University of Ghana http://ugspace.ug.edu.gh BOOK NUMBER gc tel S3 D7l The Balm e L ibrary 3 liiimH y ... 3 0692 1079 4193 0 University of Ghana http://ugspace.ug.edu.gh PSYCHIATRIC INSTITUTIONS IN GHANA: TOWARDS AN UNDERSTANDING OF ERVING GOFMAN'S TYPOLOGY A THESIS SUBMITTED TO THE UNIVERSITY OF GHANA IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE M. PHIL (SOCIOLOGY) DEGREE BY ALEXANDER DONKOR LEGON, NOVEMBER 1989. University of Ghana http://ugspace.ug.edu.gh DECLARATION OF ORIGINALITY I declare that this Thesis, with the exception ef quetatiens expressly identified herein, is a reoerd ef an original werk dene entirely by me. ALEXANDER DONKOR "2 , (C Signature ef Student ........... A. DONKOR A\ Certified fcy Supervisor a a............ Pnt^-rTT.. T^UUSl University of Ghana http://ugspace.ug.edu.gh CONTENTS Page Abstract ................................................................ i Acknowledgements ................................................. ii CtLPTLR ONE: METHODOLOGY .......................................................... 1 I . INTRODUCTION .......................................... 1 I I . DATA COLLECTION METHODS ...................... 15 III . OBJECTIVE OF THE STUDY........................ -|6 IV. RELEVANT BACKGROUND REVIEW ................. 18 CHAPTER TOO; HISTORICAL DEVELOPMENT OF PSYCHIATRIC INSTITUTIONS IN GHANA ..................................... 31 I . INTRODUCTION .......................................... 31 I I . INSIDE THE PSYCHIATRIC INSTITUTIONS IN GHANA .............................................. . 52 I I I . TYPES OF MENTAL PATIENTS IN PSYCHIATRIC INSTITUTIONS IN GHANA. 65 IV. THERAPEUTIC SYSTEMS IN PSYCHIATRIC INSTITUTIONS IN GHANA .......................... 78 CHAPTER THREE: PSYCHIATRIC SERVICES IN GHANA AND ERVING GOFMAN’S TYPOLOGY: AN ANALYSIS 101 I . INTRODUCTION .......................................... 101 II . THE CUSrODIAL ROLE OF PSYCHIATRIC INSTITUTIONS IN GHANA .......................... 101 III . THE SOCIAL ’ ORLP OF INPATIENTS IN PSYCHIATRIC INSTITUTIONS IN GHANA 117 IV. TRENDS ITT PSYCHIATRIC SERVICES IN GHANA................................................... 123 V. CHANGES IN INSTITUTIONAL METHODS OF TREATMENT.................................................. 124 VI. ADVANCES IN NON-INSTITUTIONAL METHODS OF TREATMENT............................................ 129 VII. ACHIEVEMENTS OF PSYCHIATRIC SERVICES IN GHANA................................................... 134 University of Ghana http://ugspace.ug.edu.gh Page CHAPTER FOUR: CONCLUSIONS ................................... ..... 142 I . SUMMARY................................. ......142 I I . LIMITATIONS OF THE STUDY 144 III. SUGGESTIONS FOR FUTURE RESEARCH ......................................145 APPENDIX ........................................ 149 BIBLIOGRAPHY 153 University of Ghana http://ugspace.ug.edu.gh TABLES Page TABLE: 1 J>ischarge Rates of Mental Patients In Psychiatric Institutions in Ghana in 1987 and 1988 ...................................... 51 2 Inpatient Respondents' Problems ............ 58 " 3 Types of Mental Patients in Psyohiatrio Institutions in Ghana in 1988 ................ 65 N 4 Group Therapy Weekly Programme at the Special Ward (male) at Accra Psychiatric Hospital .................................................... 91 5 Group Therapy Weekly Programme at Aggrey Ward (Female) at Ankaful Psychiatric Hospital............ ........................................ 92 6 Nature of Outpatient Respondents' Social Relations ............ .......................... ......... 107 7 Marital Status of Outpatient Respondents 109 8 Job Opportunities of Outpatient Res­ pondents .................................................... -(10 University of Ghana http://ugspace.ug.edu.gh - i - ABSTRACT The main thrust of this thesis has been to examine Erving Goffman's typology of a Total Institution in the light of Ghanaian psychiatric institutions. In the typology Goffman olassifies mental hospitals as Total Institutions. The typology came into being Aen he was examining psyohiatrio institutions in western cultures. A central problem that was posed in the Thesis was to see whether Goffman's typology has applicability in the Ghanaian cultural environment taking into consideration its western origin and the improvement in psychiatric medioine in reoent years. Two hypotheses which were investigated and confirmed by this study are: 1. "That the psychiatric hospitals in Ghana are closed systems in which inmates do not have an easy contact with the wider society due to lack of resources". 2, "That the psychiatric hospitals in Ghana have partially renounced their custodial nature and have resorted to diagnosis treatment and rehabilitation of patients as a result of the emergence of new ideas in the field of medioine.11 University of Ghana http://ugspace.ug.edu.gh The findings in this Thesis are that the mental hospitals are characteristically custodial establish­ ments inspite of recent improvements in therapeutic techniques and therefore in prlnoinle confirm Srving Goffide.n ' s model. r‘he study has suggested then thpt si"ce the ^ha^aia^ psychiatric hospitals like those elsewhere are only keep­ ing the mental patients in custody there is the need to strengthen their rehabilitation programmes designed for the patients to enable them to function physically and socially in sooiety. University of Ghana http://ugspace.ug.edu.gh - 11 - ACKNOWLEDGMENTS The Thesis oould not have been completed without the cooperation of several individuals. 1 wish to particularly acknowledge with gratitude the expert guidance I received from my Supervisor, Prof. P.A. Twumasi in structuring this Thesis and for his con­ structive criticisms and advice tfiioh 1 found very useful. My fieldwork was made possible through the help of the staff and patients of the three psyohiatrio hospitals in Ghana. My profound gratitude goes to them as well. Finally I want to express my sinoere thanks to Prof. Max Assimeng, the Head of Sooiology Department for his patient handling of the numerous letters that faoilitated my writing of this Thesis. ALEXANDER DONKOR November, 1989. University of Ghana http://ugspace.ug.edu.gh CHAPTER OWE METHODOLOGY INTRODUCTION This study aimed at finding out whether the psyohiatrio institutions in Ghana operated in accordance with Erving Goffman's model of the mental hospital. The motivation for the study arose out of the need to re-examine the extent of the validity of the model in the light of present - day techno­ logical changes that have occurred in the field of psychiatry since its formulation. Erving Goffman's typology of the mental hospital is con­ tained in his book entitled Asylums which was published in 1961. In the book he outlined his theory of a total institution. The theory showed the relationship between the organization of certain sooial institutions including psychiatric hospitals. He defined a total institution as: "a place of residence and work where a large number of like-situated individuals cut-off from the wider sooiety for an appreciable period of time together lead an enclosed for­ mally administered round of life". (P -n ) Goffman focused on the soeio-cultural description of a mental hospital with emphasis on the inmates' social world and moral careers. University of Ghana http://ugspace.ug.edu.gh - 2 - The other organisations include prisons, monasteries, homes for the blind, orphanages, old people's hones and military camps. The total institution is mostly residential and all aspects of the Inmate's life-eating, bathing, worshipping, reading, washing and shopping - are carried out inside it. Xt is physically out off from the rest of the community by a barrier like a wall, a barbed wire or a long distance. All the activities of the inmates occur in the imme­ diate company of the others and are oarried out together. The phases of the activities follow a atriot schedule aimed at fulfilling the objectives of a rational plan supposedly designed to meet the official goal of the institution. The institution is usually under one authority and all the inmates are treated alike* The establishment is mostly made up of a small number of a staff of supervisors and a large number of inmates. The nature of the establishment, however, creates a built - in hostility or conflict between the two groups. This is because the supervisors consider themselves as superior and righteous and refer to the status of the inmates as inferior and guilty of failure in the normal world. As a corollary than, there is a easte - like form of social stratification University of Ghana http://ugspace.ug.edu.gh - 3 - In the total institution that gives rise to a great social distance between the staff and the inmates. The organisation is bureaucratic In nature. It is a hierarchically segmented formally organised collection of of­ ficers devoted to a rational attempt of accomplishing a mis­ sion and in the case of the mental hospital it is a custodial oare. The supervisory staff are required to maintain a spirit of impersonal and univerealistic approach to duty. Inmates are treated as cases but not as individual human beings. The duty of the staff is not guidance or protection but surveil­ lance, a seeing to it that the inmates do clearly what they have been told to do. The total institution is characterised by a strict social control system aimed at enforcing conformity and re-shapi"g the supposedly antisocial attitudes and values of the inmates. Their waysof bathing, dressing, walking and even eating are observed and reports are submitted on them by the staff to their superior officers. The ultimate objective here is that the inmates are to be resocialised to assume new roles that are commensurate nith the requirements of the norms of the society in which they live. After sketching the eesential features of the total in­ stitution in general Erving G-offman went on to outline those University of Ghana http://ugspace.ug.edu.gh - 4 - that pertain to the psychiatric hospital in particular. These themes are examined below; they however constitute the foous of this study. The theory states that due to the historical development and the nature of mental illness the psychiatric institution has been starved of adequate resources, technological and human, and therfore plays a custodial role. The mental hospi­ tal is a prison - like institution where the inmates have been kept so as to separate them from the wider sooiety to prevent them from harming themselves and the general publio as well. There is more restriction on their movement than that of pa­ tients of other hospitals partly because their judgement is considered questionable and partly because they have suioidal inpulses. The mental hospital is a closed system. A most obvious characteristic of the inmates' social system is the lack of social contact with the outside world. Patients' movements are confined within the hospital walls only. They receive visitors only with permission and even their conversations with them have to take place in the full view of the staff. Similarly all letters they receive come under censorship. A patient oannot easily get out of the hospital without passing through a series of formalities for permission because University of Ghana http://ugspace.ug.edu.gh - 5 - the staff members feel that he Is self-suffioient in terms of his material requirements in the establishment. When a patient takes French leave the hospital authorities take retributive measures against the entire patient population including revi­ sion of rules on parole, trial leave and out patient status. There is a social oontrol device in the psyohiatrio hospi­ tal T#iich Goffman calls the "privilege system". This device aim at achieving the co-operation of the inmates and comprises three basic elements: the house rules, rewards and punishments. When the patient enters the institution, he is given a number of rale whioh comprises the prescriptions and the prescriptions that are to govern his oonduot while on admission. They spell out in a general outline what to do and what not to do - for example when to eat/to sleep, to receive a visitor, to go out and to go to work. Rewards are provided in exchange for obedience to the staff Offer of rewards has been institutionalised and obedient inmates may obtain extra food, reoeive note visitors, better jobs or even presents from the staff. Punishments, on the other hand, are administered for in­ fraction of the house rules and may take the form of flogging, chaining of an inmate to a post, a look up of an inmate in an isolated ward, an eleotrie shock or a ridicule. University of Ghana http://ugspace.ug.edu.gh • 6 • The patient becomes depersonalised as a result of his con­ finement and the attitude of the staff towards him. In their attenpt to adjust him to the hospital environment the supervi­ sors reduce him to a dependency child. He is subjected to a series of abasements, degradations, humiliations and profana­ tions. He may be required to remove and dispose of his own toilet, confess his sins, stand uprlgjht when talking to a staff member or he may be cainedfbr breaking a house rule. Another humiliating process in the mental hospital is the admissions procedure. One phase of the admissions procedure is personal defacement. On admission, the patient is thoroughly searched and is stripped of all his personal belongings which are returned to him only after discharge. In addition, he is shaved in a way that pleases the staff; his finger print is taken and he is given a numbered uniform. In the establishment he is known by his number but not by his name. The patient ia exposed to yet another defaming experience which is personal disfigurement. By this process he undergoes surgery, shock therapy or whipping. He undergoes physical contamination as well. He is thrown into a crowd of people of different intensity and forms of mental disorder. The patient therefore lives in a state of University of Ghana http://ugspace.ug.edu.gh perpetual insecurity since a fight may follow even a slight disagreement within his group at any time. At times he may be required to eat undean food and may be made to sleep near the dead in the same ward. Another bitter experience to which the patient is exposed is verbal profanation. He is given nicknames and is ridiculed before his colleagues. The depersonalization processes and the admission procedure give rise to a situation which Goffman calls "the mortification of the self." It is a situation in which the inmate drastically loses his self-esteem. The theorist goes on to show that the mortification of the self brings about certain behaviour patterns on the part of the inmates. In other words, thev adat>t themselves to the prevail­ ing social conditions in the hospital in several ways. Some of them adopt an intransigent line while others tow the line of the staff. Several patients do not show any form of compromise to­ wards the policies that originate from the institution. They are disobedient generally. Majority of the intransigent pa­ tients are the long - stay ones. They are recidivists or have chronio mental disorders and have therefore become acclimatised to the hospital's sooial environment. Their hope of ever leaving the institution for their homes is either little or University of Ghana http://ugspace.ug.edu.gh - 8 - nonexistent. On file other hand, those patients who are hopeful of being discharged early as indicated by their diagnosis are not stub­ born. They obey the hospital rules to the letter. Certain features are identified by Coffman as problem areas in the inmates' world. The problems centre on the sigt)s and synptoms of their mental disorder, sexual relations and alienation. Signs like delusions and hallucinations constitute conflicts in their lives. When they become possessed by these conditions they tend to unknowingly commit offences. They may slap or injure other people or spoil property. When the dis­ turbance subsides and they return into a sober mood they become very sorrowful on being made aware of the harm they had caused. The deprivation of heterosexual relationship creates a similar problem in the patients' social system. Male patients are not allowed to interact with their female counterparts in any way. Violation of rules relating to sexual relations is punishable because the supervisors believe that sexual matters tend to induce anxiety among the patients especially the males. The theorist is of the opinion that the sexual problem is the source of the homosexual impulses among the male patients which the supervisors try in vain to eradicate. The patients have a feeling of alienation from the wider society. Their physical and social separation from their University of Ghana http://ugspace.ug.edu.gh - 9 - families and friends is considered by them as a betrayal by society. The feeling is aggravated when the frequency of vi­ sits is reduced or ceases altogether. This situation gives rise to the los& of a sense of belonging among the patients. Goffman does not consider the psychiatric hospital as a therapeutic agency. He believes that the hospital is a "forcing house" where people - the patients - are held in captivity against their will, and through no fault of theirs, for the purpose of sheltering them from stresses and strains of the wider community. He sees this as the sole purpose of the hos­ pital. While on admission, he explains further, the patients are made to work - to wash plates, to scrub the floor, to rake leaves or to learn a skill in the occupational therapy workshop. The claim presented to the patients by the hospital authorities is that these tasks help them to re-learn how to live in the wider society and that their capacity and willingness to handle them are considered as diagnostic evidence of their improvement. Every patient requires a guardian or as Goffman puts it "next-of-kin". This person must be a relative and must accom­ pany the patient while being admitted. He has to sign a form to guarantee the hospitalization of his patient. The hospital asks him to supply all the needs of the patient which the hos­ pital may not be in a position to provide. He is also expected to visit his patient as often as possible. On discharge he University of Ghana http://ugspace.ug.edu.gh - 10 - arranges with the hospital authorities how best to handle the patient in the house to avoid reoidivism. In case of the death of the patient in the institution he takes care of the evacua­ tion of the corpse for burial. There are specific occasions on which the social gap be­ tween the staff and the patients is bridged. These are the periods of institutional ceremonies. At these ceremonies the two groups of people come close enough together to get a some­ what favourable image of the other and to identify sympatheti­ cally with the other's situation. These solemn practices constitute a symbol of unity, soli­ darity and joint commitment among the occupants of the institu­ tion. The ceremonies are annual in nature and take the form of get togethers, dances and games. They usually occur during the Christinas season. At the functions the usual chain of command and formality that governs staff - inmate contact is softened. In the theory Erving Coffman throws some light on the etiology and the treatment of mental illness and the stigma that accompanies an institutionalised patient after his discharge. He believes that the causation of psychiatric disorder cannot be understood by using a single formula. It may be brought about by a series of factors which combine to make the person behave that way. The patient's past life, his present circumstances, University of Ghana http://ugspace.ug.edu.gh - 11 - his personality and social environaent are all etiological factors. It is therefore impossible to understand the ill­ ness without understanding a good deal about the patient's life. As no two personalities are the same the illness dif­ fers in form from one person to another. For exacqple, the psychotic patient lives in his own world, - a world of fan­ tasy - the schizophrenic has hallucinations and delusions, while the neurotic patient is haunted by phobias. These conditions can hardly be repaired in the same sense as an attempt is made to repair or unite a fractured bone. Mental disorder is therefore a phenomenon which is ill-defined. Accordingly, the search for a quick cure for mental ill­ ness has proved fruitless. There is no pill, and no injection that are administered which bring the patient back to health overnight. The treatment involves a therapeutic programme which is standard for all persons; it is not specific. Several therapeutic methods may have to be applied and treat­ ment may be extended over a year or more before results may perhaps be achieved. Generally, in mental illness, treatment does not provide a probability of success great enough to justify the practice of institutional psychiatry as an expert service occupation beoause no particular method is actually effective and de- University of Ghana http://ugspace.ug.edu.gh - 12 - pendable. For exaitple, psychotherapy functions to point out the wrong ways of the patient to him — to see the errors of his ways; sedative treatment is given to hypnotise and immo­ bilize patients so as to reduce staffing; woik assignment is described as an industrial or occupational therapy and it al­ lows the patient to express his capacity for doing household duties or for using his skill. However, since several hospitalized patients relapse the institution tends to damage the life chances of such individuals. As far as the mental patient is concerned, institutionali­ sation has another disadvantage. Once a person has a record of having been in a mental hospital the public at large, for­ mally in terms of employment restrictions and informally in terms of day to day social treatment or interaction, oonsiders him as a person who is to be set apart. He is to be watched in the way he behaves because he may turn to be antisocial at anytime. Even his esployer is told to bring him back to the hospital if his condition deteriorates. His illness is thought to be in a state of slumber and may erupt at anytime. In a word he is stigmatised. Finally Goffman dwells on the protection that the law gives to the mental patient by way of his exeaption from cri­ minal penalty. He shows that a person adjudged mentally ill University of Ghana http://ugspace.ug.edu.gh - 13 - or defective (insane) by