275
COMMUNTY PSYCIATRY IN NIGERIA— THE CURRENT STATUS A.
by BOROFFKA*,
M.D.,
D.T.M.&H.
and M. O.
OLATAWURA, M.B., B.S., M.SG., D.P.M., F.M.C. PSYCH. (NIG.) Department ofPsychiatry, University College Hospital, Ibadan, Nigeria in
has come to be equated with the village Abeokuta over the years. The programme which was started as a Professor Lambo in 1954 went through various forms of expansion and modification. The organisation and the virtues of the system have been extensively documented (3,4,5,1). In an attempt to quantify the relative merit of the village system, Lambo and Dastoor (6) compared 39 psychotic patients admitted to the University College Hospital (UCH) with 40 psychotic patients treated in Aro Village. In this evaluative study, the most strinking finding was that patients treated in the village had fewer symptoms on discharge compared with the group treated in UCH. This was accounted for partly by the fact that the Aro Village group was under no pressure to be discharged, unlike the case in UCH. There were no significant differences between the two groups treated in the two different facilities on the various measures of prognosis adopted. This would suggest that there are certain factors outside the hospital that influence the outcome in Nigeria, as in other places. Three of the original four villages that made up the system around Aro Hospital have dropped out. Two others have been added to maintain the original relationship with Aro hospital (1). The following report is on the Village of Aro, the centre of activity of the original village system. The University of Ibadan assumed full responsibilty for this village in 1963, as part of the Department of Psychiatry of the University. Because of the severe shortage of beds in the UCH (only nine psychiatric beds in a 500-beded hospital), Aro Village has met the in-patient needs of psychiatric patients contacting the UCH for years. It seems to us important to examine how Aro Village has been fulfilling this role, in the light of rapid socioeconomic and socio-cultural changes that have taken place in the neighbourhood since the inception of the programme.
Nigeria COMMUNITY&dquo;daypsychiatry system Hospital, hospital system&dquo; by around Aro
.
MATERIALS AND METHODS
The case notes of all admissions to Aro Village, from January 1, 1967, to the middle of December 1971 were carefully studied. Information extracted from the records includes age, sex, marital status, level of education, occupation and diagnosis of each patient. Other items extracted are sources of referral, distance from Aro Village of place of abode of patients, type of treatment given and status of each
patient on discharge. present address :
Post Lindaunis, West Germany. 2341, Lindau-Petersfield, Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
276 RESULTS
The 512 admissions covered were made up of 283 males and 229 females. The distribution of the group is shown in Table 1. age Thus, Aro Village offers treatment facilities for all age groups, with 65% of the total in the 15-34 years age group. Marital Status Table 2 shows the family status of the group. The records of 76 of the patients were inconclusive about the type of marriage contracted, while no information was recorded for nine. Level ofEducation The living situation in Aro that educated Nigerians may not
,
Village is rural. It has sometimes been suggested respond favourably to a village situation in which most patients sleep on mats spread on the floor. The level of literacy of the present group of 512 patients is shown in Table 3. Thus, 221 (43.1 %) of the total number of patients spoke English as a second language. In Nigeria the ability to speak English correlates highly with being sophisticated, Westernised or urbanised. That educated patients or their relatives should decide on the village treatment programme is not surprising, since most of the present generation of Nigerians have had some experience of rural life at one time or another, no matter what their level of education. ,
Occupation ofthe group The following classification of occupation was adopted in the present study. Group I consists of professionals with a University degree. These include doctors, lawyers, teachers, scientists and high government officials. Group II consists of professionals without a university degree and includes teachers, administrators, higher clerical and supervisory personnel, large-scale farmers, entrepreneurs and armedforces officers. Group III consists of clerks, motor vehicle drivers, mechanics, tailors, butchers, soldiers, policemen and small-scale enterpreneurs. Group IV consists of cooks, barbers, domestic servants, petrol station attendants, goldsmiths, blacksmiths, palmwine tappers and small-scale farmers. Group V includes labourers and petty traders. Group VI includes full-time housewives, students and unemployed educated youths. Table 4 shows the distribution of the 512 patients by occupation. The village system thus provides psychiatric care for all categories of occupations. The preponderance of patients from the lower income groups merely reflects the general composition of Nigerian society. Source ofReferral The sources of referral of the patients are shown in Table 5. It is striking that a teaching hospital should refer so large a number of patients to the village. This is accounted for by the fact that provision for psychiatric in-patient care in UCH is very meagre. The psychiatric personnel based in Ibadan usually refer patients thought to require admission to the village. Perhaps of even greater interest are the 239 (46.7%) patients who came to the village directly. Most of these patients were directed to the village by ex-patients and their relatives. Others probably knew of the village programme through general
