Mental health care in African traditional medicine and society: A Philosophical Appraisal

- F. Peter Omonzejele
Department Of Philosophy, University of Benin
Benin City, Nigeria

Eubios Journal of Asian and International Bioethics 14 (2004), 165-169.

This paper attempts to explore the notion of mental ill health in African traditional medicine and African traditional society. The concept of liberty as it relates to decision-making in mental health care is central to this paper, hence, conscious effort was made to evaluate the paternalistic role of the community in most African countries with regards mental health care and as enforced by practitioners of African traditional medicine in what is referred to as 'community-individuality'. The paper summed up on the note that the community must concede decision-making to individuals (especially when it borders on harmless neurotics) and such decisions by individuals should be respected even if it contradicts the position of the community. This is because decision making is an integral part of one's humanity.
Key words: community-individuality, being-with, mentally ill, belongingness, decision-making, traditional values, caring control, autonomy, individual, liberty.

Since time immemorial mental health care has engaged the minds of thinkers, for instance during the ancient period philosophers like Anaxagoras (about 500 BC) made efforts to distinguish between mind (nous) and body (matter). Plato (427-347BC) in the "Thaetetus", "Timaeus" and "the Laws" (Jowett, 1937) categorized insanity into organic and affective disorders. Aristotle (384BC) in his study of the mind concluded that the mind controls and affects the body. Augustine (354 AD) explained that diseased minds have grave impact or consequences on the body. Freud (1962) in his study of the mind, explained the interplay of the human personality, which he categorized as the id, ego and super ego. Frankl (1962:98) opioned that the mind is perpetually in need of meaning for its relevant existence. Unfortunately, Africans have no documented history of mental health care. That is not however to mean that mental health care was non-existent in African traditional society (ATS) and in African traditional medicine (ATM). On the contrary, procedures of mental health care have been transmitted via oral tradition from one generation to another.

Definition and Causes Of Mental Ill-Health In ATM
In African traditional medicine, mental ill-health is defined as a situation whereby the victim is prone to interpreting issues haphazardly as registered in his tortured consciousness. Ozekhome, (1990:104) explains that, in extreme cases of neurosis, the entire system of the patient is unstable and may be unable to differentiate between realities and imaginations, may not pay heed to impending dangers and may be unable to recognize people previously known to him. This is because an extreme neurotic is depersonalized. While the mild neurotic is prone to misbehaviour, for instance, he may desert family members without reason, may be tempted to engage in indecent canal knowledge of married women and may even be a pedophile, as aptly indicated by Ozekhome (Ibid:110). "Indeed such a victim does not really care about what he does or says, and at wherever. One may even ask him a serious question, out of lacking the know of his state, and his response is just wild and ungraded laughter. Thus, such a person's senses are obviously not in their proper or appropriate proportions. Therefore, he needs a redirection of his wildly radiating consciousness by the meticulous administration of therapeutic devices on him or her."
Ozekhome who has practised traditional medicine for several decades opined that, the neurotic is strangely protected by some auratic radiance against evil forces such that no spell can harm him. This according to him, is because there is spiritual connotation to neuroses.
Omosede Adhiobare (2004) and Omon Oleabhele (2004), both traditional psychiatrists in the employment of Edo state government of Nigeria are in agreement with Ozekhome with regards the causes of mental ill-health. They agreed that the causes of neuroses are as indicated in western medicine (which is the inability to interact well environmentally, socially and physically) but also added that mental ill-health could also be caused by spell casting and evil machinations. In this regards, there is some sort of difference in western and African traditional medicine, which consequently reflects in the treatment procedures. In the words of Ozekhome (1990:113); "Also, malevolent forces such as witches, wizards, sorcerers, demons and the sorts can causes brain disorder. The causes is usually aimed at punishing a parent through such evil visitations on the off-spring, perhaps because attempts to undo such a parent directly or indirectly have proved utterly abortive. On another note, brain disorder could result from the contact with a spiritual being whose coded rules might have been transgressed by the weary and at times restless young person."
This signifies the major difference in terms of causation of neuroses between western and African traditional medicine. Mental health care in ATM though efficacious tends towards spiritualism and divination which in most times is difficult to provide good epistemic explanations for to the uninitiated.