medical certification cannot be punish­ ed for any crime he commits. This is because according to law, such a person's reasoning faculty is defective and therefore does not understand the nature and the wrongfulness of the act he is committing. He believes that although the law exempts the insane from criminal responsibility yet it creates a pro­ blem for him in another area in his social life. Since he is considered to have a defective mind he is thought to be unable to take reasonable decisions on his own. He is therefore de­ prived of his civil rights. He cannot vote in an election, he cannot make a valid will or institute a divorce action etc. Erving (roffman's description of the mode of operation of the psychiatric hospital touches on several issues: interper­ sonal relationship between the staff and the patients, the role of the hospital, the morel career of the patient on admission, the causation of mental illness, treatment processes and the stigma that accompanies institutionalization of 'the mental patient. The propositions discussed above could be grouped under seven broad headings. (1) Is the purpose of psychiatric institutions in Ghana custodial or therapeutic? (2) Is the psychiatric hospital a close system? University of Ghana http://ugspace.ug.edu.gh - 14 - ( 3) How does the privilege system function in the mental hospital? (4 ) What is the admissions procedure in the psychiatric hospital? (5) What are the problem areas of the mental patients? (6) What are the treatment programmes in the psychiatric hospital? (7) Are psychiatric patients stigmatised? What this research attempted to do was to find answers to these questions. In pursuance of this objective the activities of the psyohiatrio hospitals in Ghana were examined in the light of these themes in Chapters 1’wo and Three below. Panel discussions were engaged in mostly with therapists and patients at group therapy sessions and at occupational therapy workshops. All the male and female occupational therapy workshops in the three mental hospitals were visited and there were dis­ cussions with staff and patients on duty. University of Ghana http://ugspace.ug.edu.gh - 15 - II DATA COLLECTION METHODS The bulk of material contained in the study was obtained from three groups of people associated with Ghanaian mental hos­ pitals: the staff, inpatients and outpatients. The three hospitals constituted the areas of study. The justification for the study of all the three establishments stemmed from the requirement of this study to understand the psyohiatrio service in Ghana for comparison with Erving Gof- fman's typology. The fieldwork lasted for six months - July to December 1988. In all thirty-six visits were made to the study areas. Following sociological techniques in such an enquiry, the investigative methods employed comprised mainly structured interview of the seleoted informants, documentary study and panel discussions. The interview method was used in obtaining field saterlal from the staff, and the inpatient and outpatient populations. Hospital documents were consulted in seeking in­ formation on the records of staff and patients. Panel discussions were engaged in mostly with therapists and patients at group therapy sessions and at occupational therapy workshops. All the male and female occupational therapy workshops in the three mental hospitals were visited and there were discussions with the staff members on duty and patients. University of Ghana http://ugspace.ug.edu.gh - 16 - The population of the study in the three hospitals was 3734. and it was made up of 497 staff members 1733 inpatients and 1504 outpatients. From the population, a sample size of 423 was chosen for interview. The sanple comprised 100 staff members, 173 inpatients and 150 outpatients. Ill OBJECTIVE OF THE STUDY It is the objective of the research to find out whether Goffman's typology has oross - cultural validity in Ghana in this day and age of technological improvement in psyohiatrio services. Before the advent of colonial rule in Ghana mental illness was traditionally thought to be brought about by supernatural forces - witchcraft, break of taboo, magio, demons and ancestral spirits eto. Accordingly, its treatment was in the hands of traditional healers such as fetish priests, herbalists and spiritualists. Included in their pharmacopoeia were herbs, animal parts, vegetables, roots of plants, exoioism and magical spells, (Forster, 1958$ Ampofo and Johnson 1978). The tradi­ tional healers or native dootors were considered as specialists in the field of medicine and were held in high esteem by society. They flourished in all parts of the oountry. University of Ghana http://ugspace.ug.edu.gh - 17 - British Colonial Rule was established in Ghana in the middle of the 19th oentury. It was not long afterwards in i878 that Western medioine now known as modem medioine was introduced. And towards the end of the oentury an Asylum was opened in Aoora. At present there are three psyohiatrio hospitals in the country: Aoora, Pantang and Ankaful. The three hospitals together have a total bed capacity of 1809/ Mental patients seek psyohiatrio care at these hospitals as a last resort after abortive treatment by traditional healers, (Twumasi 1986). This situation prevails particularly perhaps beoause the Ghanaian Society is not well informed about the effectiveness of psyohiatrio service today. Asare (1986, 1988) maintains that with the introduction of effective psychotropic drugs in the psyohiatrio hospitals since the 1960s the role of the hospitals is changing considerably. 1. Source: This figure was obtained from a ward to ward counting of beds at the time of the study. University of Ghana http://ugspace.ug.edu.gh • 18 - In line with the objective the following hypotheses are to be tested] (1) That the psyohiatrio hospitals in Ghana are closed systems in which inmates do not have an easy contact with the wider society due to laok of resources. (2) That the psyohiatrio hospitals in Ghana have partially renounced their custodial nature and have resorted to diagnosis, treatment and rehabilitation of patients as a result of the emergence of new ideas in the field of medicine. IV. RELEVANT BACKGROUND HEVIBff Geoff Shepherd ( 1984) traces the history of the concept of asylum and the rationale for its custodial character, He main­ tains that the prehistory of asylum (plaoe of refuge) can be traced back to the early part of the medieval period. He shows that the first Lunacy Legislation took place in England in the year 1320. By that Act Lunatics were confined to a hospital in London called Bethlem and their properties were vested in the crown. Shepherd believes that that period marked the first institutionalisation of the mentally ill in the world. University of Ghana http://ugspace.ug.edu.gh - 19 - The main objective of their institutionalisation was to segregate them from the wider society and thus protect society from their harmful activities. In 1601 another legislation came into force in England. It was the Poor Law Act and it simply lumped the lunatics to­ gether with the rest of the poor who according to the defini­ tion of the law included the old, the blind, the orphan, the lame and any other person who could not look after himself. Prominent people at that time like church leaders and landowners were appointed by each parish or community to take care of these destitutes. During the period of Enlightenment in the 18th and 19th Centuries, the community became more interested in the mentally disordered. With authority from the British Government private people were allowed to take charge of the lunatics. Private madhouses were built for the safe keeping of the mad. The mad­ houses however varied in terms of the services they offered. Some were undoubtedly caring and concerned while others dis­ played a level of callousness and brutality which was highly appalling. In addition they were not subject to any kind of outside scrutiny. There was as such much growing pubMo con­ cern about the nature of their operations. University of Ghana http://ugspace.ug.edu.gh - 2 0 - During the period under consideration, one important shift in public opinion was the idea that social problems might be oaused by the societies containing them. Social problems were no longer seen simply as the result of some ex­ ternal malevolence or divine will but as the product of de­ fective social structure. If these sooial structures could be perfected, it was reasoned, then the problems would disap­ pear. People then began to suggest that mental illness might have environmental rather than solely natural causes, and therefore that if the right kind of environment could be created, mental illness might be treatable. It was the shift in this etiological belief that contri­ buted to the invention of the asylum. The first step was an enactment of a legislation that regulated the affairs of the madhouses. The aim wag to bring about humane and therapeutio conditions in the institutions. By that Act the madhouses were not to be only safe havens where the madmen might be dumped and quietly forgotten. Instead they were conceived as an advanced social environment where through the provision of the refuge from the stresses and strains of an obvious corrupt society the mentally ill might be reformed and reha­ bilitated in order to be productive in life. University of Ghana http://ugspace.ug.edu.gh - 21 - In 1808 the first country Aeylun.s Act was passed in England. Local communities were made to fund and build their own lunatic asylums. Similar developments took place in U.S.A. The primary objective of the asylum was to treat the patients so far as their conditions would possibly admit, as if they were healthy human beings. Certain principles were upheld as guidelines for the moral treatment of the patients. They comprised, an acceptance of a con­ tinuum between sanity and insanity. The mentally ill were not to be seen as belonging to a qualitatively separate category of people. In general an attempt was to be made to create a well - ordered and homely environment like a good family unit. Staff were to ndx freely with the patients on equal footing; patients were to be encouraged to help one another in time of need. There was to be positive enoouragement on the part of the staff to instill a sense of hopefulness among the patients. The asylum was considered an important refuge for the patient and therefore he was not to be punished. It was also required to protect him against the strains and stresses of modern life. As a consequence, it had to be sited far away from the industrial towns which were polluted and noisy. It was important to avoid monotony and University of Ghana http://ugspace.ug.edu.gh - 22 - boredom in the institution. Patients had to be given work and education in order to engage their minds. By the middle of the 19th century every local community in England and even in U.S.A. had an asylum in which these principles of moral treatment prevailed. In fact the period saw a tremendous spate of the building of mental hospitals in the histories of the two countries. In England the most po­ pular were Bethlem Lincoln and York. Surprisingly, these principles were short lived. Standards in the mental hospitals were maintained for sometime but began to decline woefully at the end of the first world war. Several reasons contributed to the decline. There was a triumph of legalism over medicine. The public became increasingly worried by the spectre of illegal detention of lunatics in the mental institutions. Because unlike the 19th century and before, about 90% of patients were treated in the hospitals without medical certification. incarceration The fear of illegal i led to a preoccupation with legal safeguards before admission. This made it inpossi­ ble for the asylums to deal with early diagnosis and treatment of the mentally ill because before they were to be admitted they had to be obviously mad and more or less hopeless. The result was that the asylums were left with only the most University of Ghana http://ugspace.ug.edu.gh - 23 - difficult and chronic cases to deal with. This situation undoubtedly contributed to the emergenoe of oustodial care in the hospitals. Shepherd goes on to show that condition demoralised the staff so that ambitious young and dedicated doctors who were interested in advancing the oause of the mentally ill were not attracted to the field of psychiatry. Consequently psychiatry was left with a low pro­ fessional status in comparison with the rest of medicine, poor staffing and suffering standards. The asylums were overcrowded. This condition nullified the principles of moral treatment which were fundamentally based on a recognition of the patient's individuality and the creation of a homely atmosphere. The principles were no longer possible to be praotised. There i»as a growing public concern over the curability of mental disorder. As it became evident that the early hopes of ouring mental illness through insti­ tutional means were over-pptimistic because of the accumulation of ohronic and inourable cases, staff felt that the option available to them was simple oustody. They found it difficult to aooept a ooncept of aotive care or the necessity of main­ taining a continuous state of treatment which could prevent deterioration. University of Ghana http://ugspace.ug.edu.gh - 24- - The effects of the second World War were equally dis­ astrous to the professional status of psychiatry. Memories of the war and the concentration camps were still fresh in people's minds for over a decade after the war so that the concept of institutional care came to have a distinctly pejorative ring about it. In the opinion of Shepherd, Erving Goffman began study­ ing his total institutions at the time the atove sentiments were detrimental to the image of psychiatry. It is no wonder that his views are a reflection of those sentiments, Twumasi (1979) draws attention to the wide ran^e of treatments in psychiatry but re rets thst they do not yield clearcut results. He observes that treatment ia given by a ■wide variety of medical personnel - psychiatrists, psychiatric nurses, psychoanalysts, psychologists sooial workers and trained counsellors. Patients are treated singly and in groups. Many oures are administered - electrio shocks, drugs and advice. As the sendees and the psychiatric personnel are enormous the mental patient is not directed to only one medi­ cal section of the hospital but is given the psyohiatrio service that is available. He goes on to explain that the characteristic factor common to this large number of treat- University of Ghana http://ugspace.ug.edu.gh - 25 - merits is that the treatment is not speoifio. Citing an exam­ ple, he shows that psychiatrists cannot diagnose or locate specifio emotional imperfections. He admits that psychiatric treatments that prove definite results are drugs and other physical treatments (electro - convulsive therapy for example) but even here there are strong differences in opinion con­ cerning how and when they should be used. Dunham and Weinberg (i960) throw light on the custodial funotion of the mental hospital and the mental patient's career there. They believe that the chief ooncem of the custodial system is to keep down oosts and to manage property carefully. The patient's inpaired condition to be changed is overlooked. They lament however, that that hospital culture in most oases tends to intensify the symptoms of the mental patient. The patient initially comes to the hospital aggressive, hostile, critical and argues with doctors and nurses for a need to change his condition for him. To his dismay, he finds with the passage of time, that his demands are not met. Even visits by relatives and friends may be irregular or may cease altogether. Eventually he adjusts himself to the sooial condition prevailing in the hospital. He gives up any hope of reoovery. University of Ghana http://ugspace.ug.edu.gh - 26 - Dunham and Weinberg argue that this situation leads to a transition into chroniclty and also hie adoption of an in­ transigent attitude towards the staff. iorster and Barbara (1978, P .85) suggest that stigma is truly a condition that acoompanies psychiatric illness. They writes "Psychiatric label has a life and an influence of its own. Onoe the impression has bean formed that the patient is schizophrenic the expectation is that he will continue to be schizophrenic. The label endures beyond discharge from hospital with the confirmed expectation that he will behave as a schisophrenic again". Eventually, the patient also accepts the diagnosis with all its expectations and behaves accordingly. Kathleen Jones (1978, Pp 330-331) writes in defence of psychiatry and its variety of therapies. In her article she insists that the psychiatrist is an innovator; that psychia­ try has always been looking for new ways of treatment perhaps because the problems it deals with are so intractable and so nuch a part of the basic human dilemmas. Many attenpts have been made; she argues further, for new methods of treatment - from cold bath, malarial therapy, electro convulsive therapy to the psychotropic diugs. Along­ side these there has been a steady development of social the­ rapies - group therapy, occupational therapy, psyohotherapy - University of Ghana http://ugspace.ug.edu.gh - 27 - outpatient olinios and oommunity psychiatry. All these have stood the test of time and have enthusiastioally added to the oomfort and happiness of patients. She concludes: "If that is considerably an unsoientific aim one might query, what else are the psychiatrists in business for?" Gregory ( 1961) takes issue with the relationship between the law and psychiatry and echoes the observations made by Erving Goffman. He explains that the physician can be com­ pelled by the judge to answer questions in court involving facts observed by him about a patient to prove his insanity. With his insanity proved the criminal defendant is then never held responsible for the criminal offence beoause he is con­ sidered not to have known the nature, the harmfulness and the wrongfulness of his act. However, a person proved insane by a medical officer loses some rights; he cannot buy or sell property or sign legal papers; he cannot vote or hold an office or may not drive an automobile; he may not practise medioine, law or any other learned profession; he may not marry or institute a divorce action at a court of law (but incurable insanity is allowed for divoroe); he may not make a valid will and he may not consent or refuse adopting a ohild. University of Ghana http://ugspace.ug.edu.gh - 28 - These rights are, however, restored after reoovery. Other writers take G-offman to task for presenting an inade­ quate picture of the mental hospital. Soull (1983, Pp.335-339) writes! "C-offman's primary source is a relatively brief period of fieldwork in a single hospital. It is an ethnography of a particular institu­ tion in this case. The outcome is a general delineation of an organizational type of which all mental hospitals belong alongside with prisons, monasteries military schools, old age homes and concentration camps". Soull identifies several weaknesses in the evidential base on unhioh Soffman's theory rests. He argues that there is not even a token attempt in Coffman's woric to confront the issues of what explains what brought the mental patients to the hospital in the first plaoe. The olaim that they are the viotims of oontingenoies and somehow betrayed into the insti­ tution by their kins is unsubstantiated. The blame for their situation is considered by the theorist as not lying at all on their own conduct or mental state but rather in a conspi­ racy of others to secure their exclusion from society. Soull concludes that the author does not make any attempt to assess the contribution of psychological and enviommental influences on idiat he (the author) calls the "moral career" of the pa­ tient in the hospital. University of Ghana http://ugspace.ug.edu.gh - 29 - Like SjuII , siegler and Osmond (1971, pp.419-424) ori- ticise the theory of the total institution vehemently. In their artiole entitled "Goffman's Model of Mental Hospital" they suggest that the definition and etiology of mental ill­ ness, the behaviour pattern including the suicidal inpulses of the mental patient, the prognosis and therapies (except surgery and shook therapy) rrere not properly discussed in the theory. They observe that the author's point of view of the function of the mental hospital is that it is to subdue, de­ grade and humiliate people who are for unknown reasons exiled and confined there so that they will be easier to control. If the patient should ever leave the hospital, he is discul- tured and stigmatised. His kin and employer are told to bring him back to the hospital if he happens to have difficulties. The mental patient loses his civil rights. His only defined right is his aocess to food, clothing and shelter. He has no duties that he acknowledges as such when he is in the hospital; if he works, it is either beoause he is forced to do so or out of boredom. Siegler and Osmond argue that; "In Goffman's view there are medical personnel but they do not seem to have any medical func­ tion in the hospital; instead, they seem to provj.de a medical facade for the institution which is partly a punitive one and partly a University of Ghana http://ugspace.ug.edu.gh a storage dump. Society has the right to look people up in a mental hospital. It has the duty to feed, clothe and house them, to provide ordinary medical care and to keep them from harming themselves"- In sum, the review of relevant literature on the opera­ tions of psyohiatrio institutions portrays a picture that reinforces oustodial posture. For example, the views of Shepherd, Gregory, Twumasi, Forster and Barbara, Dunham and Weinberg in many ways do not appear to depart widely from the propositions laid down by Erving Goffman. The next Chapter examines the characteristics of psy­ chiatric hospitals in Ghana with particular reference to their oustodial posture, categories of mental patients and treat­ ment processes. University of Ghana http://ugspace.ug.edu.gh - 31 - CHAPTER TffO HISTORICAL DEVELOPMENT OF PSYCHIATRIC INSTITUTIONS IN GHANA. I Introduction: In this chapter we are examining the historical growth of psyohiatrio Institutions in Ghana with a view to providing the background to the disoussion. The