public
awareness. Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
277
Diagnostic Groups Mainly due to the dearth of in-patient facilities in Nigeria, psychotic patients usually constitute the majority of psychiatric patients admitted. Table 6 shows the diagnoses of the 512 patients admitted to Aro Village from 1967-1971. Schizophrenia, unspecified (26.6%), was the most frequently made diagnosis, followed by the catatonic type (20.3%). Next comes paranoid schizophrenia (18.4%), followed by hebephrenia (8.2%). On the face of it, catatonic schizophrenia appears to be quite common in this part of Nigeria. It needs to be pointed out, however, that catatonic excitement
may be difficult to differentiate from mania or excitement states. The diagnostic inclinations of the attending physicians may also have introduced a bias. The diagnoses, moreover, were not made in a standardised manner. Of the 30 cases (5.9%) of the series that lacked psychotic features, 11 were treated for epilepsy.
Patient’s Home Address The few available psychiatric facilities in
developing countries like Nigeria tend attendance rates. Thus a cursory look at any outpatient clinic of any of these facilities tends to give a rather exaggerated picture of the prevalence of psychiatric disorders in the neighbourhood. In fact, many of the patients frequently travel long distances to get psychiatric help. Table 7 shows the distances of the patients’ homes from the two main centres of therapeutic activities, namely Aro Village, which provides the in-patient facilities, and UCHIbadan, where the patients discharged from Aro Village are followed up as outto
have
high daily out-patient
patients.
It is seen that more than half (55.1%) of patients in this series travelled long distances, either to reach Aro Village or to come to UCH-Ibadan for out-patient supervision. This factor alone accounts for a high attrition rate in the follow-up clinic in UCH, which affects the relapse rate of psychotic patients in Nigeria. Period ofAdmission Patients treated in Aro Village tend to have more control over their length of stay, up to a point, than is the case in other psychiatric units. Since the village bears no outward mark of an institution, the relatives of patients succeed fairly often in their pleadings with the treatment staff to postpone the discharge. Even when a patient is well enough to go home, some relative would sometimes ask for postponement, in order to make really sure that all is well with the patient. This tends to be off-set by some other patients and relatives, relatively urbanised, who clamour for early discharge from the village. Table 8 shows the length of time spent by this series of patients. It is seen from Table 8 that 296 (57.8%) of the patients were discharged by the end of three months. By the end of four months, 76.4% have been discharged, and this rises to 88.9% by the end of five months. After six months, only 25 (4.8%) of the patients have yet to be discharged. One patient actually spent eleven months in the village. Treatment Programme in the Village The programme of treatment is best illustrated by recounting a typical day’s life for patients in the village. Patients scheduled to undergo ECT are brought by their relatives to the treatment room in the morning, without breakfast. Treatment is administered Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
278 the nursing staff; premedication with Atropine is infrequent. After recovery, relatives collect the patients for rest in their rented rooms. After about two hours, patients who are well enough may join fellow patients in the occupational therapy shed for games, informal discussions or handicraft or engage, with their relatives ,in household chores. Patients on routine medication report in the morning at the treatment centre with their relatives. The latter give what amounts to a night nurse’s report, and medication is given accordingly. Those who are well enough go to the occupational therapy shed for games or informal discussions or see to their personal needs in conjunction with their relatives. The same process is repeated for afternoon and evening medication. After the afternoon siesta, there is an organised group meeting, conducted in turn by members of the treatment team, usually the nursing staff. The treatment centre closes by 7 p.m.; emergency psychiatric attention is provided by the nursing officer on call; psychiatrists and trainees provide general supervision of the village programme. The usual range of drugs, nursing care and other physical treatment available in any standard psychiatric centre is provided in Aro Village. The essential difference is the special and peculiar therapeutic melieu that the village provides. This will be described presently.
