Mind the Gap: Personal Reflections on the Mental Health Infrastructure of Ethiopia
By Yeshashwork Kibour, PhD
Dr. Yeshashwork Kibour is a graduate of the Howard University clinical psychology program and is currently the associate director of clinical training at Argosy University, Washington, DC. In her private practice in Washington, DC, Dr. Kibour specializes in the treatment of trauma with a diverse population. She is a steering committee member of Psychologist for Social Responsibility (PsySR) and a member of the Trauma and International Psychology divisions of APA.
After graduating from college, I wanted to do something professionally that made a real difference in the lives of people in my immediate world. At that time, this meant people from Ethiopia. So in the summer of 1994 I went to Addis Ababa, Ethiopia, after finishing my undergraduate degree in the US. I was fortunate enough to be allowed to follow the finest Ethiopian psychiatrists, social workers, occupational therapists, and physicians as they treated patients of Amanuel Psychiatric Hospital, which at the time was the only psychiatric hospital in the country. What I experienced and saw has impacted me in ways that continue to unfold as I encounter multiple facets of what it means to be a psychologist.
I will forever remember the smells of cardamom and clove that spiced piping hot tea, and of kerosene, which was used to disinfect floors. These smells permeated the air at the break of dawn on the hospital grounds. I witnessed the droves of potential patients who waited for hours in queues that did not seem to move, and that made it seem as though Ethiopia must have an excessively high rate of mental illness. In fact, the documented rate of mental illness was (and is) lower than, say, the United States. At this realization, I appreciated the indigenous ways that acted as communal defense mechanisms and immunized many from reaching a breaking point. Systems such as “Mehaber” (a collection of individuals with a common interest or identity that meet regularly); “Ekub” (a private communal banking system made up of a small group of people); and elaborate weddings and funeral ceremonies around which many people’s lives revolve, to name a few, serve this function.
But the largest issue, I later understood, was a profound lack of services for those who needed them.
The Gap Between Needs and Services
My education began with definitions. I struggled to understand what constitutes “need” as I grappled with the qualitative difference, in terms of the impact on family and on the community, between a young man experiencing his first psychotic break at the age of 17 and a functioning alcoholic who maintains a job and physically abuses his wife and children. I also grappled with different perspectives. On the one hand, I admired the courage embodied by patients who had to overcome multiple barriers, including stigma, to access services. On the other hand, I felt indignant about overextended hospital staff who had to resort to physical restraints with their patients, because of inadequate supply of appropriate medications, or who had to house the “criminally insane” with other patients because of lack of physical space. As I witnessed the dedication and resourcefulness of the staff who treated such needy patients with limited resources, I became determined to play some part in creating change in the overall system of mental health delivery in Ethiopia.
Fast forward to 2006, twelve years later. I am now a psychologist working in two major areas of psychology: as an associate director of clinical training with Argosy University, and as a therapist in private practice. In the latter capacity, I work with a wide range of clients from both mainstream and immigrant communities suffering from depression, anxiety, posttraumatic stress disorder. I specialize in trauma. My work with immigrant populations affords me the honor of working with refugee and immigrant survivors of politically motivated torture, gender based violence, and human trafficking. I also work with Ethiopians suffering from various mental health issues in the Washington, DC, metropolitan area.
Continuing my mission, I, along with a handful of other Ethiopian professionals in the field of psychology and mental health in general, co-founded Ethiopian Psychological Association International (EPAI)2. One of our initial projects, actualized with the help of APA’s Office of International Affairs, was to send very much needed books on a range of topics in psychology to Addis Ababa University via freight.
In 2006, I returned to Ethiopia with the goal of tracking the books, as this had turned out to be a much more arduous task than any of our members anticipated, and to assess the status of the gap I observed in 1994.
