Original Manuscript
Transcultural Psychiatry
‘We are all working toward one goal. We 1–17© The Author(s) 2023
want people to become well’: A visual Article reuse guidelines:
exploration of what promotes successful sagepub.com/journals-permissionsDOI: 10.1177/13634615231197998
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collaboration between community mental
health workers and healers in Ghana
Lily Kpobi1,2 , Ursula M. Read3 , Roberta K Selormey2,
and Erminia Colucci4
Abstract
The practices of traditional and faith-based healers in low- and middle-income countries in Africa and elsewhere have
come under intense scrutiny in recent years owing to allegations of human rights abuses. To mitigate these, there
have been calls to develop collaborations between healers and formal health services to optimise available mental health
interventions in poorly resourced contexts. For various reasons, attempts to establish such partnerships in a sustainable
manner in different countries have not always been successful. In this article, we present findings from the Together for
Mental Health visual research project to showcase examples of healer–health worker collaborations in Ghana that have
been largely successful and discuss the barriers and facilitators to establishing these partnerships. Data reported in this
article were collected using visual ethnography and filmed individual interviews with eight community mental health work-
ers, six traditional and faith-based healers and two local philanthropists in the Bono East Region. The findings suggest that
successful collaborations were built through mutually respectful interpersonal relationships, support from the health sys-
tem and access to community resources. Although these facilitated collaboration, resource constraints, distrust and eth-
ical dilemmas had to be overcome to build stronger partnerships. These findings highlight the importance of dedicated
institutional and logistic support for ensuring the successful integration of the different health systems in pluralistic
settings.
Keywords
Ghana, mental health, human rights, traditional healing, collaboration, visual ethnography
Background factors such as limited availability of biomedical facilities
and health professionals, as well as systemic issues such as
The use of psychiatric services remains relatively low in cost and accessibility, also play an important role in deter-
many low- and middle-income countries (LMICs) where mining the under-utilisation of biomedical mental health
traditional and faith-based healing systems tend to dominate
health-seeking pathways (Rathod et al., 2017). It has often
been suggested that in such contexts, particularly in Africa, 1Regional Institute for Population Studies, University of Ghana
a major reason for the popularity of non-biomedical inter- 2Department of Psychology, University of Ghana
ventions is related to health beliefs that lean more toward 3Centre for Mental Health & Wellbeing Research, Warwick Medical
supernatural explanations for mental illness (Gureje et al., School, University of Warwick
2015; Musyimi et al., 2016; Opare-Henaku & Utsey, 4Department of Psychology, Middlesex University London
2017; Read, 2012). Although beliefs in spiritual and
Corresponding author:
animist factors related to ill-health are common in Africa, Ursula M. Read, Centre for Mental Health and Wellbeing Research,
as in many other countries (Green & Colucci, 2020), Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
several studies have identified that additional context-related Email: ursula.read@warwick.ac.uk
2 Transcultural Psychiatry 0(0)
services (Ae-Ngibise et al., 2010; Badu et al., 2018; Esan in scope and concentrated in urban areas. Many communi-
et al., 2019). There is, in fact, evidence to suggest that spir- ties, particularly in rural areas, were underserved, leading to
itual beliefs do not prevent help-seekers from making use of significant unmet need and a treatment gap of over 90% (M.
several healthcare streams, operating within a pluralistic Roberts et al., 2014; WHO, 2019). Families and communi-
approach in which the perceived benefits of different ties commonly seek help from practitioners such as trad-
approaches to care are considered to be mutually enhancing itional healers and herbalists who use plant-based
(Badu et al., 2019; de-Graft Aikins, 2005; van der Watt et al., medicines. Furthermore, with the upsurge of
2017; Read, 2012). neo-Pentecostalism, there is widespread use of Christian
The practices of traditional and faith-based healers in faith-healing in residential centres called ‘prayer camps’,
Africa and other LMICs have, however, come under operated by syncretic and neo-prophetic churches (Osafo,
intense criticism in recent years owing to allegations of 2016). There are also several Islamic healers. These
human rights abuses including the use of mechanical so-called alternative health providers use practices and
restraints, forced fasts, corporal punishment and social approaches to distress and healing that are often shared
exclusion (Human Rights Watch, 2020). In addition, it with the communities in which they operate. Such healers
has been argued that limited knowledge about specific treat- occupy positions of power and influence, and their interven-
ment approaches does not allow a systematic evaluation of tions, such as animal sacrifice, prayers, fasting and deliver-
their efficacy (Arias et al., 2016). Thus, evidence-based best ance from evil spirits, may be considered by those who use
practice based on scientific rigour has been difficult to them as more desirable than biomedical treatments (Kpobi
establish with traditional and faith-based healing systems, & Swartz, 2018a; Ojagbemi & Gureje, 2021; Read, 2017).