usually by
Outcome The results of treating this series of patients in the village were extracted from the case records. A broad definition of improvement was thus possible. This is shown in Table 9. Table 9 shows that the immediate outcome for 396 (’70.3%) of the series was good. Those who were judged to be well enough to be looked after at home and those who failed to improve tended to stay long in the village. The seven deaths were accounted for by five patients who succumbed to an epidemic of diarrhoea in the region and two others who died as a result of extreme inanition, having been kept away at native healers’ facilities for a long time. There was no death from ECT. It is the practice to transfer patients who need energetic physical treatment for physical conditions like heart disease, pulmonary infection, severe anaemia, etc. to the UCH Ibadan or other hospitals near by. DISCUSSION
When mental health
care was
carried
to
.
the
people by
the innovative
village
system of Lambo in the mid-fifties, psychiatric facilities were very meagre in the country. Twenty years after, the facilities have undergone little change even though the country has witnessed rapid socio-cultural and socio-economic changes. For example, there is a great drift of the population from rural to urban areas.
There is more money in circulation, many rural areas now have pipe-borne water and electricity. It may be argued that since the general population has only limited choice, because psychiatric facilities in the form of modern hospitals have not increased, the popularity of the village system cannot be fully assessed. There are indications, however, that this type of treatment programme is acceptable and desirable. As has been shown above (Table 3), Nigerians from all educational and occupational walks of life have used the facility. As far as the present generation of Nigerians is concerned, their traditional belief systems, their world view of disease causation and the remedies deemed appropriate are largely unaltered by their level of education. If some baffling symptoms fail to yield to Western or orthodox medication, Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
279 the Nigerian will readily seek or accept native procedures, including ritual sacrifices (2). Many of our patients covered long distances to reach Aro Village (Table 7). Many of these (46.7%) came directly, having learnt of the treatment programme from former patients and others. A good number of our patients’ relatives, including educated ones who are aware of the existence of psychiatric hospitals, opt for the village system, because of their desire to conceal the illness from other people. The initial anxieties of some relatives of patients about the attitude of the public to the illness in their sick member are allayed by the setting of the facility; and the village programme is aimed at modifying these attitudes even further. On arrival at the rented rooms in the village, the relatives are usually surprised at the relaxed and reassuring attitude of the landlord and his family. The villagers usually start by telling the new arrivals’ relatives that the condition of the newly admitted patient is mild, compared with what thev have seen in the village over the years, adding that &dquo;once the head treatment (ECT) is administered, the rest is simple&dquo;. During the open air cooking of evening meals, the new member is further surprised by the accepting and accommodating attitude of the villagers to those who are well enough to participate in the kitchen chores. Indeed, it is not easy to distinguish patients and relatives from villagers during evening communal village life. Organised group meetings that involve patients, relatives and villagers further serve as a forum for modifying unwholesome attitudes to mental illness. Since, on the average, patients may be expected to stay for fairly long periods, relatives take turns to stay with patients. The modification of attitude is thus extended to many members of a patient’s family and ultimately to their home village or town. Although the village programme does not put pressure on patients and relatives to leave, once the patients are well enough to be discharged, a conscious effort is made by staff to get them to shift to out-patient status. Relatives often press to be allowed o stay longer, to make sure that the patient does not relapse. This sometimes stems from previous attendance at faith or traditional healers. Factors that favour relapse, such as failure to take maintenance medication., unresolved psychosocial conflicts, etc., are regularly dealt with in spontaneous or organised group
meetings.