Upon my arrival, I was shown that the books had arrived safely. I had the honor of conversations with the Psychology department staff, who identified major barriers to advancing the field of psychology in Ethiopia. Their expressed needs included teaching manpower, faculty training on current trends in the field of psychology, text books, access to web-based learning and other information technology to facilitate networking, research, and access to training for those located in remote areas. I was convinced that when these needs were met, there would be greater hope for generating a pool of mental health professionals skilled at providing culturally appropriate services -- to both the 17 year old experiencing his first psychotic break and those who suffer silently.
To achieve this goal, Ethiopia, like many developing countries, needs resources to capitalize on existing societal strengths. It also needs to define mental health based on what is culturally and linguistically appropriate for the contemporary setting. Given the significant value of indigenous psychology, it is detrimental to have such definitions imposed by an external group. What better place to have such discussions but within the parameters of a robust graduate level psychology program.
I have witnessed the parallel processes of the growth of the Addis Ababa University psychology department and a painstakingly slow and arduous uphill battle to define and deliver quality mental health services to the general population. Current projects for the AAU department of psychology include opening new masters and doctorate level programs in Clinical and Health Psychology, and upgrading the department of psychology to an Institute of Psychology with the hope of giving it more autonomy to develop itself in various program areas. At the same time, the mental health arena continues to face multiple barriers. In fact, the World Health Organization (WHO) described mental health in Ethiopia as “one of the most disadvantaged health programs in Ethiopia, both in terms of facilities and trained manpower . . . with estimates of the average prevalence of mental disorders in Ethiopia at 15% for adults and 11% for children”. There are still few facilities. Black Lion Hospital provides some psychiatric services, but Amanuel Hospital continues to be the only psychiatric hospital in the country. Amanuel Hospital provides services predominantly on an outpatient basis. Its limited inpatient treatment service is just 361 beds that are restricted to acute care (Fekadu, Desta, Alem, & Prince, 2007).
Barriers to Bridging the Gap
In my best understanding of the gap between need and service, the solution is at best, incredibly complex. Barriers to bridging this gap include but are not limited to the following:
Lack of capacity, which may be the primary issue that impacts Ethiopia’s ability to provide adequate mental health services to the population. With only one graduate training program in the country housed in Addis Ababa University’s Psychology Department, Ethiopia does not stand a chance of meeting the need. The burden surely does not fall solely on the field of psychology. Certainly the Addis Ababa University’s school of social work and psychiatry departments in both Amanuel and Black Lion Hospitals play vital roles. However, post-graduate training of physicians in psychiatry did not begin till 2003. Efforts to extend services to remote locations, including the training of psychiatric nurses as well as the integration of mental health into primarily care, both viable options, fall short of addressing the need. At this point in history, all these programs combined do not graduate enough students at the graduate level yearly to even begin to meet the demand.
Over-reliance on the medical model, which raises a pathology model for considering who needs mental health services in Ethiopia. This affects how “mental illness” and “mental health” are defined, and raises questions such as: What is the cutoff point between the “sane” and the “insane.” Over-reliance on the medical model, in my opinion, creates an artificial cutoff between those presenting with obvious symptoms and those who quietly suffer. There is a general belief that only individuals in the throws of psychosis need mental health services. This is particularly damaging as it potentially thwarts the initiation and effectiveness of efforts geared toward prevention, e.g., psychosocially focused services. At present, the fates of those suffering lie primarily in the hands of psychiatrists in a country where the ratio of psychiatrists to population is 1: 6 million, according to WHO estimates. Even with waves of psychiatric nurses that expand psychosocial work to remote areas, only a very few of those that desperately need treatment have access. Therefore, simultaneously nurturing medical and alternative models (e.g., mind-body medicine, non-Western interventions) is timely for Ethiopia.