main focus is to exa­ mine whether in Ghana these institutions approximate Coffman's typology of the mental hospital. The history of psychiatry in Ghana dates back to the latter part of the 19th Century. On the 4th of February 1888 the then Governor of Ghana, Sir Edward Griffiths signed a legislative instrument that established a Lunatic Asylum in the Higi Court of Viotoriaborg, one of the then castles in Accra situated near the Arts Centre. The primary function of the asylum was to protect the publio against dangerous lunatics and to prevent the lunatics especially those with suioidal impulses, from harming them­ selves. In the asylum they were offered no medical treatment and were looked after by Prison Warders. They were mixed up with prisoners and were treated like them, Forster et al (i988). University of Ghana http://ugspace.ug.edu.gh - 32 - Two deoades after its establishment the asylum oould not oope up with its increasing number of patients. In 1905 it had 80 patients and in 1906, 110 . The situation then oalled for the need to set up a separate and permanent institution for the mental patients, in order to segregate them from the prisoners. As a consequence the Aocra Mental Hospital was established and was opened in 1907. The new mental hospital continued to maintain its original name, Lunatio Asylum, and was accordingly custodial by function. The building contained General, Criminal and Female Blocks. In addition, it had an administration office, a -visiting medi­ cal officer's offioe, a dispensary, a store, a gatekeeper's room, a night warder’s room and a kitohen. A matron was in oharge of the hospital and was assisted in his duties by un­ trained hospital attendants. The first psychiatrist to head the Lunatio Asylum was Dr. Maolagan who was posted from Britain and assumed duty in 1929. Dr. Maolagan is still remembered in the psyohiatrio service in Ghana as a result of the reforms he instituted: he stopped the oaning and punishing of patients, the chaining of patients to posts and their restriction to single rooms without the directive of the dootor. He instead housed the patients in wards according to their degree of mental dis- University of Ghana http://ugspace.ug.edu.gh - 3 3 - turbance and provided a separate accomnodation for those who in addition to their mental illness ware physically siok. During his tenure of office he also made available to the psyohiatrio service in Ghana the concept of therapeutic community which had been prevailing in England. By this system the mental hospital is considered as a community with the patients being an integral part of it. They are consulted on all matters affecting their welfare. They take part in ward meetings with the staff and their views are considered. Dr. Maclagan left Ghana in 1942. Social development of the Accra Mental Hospital continued after him and in 1951 Dr. Forster, the first African to assume leadership of the hospi­ tal, was appointed. During his tenure of office he carried out much expansion work which included the establishment of more blocks, the introduction of more therapeutic techniques and the training of no re psychiatrists and psychiatric nurses. The physical facilities of the hospital he brought into being, include the Consultation Rooms, the Outpatient Department, Reception* Dispensary, Kitchen, Hospital Welfare Office, the Wards, Occupational Therapy Workshops, the Laundiy, the Re­ frigerated Mortuary, the Administration Block, the Reference Library, the Patients’ Libraxy, the Records Office, the "urses University of Ghana http://ugspace.ug.edu.gh - 34 - Training School. In spite of the expansion work which has been going on since its establishment, the patient population pressure on it has al-Eiays remained a problem and has to a large extent necessitated the building of more mental hospitals. As early as 1909 the Accra Mental Hospital had an inmate population of 275 and in 1934 it had risen to 600. By 1960 the figure was l7C0j meanwhile it had been built to cater for only 200 mental patients. The condition was con­ sidered alarming so it became necessary that something had to be done about i t . As an interim measure an annex was esta­ blished at Atimpoku near Akosonbo to where 300 of the inmates were transferred. The setting 15) of the Aoora Mental Hospital Annex could still not solve the problem of the pressure of the inmate population on the hospital. The need then arose again for the building of another mental hospital. Consequently an appro­ priate site was found at Ankaful 15km Southwest of Cape Coast in the Central Region. Ankaful Psychiatrio Hospital was then established and was opened in 1965. The patients at Atimpoku were sent to Ankaful and the Accra Annex was abolished. Unfortunately, the building of Ankaful Psychiatric Hospital could again not solve the problem of congestion at Accra Mental Hospital. University of Ghana http://ugspace.ug.edu.gh - 35 - In the early 1970s the nation's Health Service autho­ rities realised that the two mental hospitals were still not sufficient to handle the enormous growth in the number of mental patients. It therefore became imperative that another one had to be built. As a result the Pantang Psy- chiatrio Hospital oame into being in 1975. Both Ankaful and Pantang Psyohiatrio Hospitals have the physical facilities found at Accra Psychiatric Hospital. They however, differ from, that of Aocra in one respect; that they are not walled. In terms of modem medicine the three hospitals, Aocra, Pantang and Ankaful handle all psychiatric cases referred to them. They receive patients from all parts of Ghana and from overseas. In spite of modem innovations in medioal science, the three hospitals remain largely custodial in character. The patients are mainly kept there in order to cushion them against the strains and stresses in the wider community and in order to allow society to have peace. Their movement and behaviour even within the premises of the hospitals are under surveillance. They are exposed to a large variety of treatments all in an attempt to bring the illness under control. The drugs that the hospitals use in the treatment University of Ghana http://ugspace.ug.edu.gh - 36 - of the patients are principally hypnotics and tranquili­ zers which only make them calm but cannot in fact cure them. Being aware of the ohronioity of mental disorder, the psychiatric authorities make sure that even patients discharged from the hospitals are controlled by their re­ latives. The relatives are advised not to infuriate them so as to avoid relapse. As a result of the indefinite nature of the treatment there is a high incidence of reoedivism in the psychiatric hospitals. .About of the inpatient respondents have been on admission more than onoe. In order to keep the number of inpatients at a mana­ geable level the hospitals make a tremendous use of trial leave and parole. Patients on trial leave and parole status are usually patients whose mental conditions have improved. Patients on trial leave stay at home and see their psychiatrists about onoe a month for drugs. Parolees live - at the hospital but are allowed to go home on Fridays and return to the hospital on Monday mornings. About U-T/ of the inmate population of the three hospitals are made to avail themselves of these facilities. Those whose conditions deteriorate are recalled for admission. University of Ghana http://ugspace.ug.edu.gh - 37 - The psyohiatrio hospitals in Ghana have therefore sinoe their inception been maintaining the custodial role and the following may be mentioned as the factors that have contributed to that situation. They are: Inadequacy of medical resources, Overcrowding; number of patients to a ward; Governmental policy, People's out­ look towards the mentally ill, the closed nature of the psychiatric institutions, Discharge rates. These features are discussed below. Inadequacy of Medical Resources. Resources at the disposal of the hospitals in terms of human labour and drugs are not sufficient to meet the needs of the inpatients. The number of patients that a psychiatrist is required to handle is invariably large. The three hospitals together have a total of seven qualified psychiatrists and 1733 in­ patients. Five out of the seven psychiatrists and 1371 out of the inpatients are at Accra; therefore at Accra psychiatric hospital each psychiatrist is in charge of an average of 274 inpatients. Even two of the psyohiatrists are not the hospital's permanent employees; they are on loan from University of Ghana http://ugspace.ug.edu.gh - 38 - University of Ghana Medioal School st Korle Bu Teaching Hospital. At Pantang there is only one psychiatrist and he is res­ ponsible for the 193 inmates of the hospital, while at Anka- ful one psychiatrist is handling all the hospital’s 169 inpatients. These data indicate that the work load on the psychia­ trists is just too much and it may be difficult for them to provide adequate treatment. Similarly on their rounds in the wards in the mornings it is hardly belie'"able if the psychiatrists will have the time and the energy to visit all the patients since at the same time they have administrative duties to perform and outpatients to attend to. The situation is more pathetic at Pantang and Ankaful. In each of these hospitals if the psychiatric' specialist is unable to report for duty, the hospital hardly funotions. The psychiatrist at Ankaful has lamented: "The whole hospital including the outpatient department hinges on me. When I am absent no patient receives a prescription". The inadequacy of medical officers attached to the psy- ehiatrio hospitals similarly perpetrates their custodial role. The medical officers are responsible for handling University of Ghana http://ugspace.ug.edu.gh - 39 - the non-psyohiatrio disorders of the inpatients. There is one medical officer each at Accra and at Ankaful but there is none at Pantang; instead there is a medical assistant. However, by the nature of their disorder mental patients with infectious diseases and. those who need surgery must ideally be attended to in the psyohiatrio hospital. As a result of the shortage of medical officers in the psychia­ tric hospitals, the isolation wards where their inpatients with physical ailments are kept are characterised by con­ gestion. At Accra during the study there were 26 patients in the male isolation ward and 21 i« the femele isolation ward. These wards were seen to be stinking more than the other wards. Patients in pains were seen screaming. It seems there is also lack of attention in the wards. In the male isolation ward an elderly weak patient had eased him­ self and had soiled his tattered pair of trousers. It was a fellow patient who ms washing him. Psychotherapeutic service in the mental hospitals is equally inadequate in terms of personnel. The whole psychia­ tric service in the country has two trained psychologists who carry out psyohotherapy. They are both stationed at Accra Psychiatric Hospital. At Pantang and Ankaful psyoho­ therapy is carried out by the psychiatrists themselves. University of Ghana http://ugspace.ug.edu.gh - 40 - As Cochrane (1985) has argued if mental disorder is partly a by-product of strained interpersonal relations then psychotherapy may be considered as an Indispensable therapeutic programme to combat it. Indeed, the lack of trained psychotherapists in the psychiatric institutions in the countiy can hardly give them a therapeutio outlook. With a total of 1733 inpatients and only two trained psychotherapists serving their needs (even one of them, nas on a very long course overseas at the time of the study) the conclusion may be drawn that majority of the patients are being denied this important service. This situation further reirtforoes the custodial character of the psychiatric hospi­ tals because it seems the patients are being kept in the hos­ pitals without sufficient amount of treatment. The shortage of human resources is not the only problem associated with treatment} drugs are equally in short sup­ ply. Psychotropic diugs came into being in the late 19503 and have revolutionised mental hospitals in terms of treat­ ment ,(Sutherland .376), In Ghana these diugs are supplied free of charge to tffi inpatients but the supply iB restric­ ted. In all the seven group therapy sessions that we took part in the three hospitals the patients were told by University of Ghana http://ugspace.ug.edu.gh - 41 - the nurses to "make do" with the few drugs available. In other words the drugs are rationed because the institutions do not have them in large quantities. It follows then that the patients do not obtain the quantity of drugs that they need for their recovery. The result is that they are only being acoommodated and watched so that their illnesses may not get out of hand and ultimately as noted by Shepherd (pp cit) to protect sooiety against harmful elements. Overcrowding: number of patients to a ward. Another factor that emphasises the custodial character of the psychiatric service is overcrowding. This condition occurs at the Accra Psychiatric Hospital alone and it has been characteristic of the hospital since it was set up. The hospital has 23 wards and with a total of 1371 inpatients, there is an average of 59 patients per ward. This situation is contrary to the average of 25 patients per ward suggested by Dunham and Weinberg (op cit). The result, then, is nothing but congestion - too many patients oocupying a single ward. Coupled with the overcrowding problem is that of venti­ lation. Because the arohictecture of the hospital belongs to a by-gone age, the windows of the wards are too high, too few and too narrow. As a consequence, the ventilation University of Ghana http://ugspace.ug.edu.gh - 42 - system in the wards is deplorable. The arrangement of the beds compounds the nvarcrowfling problem. As a result of the largeness of the number of pa­ tients in a ward, the beds are too close to one another so that one can hardly pass through them. As already pointed out, the hospital has 809 beds. This means 562 inpatients are without beds. During the re­ search we observed that such patients sleep on straw mat­ tresses spread on the floor. Because of the congestion in the wards, for most of the time the patients stay at the courtyard in order to obtain fresh air and to stay away from the stench that characterises them. It is an undisputable fact then that the overcrowding in the wards gives them a cell-like appearance and the fact that all their daily activities are confined to them cer­ tainly give the inpression that the custodial character of the institution cannot be denied. Governmental Policy Governmental policy since the inception of psychiatric medicine in Ghana has itself emphasised the custodial aspect University of Ghana http://ugspace.ug.edu.gh of care. The original parliamentary act that established the mental hospital in the oountiy as already noted, pro­ vided that the hospital 3hould be a plaoe where the mental patients should be made to rest so that the larger community would not be disturbed by them. This trend in governmental policy is still in foroe. The National pedemption Council Mental Health Deoree (*TRCD) 30, 1972, maintains thst the mental hospital is to protect the community by assuming responsibility for the mentally ill who mould otherwise be sources of danger to it . The Decree makes the following provisions: In part V subseotion 20, it declares: "The commissioner may establish a state psyohiatrio hospital or hospitals for the reception and custody of persons committed thereto in pursuance of crimi­ nal proceedings brought against them or admitted thereto from a piiaon". And in subsection 26 it goes on to say that: "Special provision, shall be made for the accommodation of patients whose conduct may be at anytime harmful to themselves or other people". In fulfillment of these provisions the psychiatri.0 hospitals receive patients referred to them from the general hospitals, the courts, the police, organisations, em­ ployers and from individuals". University of Ghana http://ugspace.ug.edu.gh - kb - The law gives the hospitals more powers in their offer of protective custody to lunatics. From time to time the psyohiatrio hospital authorities team up with the police, the city and the local councils and arrest the madmen loitering in the streets. They refer to suoh madmen as "Vagrants". At Accra Psychiatric hospital there is one ward called Vagrants’ Ward (Ward C2) which is mainly occupied by such patients. * People's Outlook Towards the Mentally ills The Stigma. Mental patients who have been institutionalised tend to lose their social acceptance because the general public feels that their illness is never totally curable. What the mental hospital does is to give them a temporary sanc­ tuary where they may have rest in the hope that they might regain normality. Swarte (1969) has remarked that hospitalization not only brings about the straining of the relationship be­ tween them and their social groups but also even the press portrays them in very sombre lines and special prominence is given to their danger factor and the chronioity of their disorder. University of Ghana http://ugspace.ug.edu.gh - 45 - This observation holds true in Ghana and it seems certain assumptions underlie the opinion of the Ghanaian publio about the mental patient; that they are not trust­ worthy, that they are dangerous because of delusions and are capable of attacking innocent people at any time, that the psychiatric hospitals only mitigate the seriousness of the mental problem but do not actually uproot it and that they may commit crime at any time. In a word, mental pa­ tients are stigmatised. There are however, several reasons for the stigmatisation. Since the establishment of the Lunatic Asylum in Ghana in the late 19th Century there have been several patients with chronic mental disorders who have not had a corqplete cure. In recent times many patients have been on either trial leave or on parole and have been oommuting between the hos­ pital and their homes without showing signs of improvement. Some discharged mental patients who have been roaming in the streets do not appear like people who have ever had treat­ ments for their ailments; their conditions have not shown any improvement. As a result, even after discharge from the mental hos­ pital people do not get convinoed that the patient's mental health is restored. Eventually he is isolated - his social University of Ghana http://ugspace.ug.edu.gh - h i - Ghanaian culture equally emphasises stigmatiza­ tion of the mental patient. The traditional belief with regards to the oausation of mental illness is that it is supematurally brought ahout by agents like witch­ craft, demons, magic and gods, (Forster op. cit). It is further believed that these agents inflict the disorder on the victim beoause of the offence that he might have committed like his breaking of a taboo or his inability to perform his social role of a mother a father or a lineage head. His relatives in particular therefore brai his as a person who brinfs evil to the family and conse­ quently isolate him. The Closed *Tature of the Psyohiatrio Institutions The mental hospital is a closed system. When the inmates are on admission they have difficulty in esta­ blishing social contact with the wider community. Their Communication link with the outside society and their movement are all restricted. Many reasons aocount for this custodial sort of life. Some of the inmates are criminal lunatics. They have committed criminal offences as a result of their mental state and have been brought to the hospital on court order. At Aocra Psychiatric Hospital as already University of Ghana http://ugspace.ug.edu.gh - 4 8 - noted, lunatics have their own ward, the special ward. There is an orderly at the door which is always closed and he makes sure that none of the inmates escapes. In the words of Asare (op cit) "the custodial function of the mental hospital applies to such people". The hospital offers them custody to prevent them from harming the larger society and more importantly to separate them from other people who have committed similar offer.oes but because they are not insane they have been committed to prison. Some of the patients are agitated. As a result of mood swings some mental patients with ailments like schizophrenia, manic-depressive psychosis or acute exci­ tation may become destructive and cause havoc in the outer community. Their confinement in the mental hospital and tranquilization nip in the bud their destructive behaviour. Some mental patients, particularly psychotics, have delusions of persecution. They have a false belief that some people are plotting to kill them. If suoh lunatics are at large, they are likely to take revenge on their suspects or even on innocent people #iom they may see when University of Ghana http://ugspace.ug.edu.gh - 49 - the mood of delusion sets in . The psychiatric hospital gives such patients a place of exile in order to prevent them from carrying out these crimes. Because of these reasons the mental institution puts restrictions on the movement of its inpatients. Patients who are allowed to go outside the hospital are those who have inproved and are put on errands and those on trial leave and on parole. The physioal separation of the psyohiatrio institu­ tion similarly portrays its enclosed nature. Accra Psy­ chiatric Hospital is enclosed in a very thick antiquated wall with a single gate. Even at the gate are guards who monitor the movement of patients to and from the hospital. Indeed the architectural design of the building alone gives enough impression about its physical seclusion from the outer community. Pantang and Ankaful Psychiatric Hospitals have modem architecture and are therefore not walled but they are equally physically separated from the rest of society. The factor responsible for the separation is distance. They are both not within walking distance from the town. They can be reached only by car. Indeed their physical University of Ghana http://ugspace.ug.edu.gh - 50 - isolation by way of distance emphasises their nature as closed societies. Visitors have difficulty in seeing their patients. They have to report to the orderly who stays at the ward's doorstep and the nurses on duty in the ward before they can ste their patients. Similarly guardians do not have it easy when seeking the discharge of their patients. A guardian who wants his patient to be discharged has to give a written notioe to that effect. The N .C .R .D . 