In the last few years it has been recognised that the living situation in the village is not totally acceptable to some heavily urbanised Nigerians. As soon as they recover in some measure, they press for discharge. The provision of a few rooms with modern amenities on the outskirts of the village appears to have taken care of this. Unfortunately rapid socio-economic and socio-dultural changes now seriously threaten family cohesiveness and traditional family obligations. The essential participation in the village programme by family members may not be readily available in future. This will be a factor to reckon with, when modem
psychiatric hospitals
are
provided. SUMMARY
Over
period of 50 months, 512 psychiatric patients were treated in the Aro Village therapeutic community. The majority of those admitted (94.1 %) had symptoms of psychosis. By the end of three months 57.8% had been discharged, while 88.9% were discharged by the end of five months. Of these, 70.3% were
judged
fit
a
to return to
their work. The relatives of
patients
as
well
Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
as
the
villagers
280 were
involved in the treatment programme. The advantages of this method, are as well as the implications for the future of the programme of the of traditional family ties resulting from rapid urbanisation.
discussed, loosening
z
REFERENCES
1. 2. 3. 4.
5. 6.
Asuni, T.: (1967), Aro hospital in perspective. Amer. J. Psychiat. 124, 6, p. 763-770. Lambo, T. A.: (1960), Characteristic features of the psychology of the Nigerian West Afr. Med. J., 9, p. 95-104. Lambo, T. A.: (1961), A plan for the treatment of the mentally ill in Nigeria. The Village system of Aro. In: L. Linn (Ed.) Frontiers in General Hospital Psychiatry. U. P. New York, p. 215-231. Lambo, T. A.: (1962), The importance of cultural factors in treatment with special reference to the utilisation of the social environment, Acta Psychiat. Scand., 38, p. 176-182. Lambo, T. A.: (1966), Patterns of psychiatric care in developing African Countries. The Nigerian village programme. In: International Trends in Mental Health, (Ed. H. P. David), McGraw-Hill, New York, p. 147-153. Lambo, T. A. and Dastoor, D. P.: (1972), Evaluation of the Community Psychiatry Experiment at Aro Village, Abeokuta, Nigeria. Mimeograph, Behavioural Sciences Research Unit, University of Ibadan.
Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
COMMUNTY PSYCIATRY IN NIGERIA— THE CURRENT STATUS A.
by BOROFFKA*,
M.D.,
D.T.M.&H.
and M. O.
OLATAWURA, M.B., B.S., M.SG., D.P.M., F.M.C. PSYCH. (NIG.) Department ofPsychiatry, University College Hospital, Ibadan, Nigeria in
has come to be equated with the village Abeokuta over the years. The programme which was started as a Professor Lambo in 1954 went through various forms of expansion and modification. The organisation and the virtues of the system have been extensively documented (3,4,5,1). In an attempt to quantify the relative merit of the village system, Lambo and Dastoor (6) compared 39 psychotic patients admitted to the University College Hospital (UCH) with 40 psychotic patients treated in Aro Village. In this evaluative study, the most strinking finding was that patients treated in the village had fewer symptoms on discharge compared with the group treated in UCH. This was accounted for partly by the fact that the Aro Village group was under no pressure to be discharged, unlike the case in UCH. There were no significant differences between the two groups treated in the two different facilities on the various measures of prognosis adopted. This would suggest that there are certain factors outside the hospital that influence the outcome in Nigeria, as in other places. Three of the original four villages that made up the system around Aro Hospital have dropped out. Two others have been added to maintain the original relationship with Aro hospital (1). The following report is on the Village of Aro, the centre of activity of the original village system. The University of Ibadan assumed full responsibilty for this village in 1963, as part of the Department of Psychiatry of the University. Because of the severe shortage of beds in the UCH (only nine psychiatric beds in a 500-beded hospital), Aro Village has met the in-patient needs of psychiatric patients contacting the UCH for years. It seems to us important to examine how Aro Village has been fulfilling this role, in the light of rapid socioeconomic and socio-cultural changes that have taken place in the neighbourhood since the inception of the programme.
Nigeria COMMUNITY&dquo;daypsychiatry system Hospital, hospital system&dquo; by around Aro
.