ATM and Mental Health
African concept of disease and medicine is the foundation of medical treatment in Africa. In Africa, medicine (unlike in the West) have personality and potent living force (Little, 1954:127-128). Hence, the management of neurosis by African traditional healers should be expected to be radically different from what obtains in western therapies and procedures. African traditional healers make use of divination to unearth the mental and psychological problems of their patients. In fact, psychotherapy is an integral part of African traditional medicine. This is done by trying to investigate the inner being of their patients, even when patients have not manifested physical signs of neurosis. The feat of African traditional healers in mental health care has been acknowledged in several scientific fora, according to professor Dopamu (1979:16) with reference to African medicine amongst the Yoruba of Nigeria wrote that: "...psychotherapy has always formed an essential and dynamic basis for effective methods of treatment. It enables us to know the relationship between the patient and the medicine. The medicine-man as a diagnostician, must first of all look into the social, cultural and intellectual environment and background of the patient. He can then evaluate and interpret the cause of the disease, and give the necessary help. This attitude can be described as "medical psychology". In diagnosis and treatment of diseases therefore, the Yoruba medicine man usually maintains "psychological homeopathy" in order to promote the well-being of his patient."
Oracles and divination play significant roles in the treatment of neurosis in African traditional medicine. This is because in Africa, life is traced back to its metaphysical past which interplays with the present and future (Dime, 1995:83). Professor Idowu (1973) also highlighted the feat of African traditional healers in the treatment of psychiatric and psychological problems as: " does not infrequently happens that African doctors trained in the European methods advise relatives or patients in hospitals, this is not a case for this place, or this case as I see it, cannot be treated successfully in this hospital; why don't you take the patient home and try "the native way"" (P.201).
It is thus not any wonder that most governments in Africa engage the services of traditional psychiatrists in the management of mental health.
Causes of neurosis and psychological ill-health are sometimes unknown. In such situations, African traditional healers resort to positive witchcraft (if the cause of ailment defies divination). Witchcraft could be positive or negative. Positive, if used for the good of community and humanity, but negative if used for evil. Positive witchcraft is often used to unravel the cause(s) and treatment of mental ill-health. According to Mume (1976): "Many years of association with Jeje Karuwa, the wizard of Igbinse has afforded me the opportunity to see him perform wonderful feats which I believe an ordinary person cannot do. Many diseases whose causes cannot be traced through scientific diagnosis, which also defy ordinary treatment, had been treated by him with resounding success" (p. 6).
This type of therapy and similar kinds maybe difficult for non Africans and Africans in diasporas to appreciate and understand.
Decision Making and Mental Health Care In ATS
Decision making is an important aspect of modern health care. It emphasizes and seeks to protect the rights and wishes of patients in the provision of health care. According to Mason et al (1983:225), patient rights in health care is important, in order to avoid or limit therapeutic zeal, abuses and unwarranted invasions of human personality. Furthermore, one of the principles of the American Medical Association as adapted by Edge (1999:281) is that "a physician shall respect the rights of patient". However, physicians and society are often faced with dilemma, for instance, when the mentally ill is unwilling to received health care for their conditions. The questions that inevitably come to the fore are:
(a) Should the mentally unstable be detained and compulsorily treated?
(b) Should the autonomous decision of the mental ill be respected? and;
(c) When the mentally disturbed initially consents to treatment, who takes the needed decisions not to go on with therapy?
It has been argued, that it is paternalistic to impose any type of therapy on an adult who is capable of consenting to or otherwise to medical care. Beyond this, further argument has been made for mentally and psychologically ill patients, that efforts to treat them often interferes with their behaviour. According to Mason (op. cit) "such interference is seen as unwarranted intrusion into the mental integrity of others and may result in the manipulation of behaviour in such a way as to compromise human freedom (p. 228)."
The problem however, is that often times, the consequences of our decisions (to reject or stop medical care for our conditions) affect others. This is more so as the condition of the mentally ill has implication for the community as well as the individual.
In African traditional setting and to date, when there is a mentally ill in the community, he is treated with or without his consent. If patient is violent or destructive, he is sedated by the traditional healer or by family members in order to commence therapy. Therapy is continued until cure is achieved. In some cases, the patients maybe chained, in order to prevent patients either from harming themselves or others (Ozekhome, 1990 and Omozokpia 2004).
Arguments usually provided by communities and traditional psychiatrists for the involuntary and mandatory treatment of mentally ill patients (be they harmful or harmless) are based on the responsibility of community to: care for her members be they ill or healthy, cultural obligations and responsibilities based on mutual communal welfare system, and superiority of community values over those of individuals. By this, it seems the community has usurped the liberty and autonomy usually associated with individuals in general and the mentally ill in particular.
