk and remain

quiet and it can be noticed by any close family member or members for likely quick disclosure and

treatment.

Similarly, it is important to note that the family members play a significant role in the

social disclosure of mental illness, making recommendations and commencement of treatment

contact of a patient that is mentally ill; therefore, there understanding of mental illness is

imperative. Kabir, Iliyasu, Abubakar, and Aliyu (2004) pointed out that majority of the cohort of

community dwellers in North Nigeria attributed mental illness to supernatural factors, witches, and

evil spirits among others. In addition, mental illness is view as diverse and multifaceted and

includes knowledge and beliefs about mental disorders that emerge from prevalent culture induced

explanatory models such as attributing the causes of mental illness to cultural beliefs of

supernatural factors (Griffiths, Christensen, Jorm, 2004; Lauber, Nordt, Rossler, 2005).

Consequently, it is believed supernatural forces cause mental illness and this affects the disclosure

of mental illness and choice of healers by the family members of the mentally ill patient. In a related

development, Adewuya and Makanjuola (2008) posit that the beliefs of supernatural factors on the

etiology mental illness shape the attitudes and it has shown to have a huge impact on the acceptance

of the mentally ill among the people of Nigeria. Therefore, by implication, it is vital to point out

that the primary responsibility for the care of a person with mental illness lies with the family

members who disclose the illness and make decisions about treatment and care.

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Conclusion

Mental illness disclosure and mental health help-seeking behaviour in Kaduna, North

West Nigeria is a household decision-making process, it is often influenced by the community

concept of mental illness. It is observed that the family members of the patients with mental illness

mostly decide on their behalf when and where to seek medical help. Similarly, the community’s

belief system about the causes of mental illness influences the families’ view about the possible

cause of mental illness experienced by a family member. It is also important to note that admission

into the hospital is not just merely on a patient being mentally ill but there must be a serious

commitment from the patient's family members in providing necessary care and support for the

patient as applicable.

Thus, the current moves by the global leadership inclusion of mental health in the

present United Nations Sustainable Development Goals (SDGs) is essential step to addressing the

barriers to availability of mental service in order to achieve positive impact on communities and

countries where people with mental illness can receive the needed help since Unattended or poorly

treated mental illness distance victims from self, family, and society. Hence, the chain of

psychosocial consequences arising from this situation is hostile to socioeconomic development.

Recommendations

This study recommends that moral values should be inculcated among citizens of

Nigeria in order to reduce to the barest minimum the incidence of mental disorders. There is a need

to promote indigenous healthcare care for people with mental illness as well as the creation of

policies that can support the indigenous partnership with the mainstream psychotherapeutic

hospitals and centres for sustainable development.

In addition, it is essential that more psychiatric hospitals and centres are created with

more facilities as well as upgrading the existing facilities in old psychiatric hospitals and centres.

There is the need for regular training of the psychiatric personnel in order to keep abreast with the

international best practices of the professional, while government should enact legislation to

discourage stigmatization and discrimination against mentally ill persons in Nigeria.

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Social Context of Mental Illness Disclosure in Kaduna