MATERIALS AND METHODS
The case notes of all admissions to Aro Village, from January 1, 1967, to the middle of December 1971 were carefully studied. Information extracted from the records includes age, sex, marital status, level of education, occupation and diagnosis of each patient. Other items extracted are sources of referral, distance from Aro Village of place of abode of patients, type of treatment given and status of each
patient on discharge. present address :
Post Lindaunis, West Germany. 2341, Lindau-Petersfield, Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
276 RESULTS
The 512 admissions covered were made up of 283 males and 229 females. The distribution of the group is shown in Table 1. age Thus, Aro Village offers treatment facilities for all age groups, with 65% of the total in the 15-34 years age group. Marital Status Table 2 shows the family status of the group. The records of 76 of the patients were inconclusive about the type of marriage contracted, while no information was recorded for nine. Level ofEducation The living situation in Aro that educated Nigerians may not
,
Village is rural. It has sometimes been suggested respond favourably to a village situation in which most patients sleep on mats spread on the floor. The level of literacy of the present group of 512 patients is shown in Table 3. Thus, 221 (43.1 %) of the total number of patients spoke English as a second language. In Nigeria the ability to speak English correlates highly with being sophisticated, Westernised or urbanised. That educated patients or their relatives should decide on the village treatment programme is not surprising, since most of the present generation of Nigerians have had some experience of rural life at one time or another, no matter what their level of education. ,
Occupation ofthe group The following classification of occupation was adopted in the present study. Group I consists of professionals with a University degree. These include doctors, lawyers, teachers, scientists and high government officials. Group II consists of professionals without a university degree and includes teachers, administrators, higher clerical and supervisory personnel, large-scale farmers, entrepreneurs and armedforces officers. Group III consists of clerks, motor vehicle drivers, mechanics, tailors, butchers, soldiers, policemen and small-scale enterpreneurs. Group IV consists of cooks, barbers, domestic servants, petrol station attendants, goldsmiths, blacksmiths, palmwine tappers and small-scale farmers. Group V includes labourers and petty traders. Group VI includes full-time housewives, students and unemployed educated youths. Table 4 shows the distribution of the 512 patients by occupation. The village system thus provides psychiatric care for all categories of occupations. The preponderance of patients from the lower income groups merely reflects the general composition of Nigerian society. Source ofReferral The sources of referral of the patients are shown in Table 5. It is striking that a teaching hospital should refer so large a number of patients to the village. This is accounted for by the fact that provision for psychiatric in-patient care in UCH is very meagre. The psychiatric personnel based in Ibadan usually refer patients thought to require admission to the village. Perhaps of even greater interest are the 239 (46.7%) patients who came to the village directly. Most of these patients were directed to the village by ex-patients and their relatives. Others probably knew of the village programme through general
public
awareness. Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
277
Diagnostic Groups Mainly due to the dearth of in-patient facilities in Nigeria, psychotic patients usually constitute the majority of psychiatric patients admitted. Table 6 shows the diagnoses of the 512 patients admitted to Aro Village from 1967-1971. Schizophrenia, unspecified (26.6%), was the most frequently made diagnosis, followed by the catatonic type (20.3%). Next comes paranoid schizophrenia (18.4%), followed by hebephrenia (8.2%). On the face of it, catatonic schizophrenia appears to be quite common in this part of Nigeria. It needs to be pointed out, however, that catatonic excitement
may be difficult to differentiate from mania or excitement states. The diagnostic inclinations of the attending physicians may also have introduced a bias. The diagnoses, moreover, were not made in a standardised manner. Of the 30 cases (5.9%) of the series that lacked psychotic features, 11 were treated for epilepsy.
Patient’s Home Address The few available psychiatric facilities in
developing countries like Nigeria tend attendance rates. Thus a cursory look at any outpatient clinic of any of these facilities tends to give a rather exaggerated picture of the prevalence of psychiatric disorders in the neighbourhood. In fact, many of the patients frequently travel long distances to get psychiatric help. Table 7 shows the distances of the patients’ homes from the two main centres of therapeutic activities, namely Aro Village, which provides the in-patient facilities, and UCHIbadan, where the patients discharged from Aro Village are followed up as outto
have
high daily out-patient
patients.