resulting in disdain and suspicion between systems In 2012, Ghana passed a new Mental Health Law (Act
(Nortje et al., 2016). Furthermore, in a postcolonial 846) that established a Mental Health Authority (MHA)
African context, biomedicine retains a hegemonic position with the aim of improving access to and provision of bio-
of perceived efficacy and modernity, and receives more medical mental health services. One primary focus of the
structural support in the health systems of most states. MHA has been to integrate mental health into primary
Traditional healing is, therefore, poorly understood (Kong care in order to deinstitutionalise mental healthcare. Small
et al., 2021; Kwame, 2021) and mostly unsupported by psychiatric units have been established at regional, district
state funding and investment. Yet, it is estimated that trad- and community hospitals and clinics in previously under-
itional and faith-based systems are used exclusively by served regions of the country, including in the predomin-
approximately 80% of people requiring mental health antly rural central and northern belt. This has resulted in
support in Africa (WHO, 2019). an expansion of community mental health with the deploy-
With this in mind, there have been longstanding calls to ment of hundreds of community mental health workers to
develop sustainable collaborations between traditional and health facilities across the country.
faith-based healers and formal health services in order to With the increased number of mental health workers in
optimise the mental health interventions available in primary care facilities, a further goal of the MHA is to
poorly resourced contexts (Campbell-Hall et al., 2010; encourage partnerships between mental health profes-
Petersen et al., 2011). There have been attempts to establish sionals and traditional and faith-based healers to enable
such partnerships in various ways in different countries. greater monitoring of their practices to minimise, and ultim-
However, these have not always been successful. In a ately prevent, human rights abuses. Such collaborations
review of mental health practitioners’ perceptions about also allow for training of healers and foster dialogues
collaboration in LMICs, Green and Colucci (2020) identi- about best practice. The MHA developed guidelines for
fied that traditional healers and biomedical professionals use by health workers on negotiating care and building part-
were both cognisant of the benefits of collaborating; nerships with healers. They also provided ‘registers’ given
however, there was mutual distrust of each other’s to each healer to allow health workers to collect sociodemo-
motives and practices. This notwithstanding, in recent graphic information about the people who seek their help.
years a few projects have explored ways in which colla- There is, however, limited research that examines the ways
borations between biomedicine and traditional or faith- in which such collaborations between healers and health
based healing systems can be strengthened (Baheretibeb workers are built in particular settings, the challenges encoun-
et al., 2021; Gureje et al. 2020; Ofori-Atta et al., 2018). tered, and the factors that might promote their success. To
understand this, the Together for Mental Health research
project used visual ethnographic methods to examine how
Mental healthcare in Ghana healer–mental health worker collaborations in Ghana and
Until recently, formalised mental health services in Ghana Indonesia are established, and how these partnerships have
were provided mainly through three specialist psychiatric facilitated the provision of mental healthcare within trad-
hospitals located in two southern coastal regions of the itional and faith-healing spaces. It also explored whether
country. Community mental health services were limited working together helps to minimise human rights abuses
Kpobi et al. 3
such as coercion and restraint. In this article, we report on psychiatry (called clinical psychiatry officers), community
findings from Ghana to discuss what helps to promote suc- mental health officers and mental health nurses.
cessful collaboration between mental health workers and As described above, a variety of ritual and spiritual practi-
healers and some of the challenges encountered. We draw tioners operate in the Bono East Region and many are used to
on these findings to suggest ways in which these collabora- addressmental illness and its perceived causes, such aswitch-
tions could be established in other contexts. craft, possession by evil spirits or curses. This includes
akɔmfoɔ (singular ɔkɔmfo) loosely translated in English as
‘traditional healers’. They are addressed as ‘Nana’ (grand-
Methods father), a term also used to address chiefs and elders.