30, 1972, stipulates that i f , for one reason or the other, a guardian asks for the discharge of his patient he must give a seventy-two hour written notice to the hospital authorities. The notice has to be endorsed by the phychiatric specialist in-cbfO'ge' of the hospital. Discharge Rates The discharge rates in the psychiatric institutions has not been impressive. Indeed the low discharge rate together with chronioity and relapses that characterise the hospitals' treatment prooesses gives the impression that the hospitals have a custodial outlook. The dis- University of Ghana http://ugspace.ug.edu.gh - 51 - charge rates in the three hospitals for 1987 and 1988 are shown below for illustration. Table 1 : Discharge Rates of Mental Patients In Psychiatric Institutions in Shana in 1987 and 1988^ Hospital Year Admis­ Dis­ % of Dis­ sions charges charges over admissions 1987 2,494 1,6 2 1 65 Accra 1988 1,371 877 64 1987 901 505 56 Pantang 1988 169 107 63 1987 1,060 Ankaful 625 59 1988 193 125 65 Total 6,18 8 3,860 62 According to Table 1 the highest discharge rates in the hospitals were reoorded at Accra and at Ankaful in 1987 and 1988 respectively. Each recorded a rate of 65$ . The minimum discharge rate of 56% was recorded at Pantang in 1987. On the whole the three hospitals within 2. Source: Hospital Records Offices. University of Ghana http://ugspace.ug.edu.gh - 52 - the two-year period under consideration achieved a dis­ charge rate of 62$ . The data clearly show that within these two years in question the hospitals were able to discharge only a little more than half of their patients on admission. Treatment appears not to give any appreciable results since the admission of several patients continues into the following year. I I . INSIDE THE PSYCHIATRIC INSTITUTIONS IN GHANA. This section is devoted to the examination of what occurs within the psychiatric institutions in Ghana with a view to exposing their characteristics and roles. AdmiBaions Procedure The psychiatric hospitals receive their patients through mediators like the general hospitals, the courts, the police, families and friends. Some of the patients are also brought as vagrants. The admissions procedure itself is simple. A new patient reports at the Reception where a folder is pre­ pared for him. He is then referred to the Outpatient University of Ghana http://ugspace.ug.edu.gh - 53 - Department where his particulars on the folder are re­ corded. He may be required to give more information about himself. His next point of contact is the con­ sultation room where the psyohiatrist after diagnosis assigns him to a ward. His admission into a particular ward will be influenced by such factors as his age, sex and the degree of the disturbance of his mental disorder. While on admission in the hospital, the hospital authorities take care of any property that the patient may have. This action is taken in fulfillment of the requirement of the law. The Mental Health Decree NRCB 30, 1972 already referred to states: "the chief administrator of the hospital shall take charge of the personal property which a patient brings with him upon admission. Full particulars of the property shall be recorded in a register kept by the chief administrator. University of Ghana http://ugspace.ug.edu.gh - 54 - All suoh property shall be restored to the patient upon his discharge from the psychiatric hospital. All perishable property which a patient brings with him upon his admission shall be dis­ posed of in such manner as the ohief administrator may consider to be in the best interest of the patient". During the research it was discovered that any valuable property of the patient may be kept by any one of the following: hospital welfare offioer, the senior nursing officer in charge of the patient's ward, the hospital senior seoretary or a matron. In some cases the property may be handed over to the patient's guardian. It is a normal practice that a record of the property is kept at the hospital welfare offioe and at the offioe of the senior nursing officer responsible for the ward showing in whose custody it is . Rewards and Punishments. Goffman (op cit) and Sykes (1958) have both ob­ served that normally in the total institution rewards and punishments are instituted by the staff to enable them to achieve enough control over the inmates. University of Ghana http://ugspace.ug.edu.gh - 55 - Usually the institution has 'house' rules so that those mho obey the rules are usually rewarded and those that disobey them are punished. In the psychiatric institutions in Ghana no rewards and punishments exist. As far as the inmates are con­ cerned, no rules are specified to govern their behaviour while on admission. As a result it becomes not necessary to provide a reward in response to obedience or to punish an inmate for the infraction of a rule. An offence committed by an inmate like slapping a fellow inmate is normally considered by the staff as some­ thing that results from his condition - abnormal state of mind. Henoe *uch an act goes unpunished. I f the patient is found to be violent he is tranquilized to become calm. The Role of Visitors In the mental hospitals in Ghana both the staff and the patients enoourage visits. Visitors are allowed to enter the hospitals between 6 a.m. and 6 p.m. everyday. Visitors who maybe friends, relatives and spouses, play several important roles in the lives of the inpatients. University of Ghana http://ugspace.ug.edu.gh - 56 - The staff members believe that visits tend to eipedite the recovery of the patients. The presence of visitors brings about family reunions, strengthe­ ning of friendly ties and consequently the reduction in anxiety that afflicts the patients. Furthermore visits enable relatives to know the condition of their patients. By paying visits to their patients, relatives get to obtain first hand informa­ tion of the improvement in or the worsening of the conditions of their sick people. To the patients visits by their relatives have the tendency of strengthening the "we - feeling" between them and the relatives because they show that the social continuity between them is not out. Visits therefore bring about the avoidance of the disruption of ties be­ tween the patients and their families. What is more, visitors provide the patients with essential commodities that the hospitals cannot supply adequately. These items include food, clothing and footwear. Relatives and friends bring along with them when visiting their patients because hospitals have University of Ghana http://ugspace.ug.edu.gh - 57 - difficulty in providing them in suffioient quantities. Visiting of patients in the psyohiatrio hospital by their relatives and friends is important in another respect. In case of the death of a patient it is only through -visit that the family will get to know the news early and therefore arrange for the recovery of the body and ultimate burial. Visitors have the tendenoy of relieving patients of boredom in the mental hospital. The presence of visitors enables the patients to see new faces that they may not have seen for several days. The ohat between the visitors and the patients inspires the latter sinoe it i 3 through visits that messages for or from home reaches the receiver. Visiting of patients by their people then serves the purpose o ’ removing the communica­ tion barrier between patients and the outside world. An inportant role played by visitors in the psyohiatrio hospital therefore is to reduce the impaot of monotonous life experienced by the inpatients as a result of their daily e^osure to the same schedule of activities. University of Ghana http://ugspace.ug.edu.gh - 58 - Problem Areas of Patients Mental patients like other patients have problems to contend with. Some of these problems are symptoms of the disorder while others are social in nature. The table below exposes the problems of the irpatients. Table 2s Inpatient Respondents' Problems. Problem Number | % i . Relapse 33 19.1 i i . Signs and Symptoms 33 19.1 i i i . Offences Resulting from agitation 6 3 .4 iv. Lack of Visits 30 17.4 V. Alienation 47 27.1 JTL t Expected broken home 24 13.9 173 100.0 As table 2 above shows the respondents made mention of six core problems that disturb them. Relapge Resurgence of the mental disorder is a major problem facing the inpatients. As many as 33 or 19. 1% of them University of Ghana http://ugspace.ug.edu.gh - 5? - expressed concern about it . As a result of their mental disorder they have been hospitalised more than once, iifter discharge they feel that they are completely cured but they have to return to the hospital after a few months or years. This condition, they showed, has an adverse effect on their social activities like their mar­ riages and jobs. Signs and Symptoms The physical manifestations of the presence of the mental abnormality are a problem that agitates the minds of the patients. 19.1?? of the respondents talked about them as their problems. They are particularly worried about delusions and hallucinations which occur sponta­ neously and cannot be controlled. They have no way of getting rid of them. A 32 year old female schizophrenic at Pantang Psyohiatrio Hospital narrated her problem this way: "For the past three years I have been hearing voices and have been seeing rays of light. Before I came here two years ago I used to follow the light on the instructions of the voice. The voice used to tell me to University of Ghana http://ugspace.ug.edu.gh - 60 - go to the bush and I did so. At times I used to spend about two weeks in the bush without food, but I never felt hungry. On such occasions, a search party used to bring me back home. I continue seeing the light and hearing the voice but since the nurses control my movement I am not able to go even outside this ward". Offences Resulting From Agitation The patients' moments of agitation have tremendous adverse effects on them. of the patient respon­ dents remarked that this is their problem. They are filled with grief when they are told of the harm or dis­ turbance they cause during their mood of agitation. A 24 year old male Schizophrenic at Accra Psyohiatrio Hospital and a former undergraduate of the University of Ghana had this to say about his period of hyperactivity: "I have been told by doctor that I suffer from schizophrenia of grandeur. At times when I sit down in the ward, I get excited and filled with joy because I feel I am equal to God; I can create and destroy every­ thing on the surface of the e8rth. During certain moments I feel also that I am the head of state and I am therefore capable of destroying and University of Ghana http://ugspace.ug.edu.gh - 6 1 - rebuilding this nation within' the twinkle of an eye. During this state of delusion 1 laugh widely in the ward to the hearing of my fellow patients and the nurses. Sometimes this condition causes me to parade through the ward jubilating until the nurses shout at me to sit down. On some occasions 1 decide to give the hospital a new shape. I do this by first trying to tear my mattress into pieces or dismantling my bed or hitting the window with my fist in an attempt to break i t . I stop t -is acti­ vity only when the nurses overpower me. When they demand the reason for my action I do tell them that they are my subordinates so that !if they conti­ nue distuibing me, I shall bring my soldiers to shoot them. On gaining con­ sciousness, I regret my behaviour when I am told what I had done". Lack of Visits Several patients complain about lack of visits. 17.1$ of the respondents complained bitterly that visits by relatives and friends were either intermittent or had ceased conpletely. A deep probe into their hospital records showed that two groups of patients in particular have this as their main problem. They are the geriatric and the long stay patients. The geriatric patients are University of Ghana http://ugspace.ug.edu.gh - 62 - old and weak and their relatives and friends feel that they have no chance of reeovezy. They there­ fore do not see the need to spend time visiting them or even to spend money on tbem. The long stay patients have a similar plight. Some of them have been institutionalized for over ten years. Their long stay in the hospital, to the rela­ tives, is an indication that they are not likely to join them at hone again. Consequently suoh patients have been left to be cared for, for the rest of their lives, by the state. Alienation As the table suggests, the largest group of res­ pondents, 2 7 . 1^ , expressed concern about alienation. They claimed that by their hospitalization, as observed by Joaohim Israel ( 19 6 1) they have been, cut off from their families, their woxkplaces, their communities, their religious affinities and even from the mainstream of l ife . They have been released from the hold of their tradition and soeiety. As a result they have been left without social support. They have been stripped of their University of Ghana http://ugspace.ug.edu.gh - 63 - self esteem, their confidence, their optimism and sooiety’s moral support. The social bond between them and society has been out so that they do not realise their existence. The cohesive and stabilizing forces that bind them to the outer society have become disintegrated. When their kinsmen come to them in the hospital, their stay with them is short-lived. The longest place at which they see them off is the hospital gate. At Accra Psychiatric Hospital a 65 year old female with senile dementia remarked in a sad tone: •Whenever my relatives come here, their usual excuse is , we are in a hurry; we are going to work; we are going somemfcere and we have decided to pass here to say hello to you. It seems socipty has re­ jected those of us; who have been hospitalized as a result of this disorder". Expected Proken_ Home This problem ranked as the 5th in terms of the number of respondents who showed concern about i t . 13*9^ of them expressed the fear that on discharge they felt that they would lose their spouses. University of Ghana http://ugspace.ug.edu.gh - Gk - Out of the 2U. patients who found expected broken home as a problem associated with their institutiona­ lisation, 15 of them are women. They believed that their hospitalisation would oast a slur on them so that their spouses would not welcome them back into the matrimonial home, especially in the case of prolonged admission. At Pantang Psychiatric Hospital a 38 year old female with depression lamented: "I have been in this hospital three times within three years and it is my husband who has been bringing me. He was regular in visiting me during my last two admissions. In recent days I have discovered that his fre­ quency of coming here has diminished. When iny son came here last week, he told me that he had been seeing another woman in my husuand's room in the nights. I am now pre-occupied with thoughts centring on my future stay with that man." University of Ghana http://ugspace.ug.edu.gh - 65 - I I I . TYPES OF MENTAL PATIENTS IN PSYCHIATRIC INSTITUTIONS IN GHANA. In accordanoe with the World Health Organization's (WHO's) International Classification of Diseases, 1955, the Psychiatric Institutions in Ghana have Classified their mental patients into 16 categories. The various categories of patients are listed and discussed below. Table 3 s Types of Mental Patients in Psychiatric Institutions in Ghana in 1968 . j Types of Patients Number * '% ! 1 . Psychotics 152 8.8 2. Senile Dementia Patients 41 2.4 3 . Patients with brain damage 12 0.7 4 . Patients with delirium tremens 11 0.6 5 . Epileptics 87 5.0 6 . Schizophrenics 415 23.9 7 . Patients with depression 225 13.0 8 . Manic Depressive psychotics 102 6.0 9 . Hypomaniacs 105 6 .1 j i 10. Manic reaction patients 58 3 .3 1 1 . Patients with cases not diagnosed 75 4 .3 12. Patients with anxiety states 26 1.5 13. Mentally retarded ohildren 21 1 .2 14. Drug abusers 321 18.5 15» Alcoholics 32 1.9 1 6 . Patients with aoute excitation 50 2.8 Total 1,733 100.0 University of Ghana http://ugspace.ug.edu.gh - 66 - Psvchotics The psyohotics comprise 8 .8% of the inpatients and they are patients with emotional disorders usually characterised by severe distortion of ideas, diminished control of desires and impulses. The psychotic persona­ lity is totally disorganised in terms of reality. The psychotic*s language is disturbed making his speech incoherent. The patient has infantile regression reflected in behaviour such as ripping of clothe, re­ quirement of bathing by another person, spoon feeding and the soiling of himself. He experiences hallucinations, delusions, constant dreams, disorientation or loss of the ability to place himself in relation to time, place or person. He lives in a world of fantasy, - he lives in quite a different world in which he is not subject to the ordinary physical laws of society. He has no insight. The patient normally withdraws from the main stream of social life . Even in the mental hospital many of them are found sitting mournfully secluded from their fellow mental patients. University of Ghana http://ugspace.ug.edu.gh — 67 — At Pantang a twenty-two year old female psychotic objected to our interviewing her with an explanation "You are disturbing me". Senile Dementia Patients These patients are advanced in age. Their disorder results from reduction in intellectual functioning and much stress, (Brussel 19 6 1) . They are characterised by depression. intellectual con­ fusion, paranoid states, elevated blood pressure impairment of the capacity for thinking and concentration. They usually weep over trivial events. 2.1$ of the inpatients are made up of these people. At Accra except those mho are convalescing majority of them are in the geriatric ward. Patients with Brain Damage They comprise 0.7% of the inpatients. They have struc­ tural brain damage caused by various problems: infection like syphilis, a oar aocident affecting the brain, head in­ jury, brain tumour, trauma and degeneration. The patients have thought disorder, wrong perception of events resulting from a total intellectual impairment with ohronic consequences. University of Ghana http://ugspace.ug.edu.gh - 68 - Patients with delirium tremens. 0 .6$ of the inpatients have problem of delirium tremens. They are mainly elderly people who are chronic alcoholics. The patients have sleeplessness, great fear and profuse pers­ piration. In an interview a 56 year old man with this disorder at Accra Psychiatric Hospital told us: "When I sleep I have vivid nightmares and I also wake up repeatedly in terror. Sometimes a voice speaks to me commanding me to do something, and sometimes I feel that something is haunting me. Before I came here I had been drinking for 25 years. Hy feet are swollen and doctor has told me I have hypertension which is partly a result of my excessive drinking of alcohol". Epileptics The epileptic patients have disorder of unconsciousness with oonvulsions. Some of the patients have soars on their bodies which are results of bums received during attacks. Several attacks may occur in a day. According to the Psychiatrists, Epilepsy may be caused by a distuibance of electrical activity in the brain, Syphilis, old age, hardening of the arteries which inpedes the normal circulation of the blood, physical diseases, poison like alco­ hol and hereditary factors. It is ohronic. 5 .0^ of the pa­ tients have this problem. University of Ghana http://ugspace.ug.edu.gh - 69 - Schizophrenics Schisophrenios oonstitute the largest single group of patients and in 1988 their number was 23.9?2. Their problem is a ohronio one and they have many relapses, (Carothers, 1963} Strauss, 1958). The Schizophrenics show several symptoms which in- olude mood swings, aberrant ideas, bizarre behaviour, bizarre gestures, incoherent speech, unpredictable move­ ment, intellectual deterioration and split mind. They are ostensibly disagreeable, suspicious of others, de­ fiant and antagonistic. During interview they either refuse to answer questions or are evasive. The patients according to the therapists have delusions, hallucinations, defective insight and the impairment of the registration of recent events, though the disorder does not shorten life . The patients' world view is one of fantasy. They also show signs of regression, resuming the postures and behaviour of infants. This condition supports the view expressed by Whyte ( 1923) that at times the illness begins developing rfien the patients are young. University of Ghana http://ugspace.ug.edu.gh - 70 - At Pantang, a 22 year old female Schizophrenic replied "I am a lady" when she was asked to tell us the length of her stay in the hospital and at Ankaful a 31 year old male patient with the same problem posed a question "So you know German" when we asked him a similar question. Patients with depression These people constitute ^3•0fo of the inpatient po­ pulation. Majority of the depressive patients are advanced in age - 50 to 60 years. The disorder occurs during this period in life when the body chemistry changes and begins to decline as the organism as a whole weakens. Predisposing factors of depression include stressful events like loss of job, divorce, physical sickness or the loss of a loved one. Depressive patients are characterised by symptoms like ill-health, feelings of unworthiness, damnation, sadness, anxiety, restlessness, guilty feelings, mood swings, dearth of ideas and undeiproduction of speeoh even sometimes to the extent of mutism. University of Ghana http://ugspace.ug.edu.gh - 71 - They show physical s ig n s of hypoactivity, poor taste, sleep disturbances, dryness of the mouth, consti­ pation, poor oonoentration and pessimism. During the study we found most of them in pensive moods. They talked little and even with difficulty. Manic Depressive Psyohotlcs About 6 .0$ of the patients have the problem of manic depressive psychosis. The patients show psychotic episodes and depressive moods, that is between mania and melancholia. The manic phase presents the disorder in its upstage in terms of hyperactivity through an increase in speech, move­ ment and emotion. In the depressive aspect, however, these conditions are reduced. Common Symptoms include loquaciousness, adorning of the body with stripes or tatooing, bizarrely exag­ gerated movement and facial expressions, sorrowful concentration, refusal of food, hallucinations, delu­ sions and feeling of unworthiness. At Accra, one 41 year old man with this problem was so loquacious that he domi­ nated one group therapy session at which we were present. University of Ghana http://ugspace.ug.edu.gh - 72 - Hypomaniaos Hypomaniaos form 6 . 