It is seen that more than half (55.1%) of patients in this series travelled long distances, either to reach Aro Village or to come to UCH-Ibadan for out-patient supervision. This factor alone accounts for a high attrition rate in the follow-up clinic in UCH, which affects the relapse rate of psychotic patients in Nigeria. Period ofAdmission Patients treated in Aro Village tend to have more control over their length of stay, up to a point, than is the case in other psychiatric units. Since the village bears no outward mark of an institution, the relatives of patients succeed fairly often in their pleadings with the treatment staff to postpone the discharge. Even when a patient is well enough to go home, some relative would sometimes ask for postponement, in order to make really sure that all is well with the patient. This tends to be off-set by some other patients and relatives, relatively urbanised, who clamour for early discharge from the village. Table 8 shows the length of time spent by this series of patients. It is seen from Table 8 that 296 (57.8%) of the patients were discharged by the end of three months. By the end of four months, 76.4% have been discharged, and this rises to 88.9% by the end of five months. After six months, only 25 (4.8%) of the patients have yet to be discharged. One patient actually spent eleven months in the village. Treatment Programme in the Village The programme of treatment is best illustrated by recounting a typical day’s life for patients in the village. Patients scheduled to undergo ECT are brought by their relatives to the treatment room in the morning, without breakfast. Treatment is administered Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
278 the nursing staff; premedication with Atropine is infrequent. After recovery, relatives collect the patients for rest in their rented rooms. After about two hours, patients who are well enough may join fellow patients in the occupational therapy shed for games, informal discussions or handicraft or engage, with their relatives ,in household chores. Patients on routine medication report in the morning at the treatment centre with their relatives. The latter give what amounts to a night nurse’s report, and medication is given accordingly. Those who are well enough go to the occupational therapy shed for games or informal discussions or see to their personal needs in conjunction with their relatives. The same process is repeated for afternoon and evening medication. After the afternoon siesta, there is an organised group meeting, conducted in turn by members of the treatment team, usually the nursing staff. The treatment centre closes by 7 p.m.; emergency psychiatric attention is provided by the nursing officer on call; psychiatrists and trainees provide general supervision of the village programme. The usual range of drugs, nursing care and other physical treatment available in any standard psychiatric centre is provided in Aro Village. The essential difference is the special and peculiar therapeutic melieu that the village provides. This will be described presently.
usually by
Outcome The results of treating this series of patients in the village were extracted from the case records. A broad definition of improvement was thus possible. This is shown in Table 9. Table 9 shows that the immediate outcome for 396 (’70.3%) of the series was good. Those who were judged to be well enough to be looked after at home and those who failed to improve tended to stay long in the village. The seven deaths were accounted for by five patients who succumbed to an epidemic of diarrhoea in the region and two others who died as a result of extreme inanition, having been kept away at native healers’ facilities for a long time. There was no death from ECT. It is the practice to transfer patients who need energetic physical treatment for physical conditions like heart disease, pulmonary infection, severe anaemia, etc. to the UCH Ibadan or other hospitals near by. DISCUSSION
When mental health
care was
carried
to
.
the
people by
the innovative
village
system of Lambo in the mid-fifties, psychiatric facilities were very meagre in the country. Twenty years after, the facilities have undergone little change even though the country has witnessed rapid socio-cultural and socio-economic changes. For example, there is a great drift of the population from rural to urban areas.
