Mental illness is dreaded, stigmatized and burdensome, yet the research enterprise has not focused much attention on it in Nigeria. The few existing studies (Jack-ide et al 2013, Adelakun et 2001, Leighton et al, 1963, ) have not considered the critically important role of the family which to a large extent determines the outcome of the illness as has been recognized in countries such as the United State Of America ( Heru 2000, Lefley 1996, Biegel, Sales and Schultz 1991).
Outside the three types of healing institutions that are available for treatment of mental illness namely, traditional healers, religious organizations and modern medicine especially psychiatric hospitals, families that have experienced mental illness struggle to cope with it in isolation. There are no emergency intervention services, support groups focusing on mental illness, coordinating body to oversee public education and awareness campaigns on mental health and illness in the country.(WHO-AIM Report on Mental Health System in Nigeria 2006).
The purpose of this article is to analyze some aspects of the functioning of families which serve as strength or weaknesses in their ability to cope with the mental illness of their loved ones. The analysis is informed by qualitative data obtained during participant observation of 20 known families which have experienced mental illness, Of the 20 known families, the sufferers were 2 husbands/fathers, 3 wives/ mothers and 15 off springs.
The sufferers were all diagnosed in psychiatric hospitals as having one form of mental illness or another. In view of the fact that the mode of data collection was participant observation which took place over several years, it was not possible to ascertain the particular form of mental illness which each subject experienced. The observations were focused on the several strategies which were adopted by caregivers to cope with the mental disorder of their loved ones.
Characteristics of the Subjects
Husbands / Fathers . Of the two husbands /fathers, one was a medical doctor and the other a self-employed tertiary educated business man, At the time of the observations one was in his 40’s and the other in his 60’s. Their marriages to equally highly educated spouses were intact
Wives-Mothers. The 3 wives /mothers were in their late 30’s and 40’s at the time of observation: The three of them worked in a university two as teachers and one as an administrative staff with considerable nursing experience. Two of them were married and one of them was divorced about 10 years before she was sick for the first time.
Offsprings. The offsprings consisted of 14 men and 1 woman, all of whom were students in tertiary institutions at the time they were sick they all eventually graduated from their respective tertiary institutions although in two cases their period of studies was prolonged because of the severity of their illness. The offsprings whose ages ranged from 18 to 23 years at the time the present writer first encountered them curiously occupied the first and second birth positions in each of their families which had 3 to 4 children. It should be mentioned that except in one case in which a sibling was diagnosed about 10 years later to be mentally distressed, all the other siblings have remained normal and presently occupy important positions in their work places both inside and outside the country. It should also be mentioned that up to date none of the offsprings has married , all of them except one are still struggling to overcome their illness which began in adolescence and has lingered on to the present time in which they are in their early and late forties.
Participant Observation
As required by this mode of data collection, the writer lived in close contact for about 10 to 20 years with families which are discussed in the paper. She acted as one of the caregivers in one family and was involved in two arrangements that were designed to provide breaks for caretakers in two other families. In her capacity as the Head of Department of Counselling in a tertiary institution she was consulted when important decisions was to be taken with respect to the return of three of them to their study programs after prolonged hospitalization.
Detection of Warning Signs
None of the relatives of the sufferers detected glaring warning signs even though they admitted that they observed significant changes in their behavior. Such changes included undue sadness, irritability, argumentativeness, assertiveness and anger. Moreover it was observed that they could no longer cope with routine responsibilities at home.
Spouses and parents attributed their inability to detect warning signs to ignorance. Since they did not have previous experience of mental illness, and did not expect it they could not properly interpret observed signs . They later blamed themselves for not recognizing warning signs, One mother who reported that about 6 months prior to the illness of her son she had a nightmare about it severely blamed herself for ignoring the nightmare. She is still blaming herself twenty five years after the episode. Another reason advanced by relatives for failure to detect warning signs was that in almost all the cases the illness was accompanied by high feverish conditions which they attributed to malaria which is endemic in the country.