Akɔmfoɔ serve the abosom (usually translated as ‘small
Research design gods’) particular to each shrine and when possessed by
The Together for Mental Health project employed visual eth- them attain powers that are used to divine the cause of pro-
nography to examine the ways in which community mental blems (such as illness) and take action to address them. This
health workers and healers work together in rural communi- usually includes rituals such as animal sacrifice and other
ties in Ghana and Indonesia. Filmed observations and audio- acts of propitiation, as well as administration of plant-based
visual interviews documented and highlighted interactions medicines. In addition, a wide variety of neo-Pentecostal pro-
between healers, mental health workers, caregivers, people phets and pastors run ‘prayer camps’ or healing churches,
with lived experience of mental health conditions and other many located in rural areas. Some practice a form of syncretic
actors in the community. This approach built onmethodology Christianity known in Twi as sunsum sore, or spiritual
developed for research on human rights and mental health in churches. Pastors of whatever denomination are usually
Indonesia (Colucci, 2016), as well as previous ethnographic addressed as (o)sofoor (o)diifo.Most conduct deliverance ser-
and qualitative research on traditional and faith-based vices to remove evil spirits, and ‘strong’ prayers and fasting to
healing and mental health in Ghana conducted by the other address perceived causes of mental illness, as well as using
authors (Kpobi & Swartz, 2018b; Read, 2017, 2019). In this substances such as olive oil or ‘holy water’. Some also use
article, we present ndings from thematic analysis of inter- plant medicines. There are a much smaller number offi
views, eldnotes and visual data from the Ghana eldwork Islamic healers operating in Bono East, particularly servingfi fi
and lming. Findings from the Indonesia eldwork have the Muslim communities who have settled in the area, butfi fi
been compiled into a companion article that has been submit- we were unfortunately unable to recruit an Islamic healer to
ted for publication (Setiyawati et al., under review). Papers are take part in the study within the research timeline. Families
in preparation reporting further on the ethnographic ndings who bring their sick relatives to the shrines or prayer campsfi
and visual methods employed. In addition, two ethnographic often stay forweeks,monthsor evenyears receiving treatment
documentaries, one from each country, have been produced1 and joining in the daily life of the facility. A caregiver, often
alongside other short lms planned for future release. the mother, is usually required to stay with the patient tofi
tend to their daily needs, such as bathing and cooking.
Research setting Data collection
In Ghana, the project was carried out in three rural districts Fieldwork was conducted between April and June 2019.
in the Bono East Region: Nkoranza South, Techiman and Before commencing fieldwork, an in-country advisory
Tuobodom. The region is made up of small, predominantly group made up of various stakeholders was constituted to
agrarian communities. The dominant languages are Twi and provide guidance on issues such as potential filming sites,
Bono (a derivative of Twi). The majority religion is community entry, as well as the types of questions to ask
Christian (72%), with a smaller Islamic population (17%) and from whom. The 17-member advisory group included
and approximately 3% identifying with indigenous reli- people with lived experience of mental health difficulties,
gions (Ghana Statistical Service, 2022). Primary health ser- relatives/caregivers, psychiatrists, mental health nurses,
vices are provided through district and community-based traditional healers, faith healers, representatives from non-
health centres and clinics. In the past few years, small governmental organisations (NGOs) working in mental
mental health units have been established within these health, artists and human rights advocates.