1$ of the inpatients' population. Their mental problem is a milder form of the manio phase of manic depressive psychosis. They have manic symptoms like elation, overaotivity, flight of ideas but are not greatly developed. They oontinue to have a keen realisa­ tion of their position and environment and do not exhibit such extreme disorder of conduct as to bring them into conflict with their fellows. For a time they are merely considered witty persons with ideas and aggressiveness and it is only in the advanced stage of the illness when they become interfering, irrita­ ble , domineering and may have too many schemes on their hands that their friends suspect that there is something wrong with them. They tend to monopolise conversations, express their views dogmatically, drift from one topic to another, show overconfidence and resent restraint. They are inconsis­ tent and changeable. Their judgement is faulty; they may behave in ways that they may later regret; for example University of Ghana http://ugspace.ug.edu.gh - 1 1 - driving too fast, spending money extravagantly or giving money away without thinking about it or doing outrageous things in public. Hypomaniac patients show symptoms of restless­ ness, but are not destructive. They appear to be doing something all the time, yet they never get tired. At Ankaful there is one female patient with the problem of hypomania who parades through the verandah of her ward and retires only when she beoomes hungry. Manic Reaction Patients These patients are psychotics with extreme manic states and they form 3 . ^ of the patients. The manic reaction patient is totally disoriented for time, place and person. His conversation is in­ coherent and he is so excited that in the mental hospi­ tal he is restrained only by hypnotics. He has auditory and visual hallucinations, suspi­ cions and delusions. He is usually shameless; he dis­ plays moods of irresponsible gaity, euphoria, restless­ ness and laok of control over his actions. The patient University of Ghana http://ugspace.ug.edu.gh - 74 - has impaired appetite, insomnia, irritability, over­ production of speeoh and hyperactivity. He ia extravagant in all directions - spending, dressing and even gambling. This patient rejects oritioisms, appears very busy to the extent that he oannot even sit at one place for a long time or to sit down to eat. Patients with oaseB not diagnosed There is a sizeable number of patients whose actual mental disorders have not been specifically identified by the psychiatrists. Accordingly, they have not been categorised. They constitute 4 .3 ^ of the inpatient population. These patients do not show consistency in their behaviour patterns in terms of their psyohiatrio problems. They have mood sidings and show a variety of signs and symptoms typical of many mental disorders. Patients with anxiety states Their oentral problem is neurosis, psychoneurosis or anxiety (nervousness, tension, fear). They have episodes of visible nervousness but tiiey are invariably unable to give a reason for i t . University of Ghana http://ugspace.ug.edu.gh - 75 - The neurotics do not have any discoverable phy­ sical disease. Their problem is only an indication of nental conflict representing faulty responses to the stresses in life and especially to those inner tensions that come about froa confused and unsatis­ factory relationships with other people whether they are a legacy fro* early childhood onwards which remain to hinder future adaptations or arise in the present in relation to hopes, ambitions or jealousies. Their disorganization of the *ind is only partial because they have insight into their condition. They recognize the abnormality of their behaviour, atti­ tudes and conflict. Their thoughts and haraony are undisturbed. The source of their danger is largely unknown; they eannot explain the reason for their fear. Synptoas of their disorder include short rapid breath, accelerated pulses, sweating and frequent urination, insonnia and lack of appetite. The synp- tons are largely aanifested when the feared thing is seen. In the psychiatric hospitals they form 1 of the inpatients' population. University of Ghana http://ugspace.ug.edu.gh - 76 - Mentally Retarded Children They are children having a problem of feeble ndndedness. They are persons who have been from infancy habitually abnormal in their mental reactions. These ohildren have inadequate emotional personality and intellectual development. Thejr are psychologi­ cally immature, lack Judgement, foresight or ordinary prudence. 1.2^2 of the patients are made up of these people. At Accra, they have their own ward but at Pantang and Ankaful they have been mixed up with the other patients. Drug Abusers Drug abusers constitute the second lareest-t of patients and majority of them are young people. According to Dr. Asare, in Ghana, drug abusers fall mainly within the age group 17-24 and many of them are students. The drugs they use include "wee", ( cannabis sativa) cocaine and heroin. As many as 18.57» of the inpatients are drug abusers. The drug addicts are characterised by deterioration of memory, attention and grasp of events. University of Ghana http://ugspace.ug.edu.gh - 77 - The physical symptoms are that the addicts are feeble, debilitated creatures with greyish ooaplexion, slight disturbances of coordination affecting speech, diminished general sensibility and nervousness. They have sleep disturbances as well. Alcoholics. Alcoholics form 1 .9/2 of the population of the inpatients. Alcoholism is an all-inclusive pathological situation whiGh involves the individual's body, mind, morals and spiritual existence, environmental and interpersonal relations. The alcoholios are as a result characterised by pale complexion, unkempt appearance, poor perception and poor judgement. Many of them are hypertensive and psychotic. Patients with Acute Excitation These patients have a severe form of nania and A are uncontrollably excited. They are 2 .8% of the patients' population. University of Ghana http://ugspace.ug.edu.gh - 78 - They are characterised by flight of ideas, violence including homicidal assaults, hallucina­ tions and delusions. Their common physical symptoms include sleep­ lessness, irritability, disorientation, frequent anger, impulsiveness, frequent laughter, poor judge­ ment and lack of insight. IV: THERAPEUTIC SYSTEMS IN PSYCHIATRIC INSTITUTIONS IN GHANA. Treatment in the psychiatric hospital may be said to enoourage the patient to develop a new view of greater esteem of himself, to be relieved of sub­ jective feelings of pain, anxiety, stress and to achieve greater independence and to function more effectively ir soeiety,(forster and Barbara (op c it ). The psyahiatrie patient is never referred to the hospital solely for the treatment of the mind. Every component of his total life is inoluded in the treat­ ment programmes: his personal relations, emotions, life history et®. In addition, various tests-physical laboratory and psychotherapeutic - are carried out. University of Ghana http://ugspace.ug.edu.gh - 79 - There are in all eight therapeutic prograauaes in the psychiatric institutions in Ghana: applica­ tion of Psychotropic drugs, Electro-convulsive Therapy, Psychotherapy, Group Therapy, Occupational Therapy, Counselling, Spiritual Therapy and Recrea­ tional Therapy. (a) PSYCHOTROPIC DRUGS Psychotropic drugs are pharmacological substanoes used to manipulate the brain - to induce sleep, to relieve the patient of anxiety ana to induce an ele­ vation of aood. Drug therapy is the commonest treat­ ment in all the hospitals. A large variety of drugs are used which include: Hypnoties: They produce a calming effect on the patient. They therefore ineliliee drowsiness and sleep eg. nitrazepam, phenobarbitone. Antidepressants: Are used to stimulate and activate depressed patients in order to produce an elevation of ®ood eg. conoordin, torfranil. University of Ghana http://ugspace.ug.edu.gh - 80 - Tranquilizers or neuroleptics: They reduce agitation, produce feelings of ealm and produce either a diminution of or an indifference to hallu­ cinations and delusions without also producing considerable drowsiness or excessive sleepiness eg. melleril, largactil, trilafon. (b) ELECTRO-CONVULSIVE THERAPY (BCT). It is a physical therapy administered to im­ prove the mental state of the patient. In submitting himself to this therapy the patient is laid on a bed with his legs and arms held by about four attendants. A tongue pad is placed in his mouth to prevent him from biting his tongue during the period that the therapy is being carried out. Before then he is given a drug that produces muscular relaxation in order to decreaae the inten­ sity of his convulsions. He is also required to be in a loose clothing and to have an empty stomach. University of Ghana http://ugspace.ug.edu.gh - 81 - When all is set for the therapy the physician pushes a button and eleotric currents pass through electrodes plaoed at the patient's temples into his brain. The administration of the therapy lasts for about three seconds and the machine stops automati­ cally. The patient instantaneously undergoes convul­ sions or jerks and then enters into a state of uncon­ sciousness for about two minutes. After that he lapses into what resembles a profound sleep or coma. The convulsions are principally the grand mal type. During the period of the sleep the patient's bed is wheeled off and another one enters the therapy. When the patient receives consciousness, he appears pale but he is able to return to his ward unaided. On the average, patients receive six therapies and their conditions inprove. Others receive up to eight, the maximum (No patient is allowed to exoeed that number). Usually two therapies are given to each patient every week. University of Ghana http://ugspace.ug.edu.gh - 82 - This form of treatment is ideally applied to oases of manic depressive psychosis, Schizophre­ nia especially the agitated ones. It is applied to patients with functional psychosis but not to those with organic brain damage. It tends to increase the apprehension of the neurotic patient so only selected neurotics are treated that way. Its ®ain advantage is that it outs short the psyohiatrio symptoms. Electro-Convulsive Therapy is used at the Accra Psychiatric Hospital only; there is none at Pantang and at Ankaful. PSYCHOTHERAPY Psyohotherapy involves efforts to help patients to understand why they behave the way they do. Psychotherapists help people to recognise what envi­ ronmental factors, what ways of thinking and what aspeots of behaviour seem to get them into trouble. Efforts are made to help patients to find alternative mode of behaviour. They help patients to discover for themselves that there are alternatives to mal­ adaptive patterns of behaviour and that these al­ ternatives may allow them to find a more meaningful University of Ghana http://ugspace.ug.edu.gh • 83 “ way of life . Psychotherapy therefore involves the treatment of mental and emotional disorders by non-physical methods and without the prescription and the use of drugs. It depends mainly on verbal and non-verbal (gestural) communications. At the Accra Psyehiatric Hospital Psychotherapy is carried out by clinical psychologists. At Pantang and Ankaful there are no psychologists so it is the psychiatrists themselves who administer that therapy. The idea behind this form of therapy is that most psyohiatrio patients lack satisfactory interper­ sonal relationships with friends or relatives or are unable to communioate with them effectively about problems in their lives. Often these are life-long behaviour patterns which are considered to be contri­ butory or causal factors in the development of psy­ chiatric disorder, Gregory (op cit) Brussel (op cit). There is therefore the need for the psychiatric pa­ tient to establish rapport with a trained professional who will help him to remove his problems of emotional nature by removing, modifying or retarding existing University of Ghana http://ugspace.ug.edu.gh - Bl> - symptoms and promoting pesitive personality growth and development. This professional is the psycho­ therapist. Therapists believe that the compassion and honesty that develop within the therapeutic relationship, the intimacy and the model for identi­ fication that the therapists provide, help the patient within a s’nort time to gain a better sense of reality. Since individualt” needs vaiy, each patient has a skillfully planned programme with the therapist, TIonnally treatment should be effected with the full cooperation of the patient. Information is obtained from the patient through the interview method. He is required to verbalise his problems, worries, doubts, fears, impulses, con­ flicts, sources of anxiety and guilt, for example. These oonditions usually form the basis for treatment. Psychotherapy has several branohes and at the Psychiatric hospitals in Ghana the branoh adopted is Behaviour Therapy. The behaviour therapist views mental disorder as the result of the patient having learnt maladaptive habits but not as an outcome of dynamic and unconscious processes. In the words of University of Ghana http://ugspace.ug.edu.gh - 85 - Coroy Brooks (1982 p .76) "behaviour therapy does not dwell on the past or digging into the client's unconscious memories. The goal is to teach himself new management techniques". Similarly Sutherland (op cit) has observed, that if people are to be taught to behave in the appropriate ways their feelings would undergo a •orresponding ohange. Behaviour therapy therefere involves investigating ourrent problems of the patient and suggesting new methods for him to learn to overcome them. It concen­ trates on how to relieve specific symptoms and problems rather than spending time investigating their causes. The method is applied to both neurotic and psychotic patients. In its practical application it depends on the prlnoiple of reinforcement which states that all animals inoluding man tend to repeat behaviour emitted in a given situation i f that behaviour is followed by a reward, A reward is any consequence that gives pleasure eg. praise, eshortation, money, food, (Maddison et al, 1982; Reiss et al, 1977). In the course of treatment a cooperating or an improving patient is usually rewarded in order to encourage him University of Ghana http://ugspace.ug.edu.gh — 86 — to emit or to oontinue showing that behaviour. Two of its methods may be cited for illus­ tration. In treating a neurotic patient the therapist may persuade him to approach the dreaded object. The patient, may to his surprise, discover that no harm happens to him. This enables him to break the vi«ious circle and overcome the problem. Before the beginning of treatment the patient is made to relax and narrate the situations that cause the phobic reaction. After successive interviews the patient is advised on how to go about a change in his behaviour. He is first made to imagine the item feared. The procedure is repeated until he can tolerate imagining it without anxiety whilst remain­ ing completely relaxed. Finally he is made to ap­ proach the dreaded object in real life in order to effeot cure. For exanple somebody who fears spiders may begin treatment by looking at the pictures of spiders. He may then be exposed to situations re­ sembling actual spiders, for exanple by looking at or touching dead spiders. Finally he maybe required to handle a live spider. Treatment may cover many sessions. University of Ghana http://ugspace.ug.edu.gh - 87 - Behaviour therapy may be used in the treatment of depression. The psychologist tries to induce the depressed patient to undertake some task that ■will give him concentration. He nay be required to draw speoifio pictures. If he is able to hold on to this task for some time he will be rewarded and will be made to continue the treatment. Such a treatment is considered to provide an elevation of mood for the patient. GROUP THERAPY Group therapy is a milieu in which the patient is required to learn how to interact with others. According to Sutherland (op oit) it began in the early 1930s as an off-shoot of Therapeutic Community. Aguilera and Messiok (1982 p p .28-29) stress on the need for this form of therapy on the basis that na­ turally man is a gregarious animal. They argue that from birth, an individual is a member of a group composed of himself and his parents. His life be­ comes a suoession of group memberships expanding from the basic family unit to peer groups, play groups and groups in school, business and church. An individual University of Ghana http://ugspace.ug.edu.gh - 68 - may remain in some groups permanently or ten^pora- rily , voluntarily or involuntarily, directly or indireotlyj nevertheless he -will participate in some form of group activity. Forms Of behaviour that communicate feelings, needs and ideas develop through interaction with others. At the same time perceptions and reactions toward the feelings, needs and ideas of others develop. It has been suggested, they continue, that an individual's behaviour can be controlled and in­ fluenced by the forces of groups which he is a mem­ ber and that he becomes what he is because of the roles, statuses and functions that are given to him by them. Experiences that bring feelings of comfort and satisfaction are usually tried again whereas- those that result in frustration and discomfort are avoided whenever possible. They believe that in psychiatry there has been a shift of emphasis from considering man as a bio­ logical entity to considering him as a biopsychoso­ cial entity. Movement has been increasingly away University of Ghana http://ugspace.ug.edu.gh . a? - from an organism - centred to a social - centred conceptualization of personality dynamics. This has contributed to a rapid rise in the development and acceptance of group therapy not only in mental hospitals but also in military, veterans and private and general hospitals. Group therapy means a treatment given simulta­ neously to more than one patient so that group thera­ pists believe that they can observe and interpret the patients' behaviour very well in the context of the dynamics of the group. They are sufficiently aware that this therapy is not enough to remove the psycholo­ gical root of the patients' problems, however, it may help them to establish some mental equilibrium. It is also used to complement the basic treatment methods. In the three psychiatric hospitals in Ghana group therapy programmes exist in all t.be wards and all patients are required to participate in except those whose physical or mental conditions prevent them from doing so especially the aged and the agitated ones. At the group therapy sessions which are convened everyday the nurses on duty act as moderators and sit in groups with the patients. Because of language bar- University of Ghana http://ugspace.ug.edu.gh - 90 - riers on the part of some of the patients the groups are organised along ethnic lines. In the male wards in the three hespitals English language is predomi­ nant. At each session there is a scheduled programme to follow. Normally the sessions cover a large variety of activities and where discussions are in­ volved they centre on topics like patients' problems, the use of drugs, preparations for discharge, employ­ ment after discharge and how to keep the hospital clean. Eaoh patient is required or asked by the moderator to contribute to every topic discussed. For the purpose of illustration two group therapy weekly time tables have been produced below. One from Accra and one from Ankaful. University of Ghana http://ugspace.ug.edu.gh - 9 1 “ Table 4s Group Therapy Weekly Programme at the Special Ward (male^ at Aoora Psyohiatrio Hospital. Day P r o g r a m m e I ' 10 - 11 a.m. 2 . - 4 p .m. Monday Stoiy Telling Games and bathing Tuesday Problem solving Church Service Wednesday Health Education Bathing and general and Know your cleaning doctor and drugs. Thursday Current affairs Ward Conference, and drumming shaving, bathing and nail cutting Friday Boiling of Games and bathing clothes Saturday General cleaning Bathing Sunday Church Service Relaxation. University of Ghana http://ugspace.ug.edu.gh - 92 - Table 5: Group Therapy Weekly Programme at Aggre.y Ward (Female) at Ankaful Psychiatric Hospital. Day Time Programme Monday 9 - 1 0 a.m. Story telling Tuesday it Games Wednesday n Plaiting of hair Thursday it Discussions on drugs, problems. Friday H General discussions Saturday it Learning of new songs Sunday it Fellowship meeting The two tables, which are self explanatory general­ ly emphasise group activity and interdependence; for example shaving, general cleaning, plaiting of hair, learning of new songs and fellowship meeting. The sessions also give rise to frequent interaction between the patients and their therapists. They may then be said to give validity to the view expressed by Dunham and Weinberg (op cit) that group therapy contributes to calm atmosphere and cooperation between patients and nurses in the wards of mental hospitals. University of Ghana http://ugspace.ug.edu.gh - 93 - This form of therapy has several advantates. It encourages the patient #10 is in an atmosphere of misery to speak up; he profits as he oritically sur­ veys, analyses and interprets problems of others simi­ lar to his own. He learns to yield selfish individua­ listic impulses with the help of the crowd. On the material side, the programme provides collective treat­ ment without any financial cost. What is more, members #10 are getting better often describe the oourse of their recovery to the new members. By inoluding within the same group patients at different stages of recovery those who are most seriously ill may see from the example of others that recoveiy is possible. Patients may find this more assuring than being told by the doctor or the nurse. Feelings of uselessness and unworthiness predominant in depressive and neurotic patients tend to be repressed by group activity and discussions. Religious services on Sundays do not only reinforce the religious nature of man in general and the patients in particular, but they also tend to break the myths surrounding the mental hospitals as closed systems. University of