Reaction of Families
In all families, reaction to illness was negative and panicky. Spouses were devastated when the illness which they attributed to malarial fever was diagnosed as manifestations of mental disorders, Parents, especially mothers wept copiously. It was reported that a few mothers wept continuously refusing to be consoled until they were guided to perceive the negative effect of their weeping on their suffering offsprings .
It was reported that some parents denied the diagnoses especially since offsprings vehemently protested it declaring, that they were normal . Parents at first blamed their offspring and wanted to know through intensive questioning what they had done to cause the illness and where they had been . As was assessed later by parents especially mothers ,the beginning of the sickness was the most traumatic . Subsequently they began to accept the reality of the illness and were concerned with the practical actions that needed to be taken towards the recovery of the afflicted ones.
Treatment Options
Studies of mental illness in the country have found that of the three treatment options mentioned at the beginning of the paper namely consultations with traditional healers, spiritual leaders/exorcists and psychiatrists ,the first two were the first and sometimes the only source of treatment for most mental sufferers (Jack-ide et al 2013, Lasebikan et al 2012 , Adewuya and Makanjuola 2009 Kabir et al, 2004, Odejide and Morakinyo 2003 , Makanjuola 2003).
As far as can be ascertained all of the afflicted ones in the known families received treatment primarily from psychiatric hospitals in which they were sometimes hospitalised for periods varying from about 3 months to a year or more .As Christians they received prayer support at the onset of the illness from the churches with which they were affiliated. The extent to which families consulted traditional healers is not known. Some families admitted that extended family members exerted considerable pressure on then to consult traditional healers but they did not disclose whether or not they yielded to such pressure .In view of their elevated social status and known commitment to their Christian faith, they may have been reluctant to admit private visits to traditional healers to the present writer. However, it is almost certain ,that none of the ten families in which the major caregivers had experienced conversion would have consulted native healers on grounds of their renewed faith.
Strategies adopted by Families
Different types of strategies were utilized by families to cope with mental illness . Firstly, with respect to involvement of family members in caregiving roles, the responsibility of caregiving fell mostly on women as wives , mothers and sisters , with their male counterparts providing subsidiary caregiving . When husbands were afflicted, their wives automatically assumed caregiving roles supported by their children mostly daughters, some of whom had established their own homes but returned to parental homes for up to a month to assist in caregiving . When wives were afflicted, the category of caregivers was not predictable since they were sometimes recruited from their social network. Depending on the extent to which wives /mothers were cordially affiliated with other women in their social network the latter consisting of relatives from the extended family ,clients ,co-worshippers, colleagues, were serially invited to provide care. Since such women were well known to husbands and children ,they merely slipped into caregiving roles sometimes physically moving into the families until the wives conditions improved.
When offsprings were afflicted, mothers provided the bulk of the caregiving aided by employed domestic help and dependable members of the extended family who already knew the sufferers. When two or more people were involved with care giving there was a division of labour as to what each person did in some families, thus reducing the burden of care on any one of them .In some families there was no clear division of labour in caregiving ; any available relative served as caregivers along with others.
By hindsight families found that when there was a clear division of labour between caregivers mental sufferers fared better and tried to change to this pattern when their circumstances permitted it.
Caregivers admitted that at first they were ignorant about their role content which they had to learn on the job, through trial and error. The administration of prescribed medication to non-compliant sufferers was found to be a formidable task which became relatively easy when they detected the various subterfuges which sufferers employed to avoid needed medication.
Another distinguishing factor between families was the extent to which they continued to relate to sufferers’ emtionally. At first virtually all caregivers related to the suffering offsprings with much emotion. However with time some families learned that relating to off-springs emotionally was counter productive and began to show restraint during interaction with them.
They found that good humour and laughter produced far better result with respect to obtaining the cooperation of sufferers than blaming, scolding or nagging . In other families, despite counselling, caregivers especially siblings could not refrain from being emotionally involved.