Stigma’s insidious nature and its crippling effect must be contended with if sustainable change is sought. Fear of how one might appear to others prevents many from getting needed assistance. In my own practice, I continually fight an uphill battle with clients who find themselves unable to take advantage of pro bono services, largely due to the stigma associated with seeing a therapist. I am also confronted by clients for whom attending multiple sessions triggers an “I must be really crazy” response rather than the intended acknowledgement that in order for transformation to occur, a trusting relationship must be established with a therapist, which takes time. Perhaps most damaging is the all too common reason for psychotropic noncompliance that stems from a client’s succumbing to pressure from friends and family, who, without any knowledge or skill to ascertain the necessity of medication, urge others to stop taking medications. A client unwilling to challenge his/her source of support, obliges and suffers the consequences. Furthermore, stigma also has the negative impact of reducing the potential pool of prospective graduate students interested in studying in mental health related fields. The dire consequences of stigma plague Ethiopia, as it does many other communities worldwide.
Lack of widely accessible venues for scientific debate on mental health issues impacting Ethiopians, initiated and written by Ethiopian professionals in-country. There are outlets for exchange of intellectual ideas at the regional level, including conferences and journals such as: The African Journal for the Psychological Study of Social Issues; African Journal of Cross-Cultural Psychology and Sport Facilitation; African Journal of Neurological Sciences (owned and controlled by the Pan African Association of Neurological Sciences (PAANS)). In Ethiopia, to my knowledge, only one journal exists with the potential of creating such an avenue for psychological debate, although it has not been utilized for this to date. The Ethiopian Journal of Health Development, which recently celebrated its 25th year in circulation, is published three times a year by the Department of Community Health, Addis Ababa University and is jointly sponsored by the Ethiopian Public Health Association and the Addis Ababa University. Outside of a few articles including Fekadu et al.’s 2007 article on findings from analysis of admissions to Amanuel Hospital, there were no articles on mental health topics outside of mental health issues associated with HIV/AIDS.
Closing the Gap - Steps in the Process
How do we deal with these barriers? Many individual and collective efforts are underway to enhance Ethiopia’s infrastructure to address health needs including infectious disease (e.g., HIV/AIDS), maternal health, and nutritional needs of children in the horizon of yet another drought. In addition to Ethiopia’s own commitment, the international community has pledged significant financial support to address this issue. For example, in 2008, the U.S. government alone provided $455 million in assistance, $337 million of which went for combating HIV/AIDS. In the same year, the U.S. government donated an additional $550 million in food assistance to help the government cope with a severe drought. (Background Note: Ethiopia). However, very little, if any, of the monies are specifically allocated for mental health services. Nongovernmental organizations (NGOs) also contribute to the flow of funds, ideas, and projects to combat health gaps. For example, People to People, Inc. (P2P) is one such NGO. This group consists of a worldwide network of Ethiopian health care professionals, whose mission is to effectively develop a virtual University consisting of Ethiopians in the Diaspora and to mobilize their potential through creative programs that promote indigenous and authentic solutions to Ethiopia’s challenges. P2P partners with local and international institutions to garner support for programs in Ethiopia. While there is some debate about the efficacy of foreign aid, it is undeniable that financial resources are essential. However, financial resources, unaccompanied by programs geared toward building a country’s infrastructure that will allow it to address its own problems (as opposed accepting imposed solutions that may fall outside the community’s self sustaining belief systems), are futile.
As the pathways toward possible solutions evolve, so do my thoughts on how I could make an impact. My first growth spurt included understanding the importance of fostering equitable and healthy partnerships. Therefore, my efforts thus far have revolved around raising awareness and establishing such partnerships with the hopes of creating fertile ground for reaching long-term solutions. To this end, one goal of this article is to raise awareness of Ethopia’s mental health needs. Please do not hesitate to contact me if you would like to contribute to addressing those needs, establish partnerships, or create projects with the underlying goal of increasing capacity in-country. [Author’s e-mail is ykibour “at” argosy.edu].
Fekadu A., Desta, M., Alem A., & Prince, M. (2007). A descriptive analysis of admissions to Amanuel Psychiatric Hospital in Ethiopia. Ethiopian Journal of Health Development, 21 (2), 173-178.