Ghana http://ugspace.ug.edu.gh - 3k - They are normally organised and led by church leaders who are not employees of the hospitals. (c) OCCUPATIONAL THERAPY Occupational Therapy is a device consisting of work - usually the learning of trade - performed at the hospital and is often a requisite for discharge. The aim of this form of therapy is to bring the pa­ tient to the highest possible degree of physical, mental, social and economic independence. In this therapy attention is focused more on the medium and the long stay patients. As observed by G-ittleson and Lemmings (1969 p p .269-270) the short term patients, no matter how severe their illness will have little difficulty in re-entering the wider •ommunity after discharge because normal oommunity standards may still be fresh in their minds. On the other hand, the medium and the long stay patients may be so much accustomed to hospital support that they may have almost forgotten the demands of normal society. It is these two groups of patients who will need to have community attitude re-instilled into them. This requires some kind of teaohing process. One University of Ghana http://ugspace.ug.edu.gh - 95 - variant of this teaching process is the use of industrial techniques in occupational therapy. The decision to involve a patient in such a programme is preceded by a careful assessment of the patient's mental and industrial capabili­ ties. Normally a patient is required to specia­ lise in one skill but has the freedom to swith on to another if he likes. The physician may also direct a particular patient to take up a specific skill; for exanple a depressive patient may be asked to take up art in order to elevate his mood. The important thing as far as the therapists are concerned is not what the patients accomplish but they feel that that therapy affects their conduct positively by keeping their bodies moving, their minds occupied by giving them skills and by facilitating group participation. Occupational therapy is an integral part of the treatment process in all the three psychiatric hospitals in Ghana. Each hospital has two occupa­ tional therapy workshops; one for males and one for females. At the men's occupational therapy University of Ghana http://ugspace.ug.edu.gh «» 96 — workshop, the trades learnt include shoemaking, doormat making, blacksmithing, carpentry, tailor­ ing and basket making. The women do dressmaking and crotcheting. At Accra Psychiatric hospital there is an occu­ pational therapy show room where the patients' in­ dustrial produots are advertised and sold to the general public. This form of therapy has many advantages. It breaks up the hospital monotony and gives the pa­ tient something to do. It therefore brings him a more pleasant way of spending his time. It provides the patient with a new skill. Where he has one already, it enables him to improve upon it and therefore gives him more confidence. The therapy allows the patient to be taught how to cope with the outside world after discharge by having sample of machines to practise with inside the hospital. The occupational therapy enables the patient's degree of psychiatric disability to be measured. This can be done by means of his output. This in- University of Ghana http://ugspace.ug.edu.gh - 97 - formation may be passed to his employer who is in­ terested in getting it . Tranquilizers or sedative drugs may have a limiting effect on the patient's motor ability which will alow down his output. By measuring his output it is possible to assign a numerical percentage to the patient's work performance and therefore his work disability under differing doses of the same drugs. Training under that therapy takes into consi­ deration differences in mental and physical disabi­ lities . Skills are therefore determined not inposed on the trainee. (f ) COUNSELLING- The role of counselling in the mental hospital is to find solutions to patients' problems that arise from situational and interpersonal difficulties. It is assumed that once the solution is made clear the ego will be able to function adequately toward sol­ ving the problem. Counselling is carried out in all the three psychiatric hospitals. During counselling period a University of Ghana http://ugspace.ug.edu.gh - 90 - group of patients selected for the occasion meets the counsellor who is usually a trained psychia­ tric nurse. During the session each patient in the group is required to make a contribution by making mention of his problem. The members of the session analyse the individual problems with the help of the leader or counsellor. A group answer is sought for each problem and conclusions are drawn The search for a group answer to the pa­ tients 1 problems becomes necessary because as ob­ served by Gregory (op cit) it is believed that they became ill because they could not solve their emotional problems alone. Apart from the group counselling individual members of staff advise patients on problems affec­ ting them during the course of their duties. (g) SPIRITUAL THERAPY Spiritual healing is an integral part of the treatment programme in all the three psychiatric hospitals. As already stated in the group therapy programmes, Sundays are devoted to religious service. University of Ghana http://ugspace.ug.edu.gh - 99 - Each hospital has a chaplain vAio on voluntary basis leads these services. He consoles, counsels and baptises patients where necesBary. In Accra and Pantang the chaplaincy is carried out by an Anglican Priest and at Ankaful by a Methodist Priest. Members of Syncretic Churches also go to the hospitals from time to time to pray for the patients. (h) RECREATIONAL THERAPY. Recreational activities are organised in the hospitals to help to alleviate the boredom experienced by the patients and to encourage them to participate in group activity. This therapy is therefore consi­ dered an in^jortant section of the treatment process. The patients are made to watch television and video shows and are also exposed to games like ludo, owe re and draft. They watch the shows and play the games together with the nurses. Furthermore, the hospitals have patient libra­ ries which are stocked with story books, novels, textbooks and newspapers. The literate patients are encouraged to patronise the libraries so as to re- University of Ghana http://ugspace.ug.edu.gh - 100 - kindle their intellectual capacities and to keep them from idling about. In this chapter, an attempt has been made to e examine the characteristics and the functions of psychiatric hospitals in Ghana in the light of Erving Goffman's propositions. The factors that give rise to the oustodi&l role of the hospitals have been examined. Some light has also been thrown on the career of the patient while on admission. Similarly the various mental disorders end the various treatment processes have been treated. In the next Chapter analytical explanations are given showing the implications of these themes on his ideas. University of Ghana http://ugspace.ug.edu.gh - 101 - CHAPTER THREE PSYCHIATRIC SERVICES Iff <31 AT A M L EHVIWG COFFMAN'S TYPOLOGY: m ANALYSIS. I . IWTBOHJCTIO’* In chapter one we isolated the seven salient fea­ tures of the mental hospital disoussed by Erving Gof- fman and noted that they would be the guidelines in the study. In pursuance of this objective we described the ii&in characteristics and the role of the psychiatric institutions in Ghana in the light of his observations. In this Chapter the focus is to show, vdth analyti­ cal explanations, the similarities and the differences between the operations of the psychiatric hospitals i*i Ghana and his observations. I I . TOE CUSTODIAL ROLE OF PSYCHIATRIC INSTITUTIONS Iw GHMA. In Goffman's typology of the mental hospital, he has advanced an argument that it is custodial in nature. In chapter tm> we reached a similar conclusion and exa­ mined the reasons, as far as data available allowed for University of Ghana http://ugspace.ug.edu.gh - 1 0 2 - that. In this section our primary concern is to give sociological explanations to the custodial character of the hospitals. We are following the trend of the argument as outlined in ohapter two. We have already observed that the psychiatric hos­ pitals in Ghana are largely custodial partly because of the insufficiency of qualified medical personnel and other medical resources. The shortage of psychiatrists and psychiatric nur­ ses in particular is principally attributable to brain drain. Forster et al (op oit pp.8-9 ) maintain that "There is a large number of Ghanaian Doctors #10 have qualified as Psychia­ trists but only few, seven in number, are in our psyohiatrio hospitals. Majority of them have left the country” . The Psyohiatrio specialist at Ankaful Psyohiatrio Hospital shares a similar view. In an interview on this issue he declared: "When I completed my medical course in psychiatry there were aa many as twenty psychiatrists who are all Ghanaians in active service in the country, as far as I am aware, all of them have left Ghana” . Tsikata ( 1980) throws light on the fewness of psy­ chiatric nurses in the mental hospitals. He is of the University of Ghana http://ugspace.ug.edu.gh • 103 “ opinion that these trained people have gone to the neigh­ bouring countries because of frustrations that they en- oounter in the course of their services in Ghana. Indeed the inference to be drawn from the statements of these observers is that service conditions in the psy­ chiatric field in Ghana are not lucrative so that most trained people in that area prefer going to woric in other countries where they think these conditions are better. Inadequate funding is equally responsible for the shortage of medical resources in the hospitals. Here we wish to focus our attention on drugs and on food for the inpatients. At Ankaful, the hospital secretary observed: "Our mental hospitals are not fund-generating. Our inpatients are not charged anything for the drugs they use, for the food they eat and the beds they sleep on. Because of these reasons, we feel that the government does not want to spend much money on them. As a result we have to ration food and drugs. The food problem is , however, more intractable. In all the three mental hospitals, each patient is fed on ninety cedis (j?90.00) a day. This money is not suffi­ cient at all so those of us at Ankaful charged with the responsibility of the upkeep of the patients buy food on credit from food contrac­ tors around and when our quarterly allocation of funds comes from government we pay them. We have never been able to pay any contractor in full so we are always in debt because we buy the food on oredit in excess of the food allocation of funds. As at now, we owe majority of the food contractors so immensely that we University of Ghana http://ugspace.ug.edu.gh - 104 - cannot approach any of them again for help. Furthermore, the money problem forces the three hospitals' staff to feed all their patients on porridge without sugar in the mornings". It seems that the insufficient funding of the mental hospitals in Ghana is related to the little importance attached to the mentally i l l . It appears, as Pasquall et al ( 1981) have rightly remarked that more money is spent on the general hospitals which cater for the physically ill - the elderly, the youth and infants. These people, unlike the mentally i l l , who have little chance of ever returning to normal life , tend to arouse sympathetic responses from the mass media and from the general public. As a result they become more important than the mentally ill to politicians who are chiefly interested in catching votes. The general hospitals therefore appear to be more popular than the mental hospitals as far as the government is concerned. Overcrowding, which has also to some extent, led to the custodial character of the Accra psychiatric hospital in particular is ascribed to its inability to esq)and. All the departments of the hospital except the Nursing Training School, the Reference library and the Records Office are concentrated within the wall of the University of Ghana http://ugspace.ug.edu.gh - 105 - hospital. Hie twenty-three wards and the other depart­ ments within the wall stand on a site measuring about 100 by 150 metres. Indeed, as far as the wards are concerned there is no space for expansion. The overcrowding problem which has become chronic is then a product of a large number of reasons; the lad: of foresight of its founding fathers to acquire a larger plot of land for future expansion; the histo­ rical root of the hospital as a Lunatic Asylum; the sizes and the small number of the wards in relation to ti number of inpatients, the phenomenal growth in the numbei of departments that occupy much of the land and the wall that restricts the movements of the patients. The attitude of the government towards the mentally ill has always been to keep them away from society. That is reflected in the arrest of vagrants from the streets and their consequent detention in the mental hospital. This exercise is carried out from time to time. According to Carothers (op oit) in the colonial period, lunatics who happened to be arrested were those who lived near Europeans or worked with Europeans. Nowadays, the exercise is restricted to the urban cen­ tres mostly. The most important in recent history waa University of Ghana http://ugspace.ug.edu.gh - 106 - that of 1965 • During that year the Organization of African Unity (O .A .U .) conference was held in Accra. Shortly before the commencement of the conference, the then government ordered that all lunatics should be cleared from the streets of Accra and be kept at Accra Mdntal Hospital so that the delegates might not see them. Later on majority of them were transferred to the Accra Uental Hospital annex built at Atispoku. Society usually poses many problems to people who are or who have been psychiatric patients. Erving Goffman has argued that mental patients # 10, have under­ gone institutionalization tend to lose their social acceptance. Stallworthy ( 1983) goes further by remark­ ing that the public has a general fear that hospitalization makes the condition of the mental patient worse because it offers no everlasting cure. Eventually since his relatives feel that the patient has deviated from his psychosocial functions he brings disgrace to them so they isolate him. To find out whether hospitalised mental patients are stigmatised in Ghana we asked mental hospital out patients #10 had had the experience of being hospita­ lised to indicate the nature of their social relations University of Ghana http://ugspace.ug.edu.gh - 107 - (whether their relatives, friends and spouses relate to them positively or negatively) and their job opportuni­ ties. Some socio-demographic factors like the length of stay in the hospital, age, marital status and the job in -which the patient was before the onset of the ill­ ness were taken into account. Tables 6 to 8 below sum­ marise the assessment by the outpatient respondents of the attitude of the public towards them. Table 6: Nature of Outpatient Respondents^ Social Relations. Mature of Relation Number % Cordial 71 47.3 Poor 79 52.7 Total 150 100.0 As Table 6 indicates, the mental patients are poorly received by Society. 5 2 . of the outpatient respondents said that their social ties since their institutionali­ zation have become narrower. Unlike before they are not invited to social functions and even within their family circle^ they are not allowed to share things together with other people. And in the church, in cars, people University of Ghana http://ugspace.ug.edu.gh - 108 - who know of their affliotions do not like to stay near them. One 35 year old male respondent who lives at Tema and has been receiving treatment at Aocra Psyohiatrio Hospital remarked: "In our house I am given a room which is hidden at a corsor. Wher visitors come to the house I am not allowed by niy relatives, espeoially my uncle, to join them in conversation because my judgement is thought to be poor". Majority of these respondents indicated that they had either been on admission for one year or more or had been on admission more than once. Some of them, however, maintained that there was a cordial relationship between them and their social groups. 47.3f» of them were in this category. They ex­ plained that they had been on admission for less than one year. Another index that was used to find out whether the mental patients are stigmatised is their marital status, and this is shown in the table below. University of Ghana http://ugspace.ug.edu.gh - 109 - Table 7: Marital Status of Outpatient Respondents Marital Status Number % Divorced/unstable marriage 60 53.3 Marriage maintained 48 32.0 Marriage not contracted before 22 14.7 Total 150 100.0 Again in the marriage institution psychiatric patients are stigmatised. A large percentage of the respondents have either had their marriages terminated or do not have stable spouses because of their institutionalisa­ tion. As many as 53.3% of them have this problem. The reason, according to them, responsible for this is the chronicity of their disorder. There are, however, few others who have maintained their marriages. These people are made up of t',ose who either never stayed in the hospital for long or advanced in age together with their spouses so that the spouses do not see the need to look for new partners. 32$ of the respondents are in this group. A small percentage of them, 14*7 have never married before and have not even decided to marry now. They University of Ghana http://ugspace.ug.edu.gh - 110 - are in their early twenties or before twenty (relatively young) and they intend getting settled financially before contracting marriages. They believe that as far as marriage is concerned they do not know yet i f they ’will be stigmatised. Finally the outpatient respondents' views were eli­ cited about their employment opportunities since their disoharge from the hospital. Their responses are depicted below. Table 8: Job Opportunities of Outpatient Respondents. Status Humber % Emplcyed/Job maintained 45 30.0 Have lost job/not getting job 61 40.7 Self employed 44 29.3 Total 150 100.0 Before employers^-'psychiatric patients appear to have unfavourable images. This is apparent in Table 8 above. Of the 150 respondents only 30.0^ have been able to maintain their jobs after discharge from hospital. Majority of these people are technicians who are indispen­ sable in their employments. University of Ghana http://ugspace.ug.edu.gh - 111 - Others are in government departments and were given leave of absence while on admission. Apart from the technicians and the public servants about half of the people who have retained their jobs are employees, who spent less than one year in the hos­ pital . Inspite of this as many as 61 people or k.0,7% of the respondents have either lost their jobs or are not getting any jobs because of their hospitalization. They are of the opinion that the most conspicuous element in employers' view of the mentally ill is the assumption that they are unstable and may be called for admission to the psychiatric hospital at any time. As a result em­ ployers do not like to work with them. Majority of the respondents who have lost their jobs were employees in private organizations. They ex­ plained that when they got the attack their employers contacted their families to arrange for the collection of their entitlements because they thought the patients would not be in a good frame of mind again to return to their jobs. Others lost their jobs because they either stayed in the hospital for a very long time or suffered relapses. University of Ghana http://ugspace.ug.edu.gh - 112 - The respondents maintained that generally they have difficulty in finding new jobs. Their would-be employers get to know of their psyohiatrio disorders either at the time they are being interviewed or when filling forms for the offer of deployment after in­ terview and therefore disqualify them from getting the jobs. A small group constituting 29.3?2 of them are self- enployed. They are mostly artisans, farmers, fishermen, traders and house wives engaged in petty trading. They have no interest in earning their livelihood by being employed by other people. What the study has revealed is that in Ghana men­ tal patients are stigmatised. When they get the attack their own relatives, spouses and etqployers tend to reject them. The factors responsible for their rejec­ tion are long stay in the mental hospital and the chronicity or relapses associated with their disorder. The data have suggested that these factors enable the social groups of the patients to get the idea that mental disorder is not ourable. Their type of illness makes them social dependents so that no one gets the interest to take the responsibility for their up-keep. University of Ghana http://ugspace.ug.edu.gh - 113 - The degree of stigma increases when the patient spends much time in the hospital or with the persistence of the illness. However, i f the patient's stay in the mental hospital is short-lived, it is not likely to cause much disruption in his social ties as his social groups may not lose much sight of him. In Chapter Two we saw that the mental hospital is a closed system con?)rising chronic, criminal and agita­ ted patients who have been isolated and institutionalised by society. As a result of such a situation the hospi­ tal tends to be custodial. This observation confirms what Erving Goffman has made. The confinement of the mental patients and the "closed” nature of the mental institution have beoome socially necessary because of the following reasons: the nature of the illness and the lack of adequate facilities for treatment. Since mental disorder is invariably chronic there is the need for the hospitalization of the patients. This is because the discharge of such people into the community may present many problems. The patients are helpless, criminal and hopeless so that the community may be hostile and resistant and their families may be University of Ghana http://ugspace.ug.edu.gh - 114 - inconvenienced. The patients as a result may feel iso­ lated and insecure in the society. Therefore their confinement in the hospital gives them security and the easy life associated with their institutionalization - profuse sleeping, eating, watching of television and video shows, smoking of cigarettes, sitting in groups and looking through the window - which we observed in the fieldwork, sets their minds at ease and eventually reduces their tension. Furthermore, the mental patients are confined because of the insufficiency of after care facilities. The three hospitals together have 52 psyohiatrio nurses attached to the regional hospitals who carry out psy- ohiatric after-care service. Apart from the smallness of their number, they are not well-equipped. For example, in the Central Region there are only five of these nurses attached to the Regional Hospital in Cape Coast. They are ideally required to visit their psychia­ tric patients in their homes. Meanwhile the government has placed only one motorcyole at the disposal of these people. Even during the period of the fieldwork the motor oyole was out of order. It is obvious then that under such conditions no effective after care service University of Ghana http://ugspace.ug.edu.gh - 115 - can be oarrled out. It is therefore important to pro­ vide the mental patients with long term institutionali­ zation in terms of oustody because it is in the hospital where good nursing oare is available for their maintenance. It has 41ready been noted that one feature of the custodial nature of the hospitals is their low discharge rate of patients. This low rate is itself attributable to the ehronicity of the disorder. Data available indi­ cate that -foe most ehronio of all mental problems, schi­ zophrenia, is the most common of all the sixteen classi­ fied psychiatric disorders in Ghana. In 1987 schizoph­ renics alone aocounted for 20.9% of the inpatients in the three mental hospitals and in 1988 their number rose to 29 .1%. This conclusion replicates an earlier one reaohed by George Tooth in his study of mental disorder in Ghana in the early 1950s. Tooth, aeooxding to Carothers (op oit) found over of 1iie mental patients he studied to be sohizophrenics. His final remark was that schizo­ phrenics are the largest number of mental patients in Ghana. This analysis suggests that since the most chronio mental problem is the most common in Ghana the psychiatric hospitals are not likely to be able to provide effective University of Ghana http://ugspace.ug.edu.gh - 116 - treatment for their patients. It is axiomatic then that they cannot completely depart from the custodial role particularly beoause of the nature of the disorder that they are required to repair. What has emerged from this study therefore is the fact that the psychiatric institutions in Ghana are largely custodial in character. Their patients are made to stay within the premises of the hospitals and to un­ dergo their daily scheduled activities of eating, sleeping, receiving of medication, woiking, group therapy and entertainment. As a result their therapeutic function is minimal and this is manifested by the insufficiency of medical resources, overcrowding of patients, govern­ ment attitude towards the mental hospitals, the stigma­ tisation of the institutionalised patient by the public and the closed nature of the hospitals. This observation confirms the view of Erving Cof­ fman on the operations of the mental hospital. It there­ fore validates our first hypothesis University of Ghana http://ugspace.ug.edu.gh - 117 - That the psychiatric hospitals in Ghana are closed systems in which inmates do not have an easy contact with the wider society due to lack of resources.