There is more money in circulation, many rural areas now have pipe-borne water and electricity. It may be argued that since the general population has only limited choice, because psychiatric facilities in the form of modern hospitals have not increased, the popularity of the village system cannot be fully assessed. There are indications, however, that this type of treatment programme is acceptable and desirable. As has been shown above (Table 3), Nigerians from all educational and occupational walks of life have used the facility. As far as the present generation of Nigerians is concerned, their traditional belief systems, their world view of disease causation and the remedies deemed appropriate are largely unaltered by their level of education. If some baffling symptoms fail to yield to Western or orthodox medication, Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
279 the Nigerian will readily seek or accept native procedures, including ritual sacrifices (2). Many of our patients covered long distances to reach Aro Village (Table 7). Many of these (46.7%) came directly, having learnt of the treatment programme from former patients and others. A good number of our patients’ relatives, including educated ones who are aware of the existence of psychiatric hospitals, opt for the village system, because of their desire to conceal the illness from other people. The initial anxieties of some relatives of patients about the attitude of the public to the illness in their sick member are allayed by the setting of the facility; and the village programme is aimed at modifying these attitudes even further. On arrival at the rented rooms in the village, the relatives are usually surprised at the relaxed and reassuring attitude of the landlord and his family. The villagers usually start by telling the new arrivals’ relatives that the condition of the newly admitted patient is mild, compared with what thev have seen in the village over the years, adding that &dquo;once the head treatment (ECT) is administered, the rest is simple&dquo;. During the open air cooking of evening meals, the new member is further surprised by the accepting and accommodating attitude of the villagers to those who are well enough to participate in the kitchen chores. Indeed, it is not easy to distinguish patients and relatives from villagers during evening communal village life. Organised group meetings that involve patients, relatives and villagers further serve as a forum for modifying unwholesome attitudes to mental illness. Since, on the average, patients may be expected to stay for fairly long periods, relatives take turns to stay with patients. The modification of attitude is thus extended to many members of a patient’s family and ultimately to their home village or town. Although the village programme does not put pressure on patients and relatives to leave, once the patients are well enough to be discharged, a conscious effort is made by staff to get them to shift to out-patient status. Relatives often press to be allowed o stay longer, to make sure that the patient does not relapse. This sometimes stems from previous attendance at faith or traditional healers. Factors that favour relapse, such as failure to take maintenance medication., unresolved psychosocial conflicts, etc., are regularly dealt with in spontaneous or organised group
meetings.
In the last few years it has been recognised that the living situation in the village is not totally acceptable to some heavily urbanised Nigerians. As soon as they recover in some measure, they press for discharge. The provision of a few rooms with modern amenities on the outskirts of the village appears to have taken care of this. Unfortunately rapid socio-economic and socio-dultural changes now seriously threaten family cohesiveness and traditional family obligations. The essential participation in the village programme by family members may not be readily available in future. This will be a factor to reckon with, when modem
psychiatric hospitals
are
provided. SUMMARY
Over
period of 50 months, 512 psychiatric patients were treated in the Aro Village therapeutic community. The majority of those admitted (94.1 %) had symptoms of psychosis. By the end of three months 57.8% had been discharged, while 88.9% were discharged by the end of five months. Of these, 70.3% were
judged
fit
a
to return to
their work. The relatives of
patients
as
well
Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
as
the
villagers
280 were
involved in the treatment programme. The advantages of this method, are as well as the implications for the future of the programme of the of traditional family ties resulting from rapid urbanisation.
discussed, loosening
z
REFERENCES
1. 2. 3. 4.
5. 6.
Asuni, T.: (1967), Aro hospital in perspective. Amer. J. Psychiat. 124, 6, p. 763-770. Lambo, T. A.: (1960), Characteristic features of the psychology of the Nigerian West Afr. Med. J., 9, p. 95-104. Lambo, T. A.: (1961), A plan for the treatment of the mentally ill in Nigeria. The Village system of Aro. In: L. Linn (Ed.) Frontiers in General Hospital Psychiatry. U. P. New York, p. 215-231. Lambo, T. A.: (1962), The importance of cultural factors in treatment with special reference to the utilisation of the social environment, Acta Psychiat. Scand., 38, p. 176-182. Lambo, T. A.: (1966), Patterns of psychiatric care in developing African Countries. The Nigerian village programme. In: International Trends in Mental Health, (Ed. H. P. David), McGraw-Hill, New York, p. 147-153. Lambo, T. A. and Dastoor, D. P.: (1972), Evaluation of the Community Psychiatry Experiment at Aro Village, Abeokuta, Nigeria. Mimeograph, Behavioural Sciences Research Unit, University of Ibadan.
Downloaded from isp.sagepub.com at MCMASTER UNIV LIBRARY on March 19, 2015