It seemed to the writer that the manner in which families eventually related to sufferers could be gauged from the amount of freedom of movement they were given .Three patterns were observed as families came to accept the reality of mental illness;
Firstly, a minority of family which had learned the value of detachment allowed their afflicted members free movement during the day restricting their movement at night by locking entrance gates .They rarely interfered with their movement unless to curb occasional excesses.
Secondly, a few families who were still emotional in their interation with sufferes controlled their movement during the day and night because they had gone out and failed to return at night . Search parties usually found them in unpredictable places. Consequently sufferers were always accompanied by escorts when they ventured out of households.
The third pattern of movement control practiced by most families was intermettent control depending on the condition of health of the afflicted ones. They were granted freedom of movement when their condition improved and were restricted when signs of deterioration in health were observed.
It was difficult to assess the effectiveness of the foregoing strategies either from the view point of the sufferers or the family as a whole. Suffice it to mention that families which did not restrict sufferers at all exposed themselves to the risk of their wandering off temporarily or permanently .However since the sufferers were not lost, it would seem that from the point of view of respecting their right to freedom of movement, the risk was worth taking. The amount of freedom of movement granted to sick ones in two families was exceptionally high. When the sick ones unilaterally decided to relocate to their communities of origin in which their fathers grew up but in which themselves never lived they were provided money and travelling companions who were expected to render them personal assistance not to monitor them . They returned to their families after 6 to 9 months vowing not to repeat the experience again . It was observed that when sufferers were denied freedom of movement as a consequence of their attempt to escape ,they constantly looked for ways to escape ,thus escalating the barriers which families had to mount at entry points. It seems that the third strategy in which freedom of movement was intermittently granted, depending on the condition of health of sufferers was the most rewarding especially since it was used as an incentive to obtain more co-operation from them in the aspects of caregiving in which they were neglectful or outright rebellious.
The foregoing discussion represents only a small aspect of coping strategies which were observed to evolve in families through trial and error over a long period. It is note worthy that families did not rigidly stick to any strategy rather they modify aspects of strategy as demanded by fluctuations in the health condition of sufferers.
Recovery of sufferers
Over a period of approximately twenty five years in which the families were known the recovery of sufferers was as follows .Among the two husbands /fathers, none has recovered, one died at the age of fifty and the other who is about 78 years old is yet to recover from the illness. Of the 3 wives /mothers subjects two recovered completely within a period of about 5 years .They continued their careers in their universities and rose to the highest attainable positions before they retired a few years ago . Of the 15 off springs sufferers only 2 have recovered completely sufficiently to practice their profession. One of those who recovered did so after his two parents died in their seventies .Extended family members attributed their death to the adverse health condition of their son rather than to old age, Two of the off springs are manifesting signs of recovery and both their parents and psychiatrics are hopeful, they will soon recover .
Impact of mental suffering: Sacrifices as gain and durect rewards
In view of cultural and religious diversity as well as social economic status differences, The perception of families from different ethno – linguistic group will differ as to the extent to which they perceive and interprete some of the hardships which are associated with providing care for those who suffer from mental illness. In the experience which is discussed in this paper in which the 20 families are Christians who belong mostly to Yoruba ethnic group, the perceptions of physical, social, psychological and financial hardships were approximately similar namely; that hardships were perceived as sacrifices which they were expected to make to facilitate the survival of loved ones who have done nothing wrong to deserve their condition. They were grateful to God for providing them the health, strength and resources with which they coped with their predicament.
They were appreciative of the fact that they themselves enjoyed good mental health in the first place, Such philosophising promoted the resilience of caregivers.
