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.

REFERENCES

Adelakun M l ,Makanjuola A B  Nichom R (2001) Traditional Mental Health Practitioners in Kwara State, Nigeria .East African Medical Journal 28,190-196
Adewuya A, Makanjuola A B (2009)Preferred Treatment for Mental Illness among South Western Nigeria Psychiatric Services (1) 121-124
Biegel D.E,Sales E and Schulz  R (1991) Family Caregiving in Chronic Illness. Sage Publications California
Finley,N.J (1989) Theories of Family Labour as applied to Gender Differences to Caregiving for Elderly  Parents .Journal of marriage and family.51,79-86
Heru ,Alison(2000)Family Functioning, Burden and Reward in the Caregiving for Chronic Mental Illness Families , Systems and Health vol 18, No 1
Jack – ide,10, Makoro P and Azibiri B (2013) Pathways to Mental Health Care Services in Niger Delta Region of Nigeria .Journal of Research in Nursing and Midwife  JRWA   VOL 2 (2)
Lasebikan, V.O Owoje ,E.J Asuzu (Mrs) 2012 Social Network as a Determinant of Pathway to mental health services ,utilization among psychiatric patients in a Nigeria Hospital ,AM,African Medicine 1(2) 1990
Ewhrudjakpor, Christian 2010 ) Nigerian Orthodox Psychiatric Services, Systemic Neglect Emergent Psychiatric Institutions, African Research Review vol 4(1 )Jan.
Heru Alison ( 2000 ) Family Functioning ,Burden and Reward in the Caregiving for Chronic Mental Illness
Lefley H (1996) Family Caregiving in Mental Illness Sage Publications
Leighton A,H et al (1963) Psychatric Disorder Among the Yoruba. Ithaca, Cornell University Press.
WHO-AIMS (2006) Report on Mental Health System in Nigeria.
Kabir M,Iliyasu 2 .Abubakar I S (2004) Perceptions and Beliefs about Mental Illness among adults in Karfi Village, Northern Nigeria BMC International Health and Human Resources 4,3
Aliyu MIF (2004) Perception and Belief about Mental Illness    International  Health and  Human  Resources  4,3
Odejide O Marakinyo J (2003) Mental health and primary care in Nigeria World Psychiatric 2(3) 164-165