One is considered autonomous when he is consistent, in command, independent, the source of his own values and reluctant to control by others/authorities (Benn, 1976:123). The implication is that, for one to exercise his autonomy in health care, the patient is at liberty to accept or refuse treatment. Individual autonomy cannot be taken lightly, because one's autonomy is an integral part of his humanity. It is not in doubt that we have and cherish individual value options, which are expressed in autonomous choices and preferences we make in health care. And the importance of individual freedom and autonomy is reflected in a Patient's Bill of Rights(4) which states that, the patient may refuse or accept medical attention, in so far as the patient is aware or informed of the consequences of his decision and is within the law (American Hospital Association, 1973). Individual liberty and freedom to make choices was further reinforced by J.S Mill (174:68-9), that one should not be compelled to do anything even if it was for the person's welfare, one may only be restrained if his decisions constitute harm to others.
In African traditional medicine, where the community plays significant role in the treatment of the mentally ill (and health care in general) the implementation of the respect for personal autonomy is much more difficult. This is because of the very nature of African ethics, where decisions regarding health care (and indeed other important personal issues) transcend individuals. When individuals and family members take decisions without consultation with the community elders, such individuals and families are sanctioned, and such sanctions have social, economic and psychological implications. African life style is highly communal, often times, Africans resident in urban areas resort back to their ancestral villages when very important decisions are to be made by them.
Other than the general traditional and cultural values such as, 'kindness, generosity, hospitality, justice, respect for elders, obedience to legitimate authorities, humility and virginity (for females) before marriage (Mbiti, 1969:214), the specific traditional and cultural values that impinge directly on liberty and autonomy in mental health care in ATM and ATS is the continual cultural embrace of traditional values such as: "community-individuality" (Iroegbu, 345-349), belongingness (Ibid:374), communalism and extended family system (Iroegbu, 1994:85-88).
The cultural value of community-individuality is the place of the community in everyone's existence in Africa, hence among the Igbo of Nigeria, there is the proverb which states that, 'when a man descends from heaven, he descends into a human community (Iroegbu, 1995:345). The community partakes effectively in the lives of individuals from birth to the grave. Iroegbu (Ibid:346) aptly describes the situation as:
Being born by parents, I notice that I am not born just by them alone. I notice myself to be immediately born into, in fact by a community. The community rejoices and welcomes my arrival. That community soon finds out whose reincarnation I am. That community soon gives me a name, in fact they interpret my arrival within the circumstances of my birth: market day, festivity, season, cultural traits, omenala and other attendant events that surround each child's birth.
While Uchendu (1965:35) described community spirit amongst the Igbo of Nigeria in relation to the individual as closely knitted to the community and kindred, he explained further that:
Almost from the first, the individual is aware of his dependence on his kin group and his community. He also realizes the necessity of making his own contribution to the group to which he owes so much. He seldom, if ever becomes really detached from the group wherever he may live.
Iroegbu (1995:347) in his reflection on the African situation indicated that he realized that: "...what dominates the entire life and world view (of Africans) is not the individual just there, but the community, society or group to which he/she belongs. It becomes a self-evident truth that the community determines a lot of what life is, of what the individual makes of it, and the values that each individual adopts and realizes. The criteria of success are community-determined."
Mbiti (1969) summarized the dominant role of the community in the lives of individuals in Africa as: "I am because we are, And because we are, therefore I am".
Iroegbu (1995:355) in his efforts to synthesize the dominant role(s) of the community with individual consciousness, states that self-identity and individual consciousness is partly what the community has made out of the individual, and that the individual has no definition apriori or outside community ties, obligations and tradition. Iroegbu (1995:357) explains further that the expression of individuality in community does not undermine the liberty and autonomy of Africans, rather:
The African did enjoy liberty, relative liberty, one in a humane, caring, protecting and loving community. People were free to develop their talents. iniative had ample room. Responsibility was an extolled moral-communal virtue. It made the African leaders, heroes and great people that history attest to. Paradise the traditional society was not. But it did not obliterate freedom. It maintained authentic freedom: that is freedom in community.
Ireogbu stretched further that, subjectivity and independence was infact contrary to human freedom and autonomy. And that African human existence is that of 'Being-with'. In other words, it is within the understanding of belongingness that African liberty and autonomy may be derived, Iroegbu (1995:374) argues further that after all 'to be is to belong, to belong is to be". Thus it would be extremely difficulty in traditional African setting (and still very tenable in most African cultures to date) for an individual to solely take decisions with regards his willingness to subject himself to mental health care or otherwise. The community takes the decision and communicates same to the extended family of the mentally ill.
The extended family system is still very functional in most African cultures. The extended family system amongst its numerous functions, resolves conflicts in a given kindred, all are present in moments of joy and sorrow and the system enables the less priviledge in any given kindred to ask or seek for assistance from members of the extended family without embarrassment, this is because: "...we are made, not just for ourselves or just to climb, but for one another, and for life-together. Finally, in a social set-up where the state has no programme for letting individuals climb alone, the extended family system remains the most viable alternative" (Iroegbu, 1995:856)