Studies carried out in other countries notably the United States of America which have assessed the impact of care giving on caregivers and family systems have distinguished between objective and subjective burden. Objective burden is defined as observable concrete cost to the family resulting from mental illness such as disruption to everyday life in the house hold and financial life. Subjective burden is defined as the individuals personal appraisal of the situation and extent to which people perceive, they are carrying a burden (Heru 2000) Studies that assessed impacts have also examined perceptions of gain or rewards (Heru 2000).
In Nigeria especially among ethnic groups such as the Yoruba , in which traditionally family members especially children are socialized to care for their parents in period of crises and old age, objective burden in not likely to be acknowledged among adequately socialized persons. In the case of children who act as caregivers for parents of either gender for example even subjective burden is likely to be muted in view of expectations that children make sacrifices in return for parental caregiving during their childhood. It is believed that such sacrifices will be rewarded in their old age by children who are regarded as old age pension. The foregoing cultural belief is reinforced by the Christian ethos which attaches longevity to the amount of honor which one render to ones parents. Rather than dwell on losses which were evident in their predicament the known families recognized gains such as intensified relationship between families and neighbors who rendered assistance beyond expectation, Almost half of the families mentioned the fact that as a result of caring for sick ones they had learned to be humble and kind in relating to categories of people such as the needy, the disabled and destitute. They tried to live their changed attitude by being involved in charitable activities in their churches and communities only for altruistic reasons. One of the parents is involved in activities which promote advocacy for families who have experienced mental illness and is involved in identifying needs of families which is subsequently discussed.
There is however another trend in the country which contradict the stance maintained in the preceding discussion, namely that mentally ill as well as other categories of sick people are abandoned (Ewhrudjuice 2014) in hospitals because their relatives can no longer afford the cost of treatment and because they find the burden of caregiving overwhelming. This latter trend which is at variance with the one observed among known families illustrates the fact that generalizations which are made about any phenomenon in contemporary times unlike in the past need to be nuanced to reflect differences along social, cultural, economic ,urban and rural context. Traditional values are being unevenly eroded in contemporary times owing to the influence of the harsh economy and corruption.
The Need of Families
Families which are struggling with mental illness have many needs ,but perhaps the most urgent need is knowledge of the disease especially prognosis .If they knew more about the disease they would have panicked less and would have been more prepared for its daunting phase . Families did not expect that they would have to struggle with the illness for as long as they did. Caregivers expected that the afflicted ones with determination will just snap out of the illness rather than wallow in it. Consequently they nagged ,preached, threatened all of which tended to worsen the illness. Caregivers could not really understand the deep depression which could induce infantile behavior in adults , or the swings in mood in bipolar conditions .When they realized that sufferers were not just acting they felt guilty about accusing them of over dramatizing their condition possibly to win sympathy or avoid the challenges of daily living.
As was mentioned in the opening paragraph of the paper, there is serious lack of attention to mental health issues in the country which should be addressed. There should be massive public enlightenment on mental illness as well as educational programs targeting families currently experiencing it through hospital follow up.
Supporting groups for the mentally ill are not available .The only mentally-ill-friendly-association in the country is the Association of Friends of the Psychiatric Hospital in Lagos and Uselu, Benin City which raises funds among its members to improve the Psychiatric Hospital Yaba but does not have outreach programmes to support the mentally ill and their families.
Efforts should be made to encourage the formation of support groups for the mentally ill in general and for special manifestations such as depression and bipolar disorders as done in other countries. A plethora of support groups such as the Depression Anxiety Support Group, The Bipolar Disorder which exists in other countries should be established in Nigeria to provide psycho-education among other things for families. Ways and means should be found to reduce the prohibitive cost of hospital treatment.
Rehabilitation programs are lacking in the country. To prevent relapse several types of day care centres and rehabilitation programs should be established to harness recovery gains and integrate those who have recovered into their families and communities. Mental Self Help programme (MSHP) should be established to integrate those literate sufferers who are isolated from their communities .
In view of the fact that it has been established that well designed interventions can contribute to better mental health and well being of the population, exemplary Mental Health Promotions ,policies and programmes should be established in the country.
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