^ in ; THE SOCIAL WORLD OF INPATIENTS IN PSYCHIATRIC INSTITUTIONS IN GHANA. In this section our concern is to examine whether the social life of the inmates in the psychiatric hos­ pitals in Ghana correspond to or differ from the tjpe sketched by Erving Goffman. In this connection we are focusing on the nature of their relationship with the staff and the problems facing them nhile playing the sick role. In Chapter Two we examined how the staff in the mental hospital in Ghana relate to the inpatients under the captions "Admissions procedure" and "Rewards and punishments". As far as the field data allow our conclusions are at variance with the views expressed by Erving Goffman on these issues. Goffman maintains that on admission the mental patient is subjeoted to brutality and much callousness, electric mutilation of the flesh, . shocks, confessions of sins, ridicule and deprivation of personal effects University of Ghana http://ugspace.ug.edu.gh - 118 - by the staff in «rder t# ceerce him t* be submissive. This practice is absent in Ghana. As already shown in Chapter Two the staff's attitude towards the patients is friendly - it does not differ from the nature of the staff - patient relationship in the general hospital. We suggest two reasons for this type of attitude of the staff; the protection given to the patient by the law and the value system of the Ghanaian. The Criminal Procedures Code, Act 29, 1960 and the Mental Health Decree (N .R .C .D .) , 30, 1972, both enjoin the mental hospitals in uhana to take good care of their inpatients - to clothe, shelter and feed, them and to investigate their eases well with a view to finding the appropriate solutions to them so that their minds will be at ease. It seems that v&at the law is asking the mental hospitals to do is to safeguard the interests of the patients within the framework of a friendly atmosphere. Similarly, the value systea of the Ghanaian is an important factor when explaining the liberal attitude of the Staff towards the patients. The Rev. Kwasi Sarpong (1974) has observed that the Ghanaian's liberal attitude is found in his hospitality. He is of the University of Ghana http://ugspace.ug.edu.gh - 119 - opinion that this hospitality is boundless; it is extended to the stranger, the aged, the young and the siok. In expressing this attitude he undoubtedly ex­ pects visible results in the form of praise, and tangible rewards. It is suggested here that under the guidance of the law and his values the Ghanaian psychiatric thera­ pist shows muoh concern in the plight of his mental patient. The conoem for the patient is manifested in various ways. He encourages the patient's relative, friends and well-wishers to visit him as often as possible in order to reduce his anxiety and boredom and to maintain the brotherly relationship that may be existing between him and them. He counsels the pa­ tient on the need for good inteipersonal relations with his fellow patients and with his other social groups after his discharge from the hospital. Further­ more he plays games and watches entertainments with them and at group therapy sessions, he allows a free expression of their views on matters affecting their welfare. University of Ghana http://ugspace.ug.edu.gh - 120 - The system of rewards and punishments do not operate in the psychiatric institutions in Ghana. Goffman has observed that in the mental hospital there are very rigid rules so that patients are mani­ pulated through a variety of rewards and punishments in order to get the rules to function. The system is institutionalised. In the mental hospitals in Ghana no rules have been spelt out to govern the behaviour of the inmates so that the presence of rewards an£ punishments to enable the rules to operate becomes unnecessary. The hospital rules and their associated rewards and punishments were abolished in the Accra Lunatic Asylum in the early 1930s by the first psychiatrist of the hospital, Sr. Maclagan. Since then, they have not been revived in Ghana. Sr. Maclagan argued that the mental hospital should uphold the principle of normal treatment involving the provision of a homely environment in the hospital in which the patient would not consider himself as being in a subordinate position. Instead he was made to look' tf- how he interacts and functions in the hospital community. In other words he introduced into the hospital the ooncept of thera- University of Ghana http://ugspace.ug.edu.gh - 121 - peutio community. It is a concept by which every aspect of hospitalisation should be used as a treatment for the patient. In a therapeutic community all staff members and the patients work as a team so that the environment shall be of maxisum use to the patients. The patients are included in the responsibility and the process of decision making. They are included in the planning and implementation of treatment approaches and in the evaluation and re-evaluation of their effective­ ness. The therapeutic community is considered to present opportunities for patients to examine their behaviour and to grow in the direction of more socially acceptable behaviou It involves the use of many different types of therapy to facilitate change in behaviour; recreational and work activities, spiritual therapy, group therapy and community government involving meetings aimed at inculcating into the patients, social standards and values that they have not internalised. These practices ocour in all the three psychiatrlo hospitals in Ghana. University of (Shc^i " http://ugspace.ug.edu.gh In terms of the problem areas of inpatients the field data confirm the views of Goffman. He enumerated three problems of the inpatients namely signs and symp­ toms of their illness, alienation and heterosexual trou­ bles. During the research the inpatient respondents described the last named problem as insignificant because they were more oonoerned about how to recover and return to their families than about sexual gratification. They confirmed the two as important problems and named four others - relapses, lack of visits, offenoes oommitted when agitated and expected broken homes. Even though Goffman never mentioned all of them yet other studies oonduoted in the Euro-American environments indioate that they are universal. Dunham and Weinberg (op oit) made mention of them and two other researches on stigma conducted in Europe reached similar conclusions. In separate studies conducted in King Seat Hospital at Aberdeen, Sootland and in the State University of Groningen Holland, by psychiatrists, the oonolusion was that society tends to isolate mental patients. The patients lose oontaot with the general publio and this constitutes a profound problem to them especially in marriage, in employ­ ment and even within their own family circles, (Gordon et al, 1979). University of Ghana http://ugspace.ug.edu.gh - 123 - It seems then that a large number of mental patients' problems transcend cultural barriers. The similarity between our conclusion in this frtudy and the Euro-American ones sketched above including that of Goffman then may be attributed to the univer- sality of mental disorder itself and its associated symptoms. For example the psychotie may have delu­ sions, hallucinations and lack of insight whilst the neurotic may suffer from phobia irrespective of oulture. Furthermore, both of them maybe stigmatised and face social isolation as this study has shown, IV: TRENDS IN PSYCHIATRIC SERVICES IN GHACTA. INTRODUCTION: According to Erving Goffman's theory, treatment offered by the mental hospital is not effective so that no definite results in terms of patients' recovery are attainable. In this regard the hospital tends to be custodial. As shown in Chapter Two and Seotion I of this Chapter our fieldwork has proved that his assertion holds true in Ghana. In other words, the psychiatrio University of Ghana http://ugspace.ug.edu.gh - 124 - hospitals in Ghana have been found to have a custodial posture. It is true that the psyohiatrio hospitals have for a time immemorial been maintaining a custodial posture but their servioes have not been static in nature; they have been improving and expanding with the passage of time as a result of inprovements in medical technology. The thrust of this section therefore is to explore the trends that have been emerging in the services of mental medicine in Ghana since its inception with a view to finding out the degree of the custodial oharaoter of the psyohiatric hospitals. We are going to consider changes in both institutional and non-institutional forms of treatment and their results. V: CHANGES IS INSTITUTIONAL METHODS OF TREATMENT. As already noted, the first mental hospital in Ghana, the Accra Lunatic Asylum started as a purely custodial institution. It was manned by untrained ward attendants who offered no treatment to the patients. According to Forster et al (op cit) treatment of patients started in the hospital when the first psychia­ trist assumed duty as the head in 1929. The treatment he U n iv e rs ity o f - http://ugspace.ug.edu.gh provided was nothing more than first aid. In the early 1930s, group therapy, an eoonondoal form of psyohotherapy was introduced at the Lunatic Asylum. Its advantages include the provision of a pro­ tective environment by a group for the patient to try out new patterns of behaviour and the offer of opportu­ nity for him to express his feelings before a group. A major breakthrough in the treatment prooess occurred at the mental hospital in 1947. In that year the psychiatrist in charge of the hospital introduoed the Electro-Convulsive Therapy (ECT). This maohine is still in use and it has the advantage of re-arranging the brain cells and therefore outting short the psychia- trio symptoms (hallucinations, mood swings, delusions, flight of ideas eto.) of the mental patient. Developments in the therapeutic front continued in the hospital and the decade beginning from 1951 wit­ nessed the greatest achievements in psychiatzio service in Ghana. These achievements ooourred mostly during the headship of Dr. Forster. They included the establishment of an Outpatient Department, the construction of occu­ pational therapy workshops, the introduction of recrea­ tional therapy, counselling and psychotropio drugs. University of Ghana http://ugspace.ug.edu.gh - 126 - In 1951 modernisation of the consultation rooms began and an outpatient department was established together with seats for the patients. Now more out­ patients Can be accommodated than before. The other mental hospitals have similar outpatient departments. These departments are situated in front of the consul­ tation rooms. Accra Psychiatric Hospital alone treated 20,796 outpatients in 1986, 19,152 in 1987 and 2,598 between January and July 1988. The construction of the occupational therapy wox%*\ shops began in Accra mental hospital in the same year. At Pantang and Ankaful these workshops were set up toge­ ther with the other departments when the hospitals wsre being established. They are staffed by trained occupa­ tional therapists. Before the introduction of this therapy menial jobs associated with the maintenance of the hospital were organised for the patients from time to time to reduce their boredom. The jobs included the raking of leaves, scrubbing of the wards and the removal of cobwebs. Occupational therapy provides the patients with tasks of the art and craft type - weaving, door mat and basket making, sewing, carpentry etc. - which give the patients skills. It is very advantageous to the University of Ghanar 127 +ittp://ugspace.ug.edu.gh short-stay aoute group. Recreational therapy oomprising entertainments, games, reading and even annual get-togethers came into being in the mid 1950s. The therapy is meant to reduce the isolation of patients especially the depressed ones. The extent of a patient's activeness in his participa­ tion in this therapy is considered a measure of the state of his mental condition. Counselling, offered by trained counsellors is im­ portant as a mechanism for finding a group solution to the individual problems of the patients. It also came into being during the mid 1950a. One major product of mcdical technology is the psychotropic drug. The use of psychotropic drugs began at Accra Psyohiatiio Hospital in 1956 and valium and largactil rcere among the first to be used. As already stated, psychotropic drags constitute the backbone of the treatment piooess in the hospitals. In the words of Forster et al (op oit) these drugs "share the pro­ perty of quietening disturbed behaviour and lessening tension". Ghana28 - http://ugspace.ug.edu.c Spiritual therapy is organised for all the mental patients in the three psyohiatrio hospitals. It was began in 1967 at Accra Psyohiatrio Hospital by an Angli­ can Priestess. *Tow, a large variety of Churches, - both Synoretio and Orthodox - take part in the therapy in all the hospitals. This type of therapy has become necessary because of the traditional notions that underlie the causation of this kind of sickness. The traditional notion holds that lesser Supernatural foroes are responsible for the oausation of the illness. It becomes necessary, there­ fore, for the supreme Sod, the Hero, All-powerful, the all-knowing, the Omnipresent who holds sway over all beings to be invited to oast out these lesser super­ natural forces that might have inflioted the illness on the patients. In 1972 another soientifio method of treatment -was introduced into the psyohiatrio senrioe. This is psycho­ therapy. It has already been stated that the branch in use in Ghana is beliaviour therapy. Its advantage lies in helping the patient to revise his attitude so as to enable him to move away from his emotional crisis. University of Ghana http://ugspace.ug.edu.gh - 129 - VI; ADVANCES IN NON-INSTITUTIOWAL METHODS OF TREATMENT. The non-institutional treatment methods are those methods that take plaoe outside the premises of the hospital. They have oome about as a result of the prac­ tice of deinstitutionalization embarked upon by the hospitals. The deinstitutionalization itself has become possible beoause of the proliferation of psychotropic drugs vhich can be administered to patients outside the hospitals. By this practice patients whose conditions have inproved are discharged into the community and are given aftercare treatment. Under the term deinstitutionalization, we are going to consider community Psychiatry and Rehabilitation. Community Psychiatry Usually released patients from mental hospitals find themselves too far from the hospitals for supplementary care and as rightly observed by Grawunder and Steinmann (1980) they are too fragile to cope independently with the pressures of the outside world. I f they are to make a successful return to the community, then the community has to provide some support for them. The community must house them, feed them, give them University of Ghana http://ugspace.ug.edu.gh - 1 3 0 - emotional and financial support. All what the thera­ pists have to do is to provide aftercare servioe from the mental hospitals through follow-up visits to the patients' homes. This service is community psychiatry or what Shepherd (op cit) has dubbed "Upside down" psychiatry. The community psychiatry facility in Ghana is about one and a half decades old now. In the mid 1970s a decision was taken in this country by the National Health authorities that society as a whole should accept a more moral and financial responsibility for the men­ tally disabled without distinction as to age, social class, religion, sex or form of disorder. There was a call for a trend towards the organization in the commu­ nity of programmes which would, i f possible, keep the patient out of the hospital, thus saving him from the disruption of his community and family ties. The call culminated in the establishment of community psychiatry as an integral part of psyohiatrio service in the country. It was started in 1974 and Mrs. Juliana Owusu, then a psychiatric nursing sister (bat now a Principal Psyohia­ trio Nursing Officer) at Acora Psyohiatrio Hospital w&s the principal architect of the Scheme. Initially, the University oKBIiStiar Soheme was made up of a team of nursing sisters, staff nurses, ward masters and social workers. Their activi­ ties ware confined to the Greater Accra Region. At the moment the community psychiatric servioe is provided by the members of the senior eschelons of the psychiatric nursing service. They are attached to the Regional Hospitals. Their functions include: (a) The provision of aftercare service for those patients, discharged from the mental hospitals through followup visits to their homes, (b) The provision of mental nursing care for patients in the community #10 may not require inpatient care. (0) The education of the public on mental health through such media as public lecturers, the press, the radio, symposia, conference and brochures. Emphasis is mainly on preventive measures - identification of psychosocial and physical factors that are likely to affect people's mental state, education on local belief systems under­ lying the causation of mental illness etc. Rehabilitation Centres As a result of their illness and consequent disability, University c G h ^^ - http://ugspace.ug.edu.gh mental patients are rejected by sooiety and placed in institutions udiich are remote from their oommmitieB so that they become socially isolated. Rehabilitation is a noninstitutional sooial treatment which aims at reversing the process of social isolation and the effects of institutionalization because as noticed by Denham (1967) people who spend a long time in the mental hospital develop defeots of personality among which loss of in i­ tiative appears to be the most noxious. As a treatment process rehabilitation centre is a separate unit direoted by a psychiatrist and staffed by nurses, occupational therapists and social workers. It is by convention, af­ filiated to the psychiatric hospital from which its mates are drawn. It is fully residential. In Ghana the rehabilitation centre ourrently use is the Pantang Rehabilitation Scheme which crops and livestock. The ultimate objective of the soheme, according to the Psyehl&tric Specialist in Chargi of the Pantang Hospital is to enable the hospital to aohieve self-suffioie.ioy in the hospital's food and meat requirements and to provide jobs for its discharged patients who do not want to return to their bcmes. University of Ghana http://ugspace.ug.edu.gh - 133 - Thera is another rehabilitation centre at Elmina belonging to Ankaful Psyohiatrio Hospital. Zt was set up in 1981 and at the moment it is undergoing renova­ tion. Rehabilitation courses at the oentre include animal husbandry, farming, soap manufacturing, palm oil and palm kernel oil making, blacksmithing, tailor­ ing and dress making. Accra Psyohiatrio Hospital has acquired a plot of land at Amasaman on the Aocra-Kumasi road where it intends building an integrated rehabilitation oentre for its discharged patients. As a therapeutic programme, rehabilitation ena­ bles the discharged patient to adapt himself to the outer oommunity. We agree with Hir-Schberg et al (1976) that it shifts the outlook of the patient from one of despair and depression to an attitude of hopefulness aocompanied by a desire to make a new start in life . It teaches him to give up the status of a sick person and provides him with work. In a word, it reduces his anxiety and doubts of ever making a successful living and fills him with the desire and the energy to make life more meaningful and enjoyable. University of G h a n ^^ _ http://ugspace.ug.edu.gh VIIj ACHIEVEMENTS OF PSYCHIATRIC SERVICES P T GHA^A. Our objective in this section is to examine briefly the achievements of the psychiatric institutions in Ghana in recent years as a result of the increase in the number of and the improvement in the methods of treatment. 