The extended family system also serves as a route of communication between the community and the individual. For instance, if there is a mentally-ill in a certain community, when the elders of the community (or age-grade depending on what is at stake and peculiarities) have taken decision(s) to forcefully provide health care for the mentally-ill, such decision was communicated to the most elderly male (if he was not present in the elders' meeting and if present the message was communicated to him immediately) of a kindred who in turn calls a meeting of the extended family members and inform them of the decision(s) of the community.
However, it must be stated that not all African scholars are comfortable with the paternalistic posture of the community which seems to turn individuals in community to mere robots without the liberty and autonomy needed to take decisions-even health decisions. Okolo (1992) has been most articulate in his objection to the suppression of individual liberty and autonomy in most African communities.
In Okolo's view (1992:484), African communities suppress the self-consciousness of her people. He explains that the seeming freedom in which most Africans bask in is merely derivative, in real terms the individual was simply; "...dependent on, and largely determined by the other, that is to say the community. Little or no room is left for initiative, spontaneity, responsibility, auto-decision, auto-determination etc. which individuals cherish as individuals and which are the hallmarks of true liberty and autonomy."
Okolo's opinion is that the ever so dominant community depersonalizes and makes the African less self-conscious. Despite Okolo's strong arguments against the overbearing influence(s) of the community over the lives of members/individuals, in his subsequent work, he succumbed to the pressure of community when he wrote that, being with is what makes the African truly African and that the African is always in relation with others within the community and as determined by the community. He went ahead to recommend the value of community-individuality to other parts of the world (Okolo, 1993:39). The African proverb which states that: one could only dance well if he danced to the drumbeats of the community' generously applied to Okolo, in view of his sudden change in embracing the traditional value of community-individuality which he had previously objected to. This may be regarded as a tactic submission to African traditional values and ethics in which individual existence could only be expressed within the framework of community existence and dictates.
According to professor Claude Summer (1983:100), African traditional ethics is founded on the "natural light of reason" with conscience and community as the guide. Downess (1977:66) who has done some works in African ethics and religions, explained that, morality among Africans is interpersonal and socially based on human welfare, and individualism was discouraged.
Consequent upon the relationship that exists in the community-individual structure in Africa, questions earlier raised such as: if the mentally ill should be detained against his will and compulsorily treated? If the autonomous decision of the mentally ill should be respected? And for the mentally ill who previously consented to treatment procedure, if he could at any point in time decide not to go ahead with it? In traditional Africa (and still culturally applicable) it would seem that the mentally ill person is not in a position or at liberty to take decision(s) with regards his condition, rather, the community decides when, how and where (via and sometimes in conjunction with the extended family members) the mentally ill was to be treated for his condition, and the mentally ill could not terminate treatment for his condition unilaterally. In the view of the community,such decisions are usually in the interest and common good of the community and community members, and individuals were simply expected to abide by such decisions. However, one was compelled to wonder if the role of the community with regards decision-making as it affects the mentally-ill (especially the harmless neurotic) was not contrary to traditional African ethics which based its morality on the "natural light of reason" (Summer, 1983) and "rational reflection" (Wiredu, 1983).

Without doubt our health conditions affect others especially our loved ones, thus treatment refusal for our conditions have consequences for others (relations and community). This is because family members are usually saddened by the unwillingness of their loved ones to receive proper health care especially if such conditions are psychiatric in nature. However, non-consensual treatment of the harmless neurotic cannot be justified, since community members are not directly at risk. The harmless neurotic is neither destructive nor contagious. Compulsory treatment of the mentally ill (especially if harmless) breaches the right of the patient, this is because."...every touching of the patient is potentially a battery on that patient. It is the patient's consent-either implied or expressed- which makes the touching legally innocuous" (Mason et al, 1983:112)
Consequently, the respect of autonomy and the opportunity for decision-making in health care usually available to other patients must be extended to the mentally ill. According to Mill (1974:68-9) no one should be compelled to do anything even if it was in the person's interest and that should also apply to the mentally ill. Even the notion of caring control, be it by medical personnel or community must be resisted. This is more so in mental health care which sometimes involve behaviour and mental modification. In African traditional setting and ATM, the community must gradually come to term with the fact that health and health care is more of a subjective affair than community affair, hence the need to uphold patient decisions and respect their unique individuality.

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