'She following seem to be the achievements so far made: (a) Increase in the range of services, (b) considerable decrease in the length of stay in the hospital, (c) considerable reduction in the number of resident patients, (d) rehabilitation of patients, and (e) Open doo?'policy Inorease in the range of services. Twumasi (op cit) has remarked that the present day mental hospital is an interdisplinary complex organisation with different branohes. It oomprises medical personnel all of whom are engaged in oomplex dividion of labour with each person being a specialist in his department. There are psychiatrists, psychologists, occupational therapists, religious leaders, nurses and counsellors. They all manipulate the patient's brain in various ways in order to control his disorder. University of Ghana http://ugspace.ug.edu.gh - 135 - Before his discharge he is likely to have passed through majority of these departments. He might have undergone for example elaotro-convulsive vherapy, psychological testing, occupational therapy, group therapy and spiritual therapy, on various oocasions. All these services are syn­ chronised and are available in Ghana. They are all backed by the most important treatment method, drug therapy. Considerable decrease in the length of_ ta.v in the Hospital. Doctors Asare and Koranteng have observed that as a result of improvenent in medical science and technology, the psychiatric hospitals in Ghana have made tremendous ad*anoes in the course of treatment. These are reflected in the speed with which they discharge patients. In a hun­ dred years' anniversary brochure issued by the medical staff of the three psychiatric hospitals in 1988, these dootors made a remark that this time between six and eight weeks majority of the mental patients recover their normal health, (Forster et al, (op c it )) . University of Ghana http://ugspace.ug.edu.gh - 136 - Considerable reduction in the number of resident patienta. Another progress made in psychiatric treatment in Ghana has been the reduction in the number of in­ patients and the consequent increase in the number of outpatients. This has been achieved as a result of the existence of community psychiatry whose objectives are to provide aftercare service and to reduce the custodial characteristic of the hospitals. In 1987 the three hospitals together &ad an inpatient population of 4*455 and an outpatient population of 20,982. The out­ patients numbered nearly five times the number of the inpatients. In 1988* the hospitals’ resident patients were 1,733 while their outpatients numbered 1,504* According to these data about three fourth of the patients were on outpatient status. As already indicated in this chapter the first outpatient block came into being in Accra in the early 1950s. Now, emphasis is being placed on deinstitution- lisation. It seems convincing that the psychiatric hospitals are making attests to reduce their custodial role. University of Ghana http://ugspace.ug.edu.gh - 137 - Rehabilitation of Patients The rehabilitation of the psyohiatrio patient as an aspect of deinstitutionalisation is another attempt being made by the Ghanaian mental hospitals to di­ minish their custodial nature. With one rehabilitation centre in operation, cne being renovated and another one on the drawing board, the hospitals' primary objective in this field is to give their discharged patients voca­ tional training in skills, security and independence. As suggested by Caplan ( 1964) the rehabilitation of the pa­ tients is going to help them to resume maximum activity in the community in accordance with their individual abilities and skills. Open Door Pol icy In all the three hospitals the doers of the wards are never looked except that of the special or criminal ward at Accra. This is en attempt to remove the physi­ cal and social isolation or the closed nature of the hospitals. At Pantang the psyohiatrio specialist in charge remarked in an interview: "Our doors are never closed". University of Ghana http://ugspace.ug.edu.gh ~ 138 And at Ankaful, his counterpart stated: "We are operating on the open ward system". Several factors may be mentioned to explain the hospitals' rationale for adopting this policy. Through the application of tranquilizers they are able to tame their patients. It seems then that the period of the agitated noisy patient that characterised the Lunatic Asylum and necessitated the looking of doors is over. It appears also that the hospitals want the public to have an idea about their improvement in treatment. It has been stated already that the therapists believe that their turnover of patients is now greater. It is e pride, we believe, that they want the public to under­ stand. The unlocked doors enable visitors and even passers-by to have a quick and easy aocess to the patients. Finally, as has been observed by Peter Hays ( 1964) the therapists want the slur oast on the discipline of psychiatry brought about by their isolation of their patients to be erased. This may explain why in addi­ tion to the open ward system, the two modern mental hospitals Pantang and Ankaful are not walled at a ll. The authorities of the hospitals believe that the University of Ghana http://ugspace.ug.edu.gh - 139 - absence of walls gives the hospitals a home-like ap­ pearance so that the patients nay not notice a well- marked departure from their actual homes. We have already seen that as a result of the type of illness that they are required to treat and to some extent the interplay of certain social factors, the psyohiatrio hospitals in Ghana have been maintaining a custodial posture. This posture is true only to some extent. This is because with the passage of time especially since the introduction of the first physical therapy, the electro-convulsive therapy in the late 1940s, the hos­ pitals with the help of increasing application of medical science and technology, have been making sys­ tematic attempts to move away from their custodial position. The attempts are mainly concentrated in the intro­ duction of a large variety of institutional and non- institutional services directed towards improvement in their health care delivery. The visible effects of these developments include minimisation in the time that majority off p&ifeient̂ - ftpend on admission, tremendous University of Gh-£ - http://ugspace.ug.edu.gh increase in the number of patients on outpatient sta­ tus, increased aftercare and rehabilitation facilities and more exposure of the hospitals to public scrutiny. The overall impact of these achievements is that they have contri.'bttted to a decrease in the period in which a large number of mental patients bear the inpa­ tient status of their career. In this respect they have given ri.se to a reduction in the custodial functions of the mental hospitals. The achievements therefore confirm oar second hypothesis: "that the psyohiatrio hospitals in Ghana have partially renounced their cuadodial nature and have resorted to diagnosis, treatment and rehabilitation of patients as a result of the emergence of new ideas in the field of medicine". What we have attempted to do in this Chapter has been to explain sociologically the similarities and differences between the services of the mental hospi­ tals in Ghana and Erving Goffman's model. Like Goffman we have observed that the mental hospitals in Ghana are custodial in oharaoter and that the problems of inpatients cut across oultural barriers. On the other hand no system University of Ghana http://ugspace.ug.edu.gh - -14-1 - of rewards and punishments and special initiation proce­ dures that accompany admission are institutionalised in Ghana. The next Chapter, whioh is the concluding Chapter summarises our findings in the study and offers some suggestions whioh we oonsider useful for future research. Glrarl *4 2 - CHAPTER FOUR COWCLUSlQir. I . SUMMARY The thrust of this study has been to examine the extent to which Erving Goffnan's theory of the mental hospital Is relevant to the study of mental institutions in Ghana. The motivation for the study emerged as a result of the need to re-examine the concept because of nev ideas and technological innovations that have come about in the field of psy- ohiatiy in recent years. In ohapter one the concept was thoroughly elaborated and seven major points which were considered to constitute the core areas were isolated to be investigated in relation to psychiatric service in Ghana. These oore areas are largely related to therapy, inpatients' lights and problems and stigma. The views of other writers who have discussed the mental hospital from the sociological point of view were similarly explored. Their contributions in prlnoiple confirmed Goffman's idea that the mental hospital is a custodial institution. As typical of suoh research reports a problem was stated to pro­ vide guidelines for the investigation of the theoiy. The problem centred on the need to evaluate Goffman's typology of the mental hos­ pital in the light of the performance of present-day psychiatry, It wag backed by the establishment of two hypotheses to serve as inves- University of G h a n a ^ _ http://ugspace.ug.edu.gh tigatory tools and the spelling out of data oollection methods. The methods oompiised interviews, study of hospital doouments re­ lated to patients and participant observation. They were required to enable us to have an idea of the hospitals' sooial environment and to faoilitate the testing of the hypotheses. In Chapter Two w® briefly traced the historioal growth of the psyohiatrio institutions in Ghana. This was followed by the review of the oharacteristios of the hospitals, with a particular attention to faotors that give rise to their custodial nature and their treat­ ment programmes. In Chapter Three with the help of our field data, and the guid­ ance of the seven propositions of Goffman, we related the activities and the characteristics of the psychiatric hospitals in Ghana to the theory. Our oentral objective in this regard was to find out those propositions that apply and those that do not apply to the Ghanaian oultural oontext. Congzuenoies and divergences were found and ana­ lytical explanations were sought for them. Guided by our field data we tested our two proposed hypotheses and we found that all of them have validity in Ghana. The hospi­ tals' role has been oustodial with their inmates isolated from the main stream of sooial life sinoe their establishment; however in reoent years with the help of advancement in medioal science they have progressed considerably by way of diagnosis, treatment and rehabilitation of patients. University of Ghana 144 - http://ugspace.ug.edu.gh In sum, this study has shown that Erving Goffman' b typology of the mental hospital has relevanoe in the Ghanaian psyohiatrio servLoe in spite of the oritioal observations of Soull, Siegler and Osmond and Shepherd already noted in our relevant background review. Stated briefly, Soull, Siegler and Osmond believe that the model is limited in its application beoause it resulted from an ethnographic study of only one institution. Shepherd also argues that the prevailing sentiments of the era in nihioh the study was conduoted was not favourable to the institution of psyohiatxlc medicine and undoubtedly it had a profound influence on, Goffman's ideas. Shepherd's point of view is that at that time the image of psychiatry was at a low ebb beoause of the ppor performance of the then existing mental hospitals and the resemblance between such hospitals and concentration oamps. The validity of the model in Ghana is true but it is equally true that some progress in the area of the management of patients has been made in recent years as a result of new ideas in psy­ chiatric medioine. I I : LIMITATIONS OF THE STUDY. The following were problems to which the study oould not address itself beoause of faotors considered uncontrollable. University of Ghana http://ugspace.ug.edu.gh - 145 - (a) The views of the members of the public, especially mental patients' relatives, on the notion of stigma, were not solioited beoauae of the limitations of time and financial resources. Such views might oorraborate or disprove the existence of the phenomenon. (b) We are aware, from experience, that many mentally disordered persons are in the shrines of traditional healers and in the streets but sinoe the research was oonfined to mental patients in psychiatric hospitals (in fulfillment of the requirement of our thesis) they could not be contacted. They might offer useful ideas related particularly to their problems which could be incoxporated into this research report. (c) A large majority of this study's respondents were the mental patients who were found to be sober. Sinoe some of them mi^it not have insight, the truth in their information they provided could be suspicious. Ill: SU&SESTICWS FOR FUTURE RESEARCH. This study has suggested three areas of research that appear to be very meaningful in terms of their utility and practioal significance. They includes University of Ghana http://ugspace.ug.edu.gh - 146 - (a) Chronioity (b) Integration between psyohiatrio hospitals and traditional healers. (c) The village system as an alternative to hospitalization. CHRONIOITY We have already noted that Doctors Asare and Koranteng have shown that many patients are discharged between six and eight weeks after admission. However, the research revealed that there are several others who go beyond that and go into chronioity. It is these people who are more stigmatised. Little is , however, known about these ohronic drug users. There is therefore the need to research into the socio-demo­ graphic characteristics of patients so as to identify patients at risk of becoming long term drug users. INTEGRATION BETWEEN PSYCHIATRIC HOSPITALS AND TRADITIONAL HEALERS. Twumasi, Forster and Swift and Asuni have on different occasions remarked that traditional healers are an integral part of the medical profession in Africa and that the medioal doctor cannot close his eyes to their role. Since many mental patients are under the care of the traditional healers or go to them and come to the flfental hospital as a result of University of Ghana http://ugspace.ug.edu.gh - 147 - abortive cure offered by them, there is the need to inves­ tigate how best the two medical systems - the modern and the traditional - can come together to provide an integral treatment. THE VILLAGE SYSTEM AS AW ALTERNATIVE TO HOSPITALIZATION It is important to examine the feasibility of the vil­ lage system in the treatment of psychiatric patients in Ghana. Acoording to Swift and Asuni, this system is in ope­ ration in Nigeria. The patients live with their families in rented rooms in a number of villages near Abeokuta in Western Nigeria and receive medioal treatment at Are Psychiatric Hospital in the vioinity. The system has been in use since 1964. This faoility has the advantages of enabling f tained; of avoiding the huge expenses associated with their housing and maintenance in the hospital and of enabling them to avoid stigmatization which accompanies institutiona­ lisation. The orientation of this Thesis has been mainly to evaluate the theory that in spite of the variety of thera­ peutic programmes in the mental hospital permanent oure for the mental patients since time immemorial has remained an University of Ghana http://ugspace.ug.edu.gh illusion. The theory has been tremendously supported by our field data* It seems therefore that sinoe several patients are to live with the illness for the rest of their lives, as Cockerham ( 1986) has suggested, they are faoed with the impossibility of resuming normal roles in life so they mist be helped to manage their dis­ orders to enable them to maintain a relatively normal pattern of physiological and sooial functioning. This may be done through the medium of rehabilitation. There is therefore the need for future research to be directed towards how best the rehabilitation program­ mes in this country can be expanded in order to absorb the discharged patients of the mental hospitals. Sight should also not be lost of the need to find out the mental and physical capabilities of both male and female patients. These measures are likely not only to provide the patients with a means of earning a living but they will also enable them to maintain them­ selves physically and to be useful to their families and sooiety as a whole sinoe their dependenoe on society will be reduoed. furthermore, they will be relieved of the immense boredom and isolation that most mental patients experience after their disoharge from psychiatric institutions. University of Ghana http://ugspace.ug.edu.gh - 149 - APPENDIX INTERVIEW SCHEDULE A. FOR THE STAFF 1. Are the patients allowed to go out of the hospital without restrictions? ................................................................ 2. Are the patients' visitors allowed to enter the hospital without restrictions? ............................................................ 3 . Enumerate the hospital's rules that govern the behaviour of patients. 4 . Are the patients punished for contravening the hospital's rules? .............................................................................................. 5 . Are there any rewards for obedient patients? ..................... 6 . What are the admission formalities in the hospital? 7 . Are there any initiation formalities through which patients have to pass? .................................................. 8 . How many wards are therein the hospital?.................. 9 . How many patients occupy each ward? ......................... 10. In your opinion what are the problem areas of the patients• .............................................. . 11. What are the treatment programmes in the hospital? University of Ghana http://ugspace.ug.edu.gh - 150 - 12. What ia the hospital's annual average discharge rate of patients? ................................................................. 13. In whet ways are the discharged patients subjected to Stigma? .................................................................................. .. 14> Name the aahievements that have been made in the therapeutic processes sinoe the establishment of the hospital. University of Ghana http://ugspace.ug.edu.gh - 151 - FOR INPATIENTS 1. What is your age? .................................................................... 2. How many times have you been on admission in a mental hospital? .................................................................................... 3 . Since when have you been on admission in this hospital? 4 . Are you allowed to go out of the hospital without restrictions? ............................................................................. 5 . Are you allowed to receive visitors without restrictions? 6. What help do your visitors give $o you? 7. As an inpatient have you been given a list of rules to abide by? ............................................................. ......................... 8 . Are there any rewards that the staff give to patients who they think behave well? ......................... ........................... 9 . Are you punished when you behave wrongly in the hospital? 10. As an inpatient enumerate your personal problems 11. What forme of treatment have you undergone since your admission? ............................... . .................................................. 12. Did you face some kind of discrimination from the public after your previous discharge, if any? ............................... University of Ghana http://ugspace.ug.edu.gh - 152 « FOR OUTPATIENTS What i8 your age? ...................................... .......................... In which town do you live? .................................... ........... How many times have you been on admission in a mental hospital? ................................................................................. For how long were you on admission? ............................... Are you subjected to discrimination by the public aB a result of your sickness? ............................................... Describe how and where you meet the discrimination University of Ghana http://ugspace.ug.edu.gh - 153 - bibliography 1 . Alguilera E.C , and Messiok J.M .: Cidaia Intervention - Theory and Methodology. Blsckwell Scientific Publications Oxford, 1982. 2. Ampofo 0 . and Johnson Remould N, WHO African Technical PaperB T-e Facts cf ental health and Illness 3rd ed, N.M. Peryer Ltd. Christchurch 1983. 40 . Stranss ” .P. Psychiatry in The f.odern Wprl^ Michael Joseph Ltd. London 195c>* 41. Sutherland S. Breakdown einfell and "icolson London 19?T” ‘"~ " 42 . Swerta J.H. Btereofĉ jpes in Prorress In 1 egtal Health Free an "ugh. ed, «T and A, Churchill Ltd. London 19&9. 43 . Swift C,k. and flsurd. T . ental lealth and lisaasc. In fries Longman Croup Ltd. New York 1975. It4 . Lykeo Greeham The Society of Captives Princeton University Prass Princeton 1958, University of Ghana http://ugspace.ug.edu.gh - 157 - 45 • Talks ta •-ena Problems of Our Psychiatric Patients, in rIhe Ghanaian Times, March 15, 1980. k-b, T w j itasi P .A . Medical Systems in Ghana Ghana Publishing Corporation Tema 1975. 47. ealth Development in Ghana 1950-1985 Sociology Department University of Ghana, Legon 1986. 48. Ashanti Traditional Medicine: Its Relations to Present - day Psychiatry in African Therapeutic Systems Aderauwagun 3 .A. et al (ed ). Cross Roads Press Wiltham 1979. 49. W.H.O. International Classification of Diseases Creneva 1955. 5C. -Tbyte W .A. Outlines of Psychiatry ?th ed. Nervous and Mental Disease Publishing Conpany Washingron 1923. University of Ghana http://ugspace.ug.edu.gh