primary health centres to provide mental health and psycho- Selection of the research sites and participants was pur-
social support to the surrounding communities. With a posive, using existing research networks and visits to local
regional population of over two million (Ghana Statistical mental health teams to identify examples of collaborations
Services, 2022), there were no psychiatrists and psycholo- with traditional and faith healers. Some mental health
gists practising in any of the three districts at the time of workers and healers had been participants in earlier ethno-
data collection. Formal mental health services were pro- graphic research by Ursula Read (2012, 2019). Mental
vided by medical assistants with additional training in health workers introduced the research team to other
4 Transcultural Psychiatry 0(0)
healers with whom they had existing collaborations or with Careful consideration was given to the informed consent
whom they were seeking to collaborate and to patients/care- process because of the deep stigma that is associated with
givers who were using or had used healers. mental health issues inGhana, and previous sensationalist rep-
During fieldwork, we conducted filmed observations of ortage of healing practices and human rights concerns (Read,
interactions between community mental health workers, fam- 2021). We were also mindful of our positionality in relation
ilies and caregivers, people with mental health difficulties and to the research setting. Although the team included Ghanaian
traditional or faith-based healers. We also filmed healing ses- researchers (LK and RS), two of the researchers, UR and
sions, festivals and other rituals at two traditional shrines; EC, are White Europeans. In addition, the Ghanaian
healing, prayer and worship services at four neo-Pentecostal members of the team were not from the research communities
churches; interactions between health workers and families andhad receivedhigher levels of formal education thanmost of
in three homes; and daily routines of community mental the participants. Thus, we were mindful of the potential influ-
health nurses at four clinics/health centres. ence of colonial histories, issues of power and privilege, and
In addition to the filmed observations, we also conducted initial suspicions about our intentions, particularly in relation
filmed interviews with eight mental health workers, six to participants’ sensitivities around being filmed and concerns
traditional/faith-based healers, eleven relatives/caregivers, about how the footage would be used. We consulted closely
ten people with lived experience of mental health condi- with local nursing teams and healthmanagers regarding proto-
tions, two entrepreneurs who conducted philanthropic cols for engaging with healers and local communities and
activities in the community to support people living with appropriate forms of remuneration. All participants in the
mental illness, and one social worker. In this article, we film and interviews gave written informed consent or, if
report on findings from the health workers, healers and phi- unable to write, provided a thumb print witnessed by a
lanthropists. The majority of interviews were conducted in family member who provided written consent. We employed
Twi/Bono, with a few in English. In addition to the filmed a staged consent process in which all participants were asked
activities, fieldnotes were kept to record observations. to provide consent at each stage of the research. They were
The fieldwork was carried out by a team of social science asked todecide theextentof their participationand levelof ano-
researchers who all identify as female. LK is a Ghanaian nymity in thefilmed aspects of the study by, for instance, being
with a background in clinical psychology and has done filmed from the back. This consent was reviewed if the partici-
research on traditional and faith-healing in Ghana. She con- pant was filmed on more than one occasion.
ducted most of the interviews and supported the development In cases in which participants preferred to remain
of the research approach in thefield. She also conducted obser- anonymous, we assigned pseudonyms in the transcriptions
vations and analysis of data. EC is Italian based at aUKuniver- and censored their footage so they could not be visibly iden-
sity andwas the principal investigator for the project. She has a tified; for example, through blurring the face or editing out
background in cultural psychiatry, clinical and community footage where the participant was visible.
psychology and visual anthropology, and led the technical
and conceptual aspects of the filming and observations. UR
is a British medical anthropologist and occupational therapist Data analysis
who has conducted longstanding research on mental health All filmed interviews and observations were time-coded
in Ghana, primarily in the Bono East Region. She led the con- and transcribed verbatim in the original language. These
ceptual developmentof the studywithEC, facilitated site selec- were subsequently translated into English by RS and
tion, community entry and data collection through her existing checked by LK and UR. Discussions around the most
research networks, and conducted ethnographic observations appropriate translation were held with the team.
and data analysis. RS is a Ghanaian with a background in clin- Fieldnotes were also typed and included for analysis.
ical psychology. She translated the researchmaterials and pro- Thematic analysis (Braun&Clarke, 2006)was conducted
vided interpretation when necessary. She was responsible for in an iterative and comparative process triangulating film
consenting participants as well as conducting some interviews transcripts with visual data from the film footage, photo-
and participated in preliminary analysis of the data. graphs and fieldnotes of observations. An initial process of
manual coding of the observational and interview data was
used alongside repeated viewing of the film footage to iden-
tify emerging themes. These themeswere then used to inform
Ethical considerations the editing of the filmed footage for the ethnographic docu-
The study received ethics approval from Ghana Health mentary, Nkabom: A Little Medicine, A Little Prayer (avail-
Service Ethics Review Committee and Middlesex able at https://movie-ment.org/together4mh/). A second
University’s Psychology Research Ethics Committee. We process used NVivo 2020 software to code the interview
also sought permission for the research fieldwork from transcripts, building on this initial analysis. The analysis
the MHA in Ghana, Nkoranza South traditional council, involved familiarisation with the interview transcripts
as well as the district and municipal health directorates. through the translation process and repeated reading,
Kpobi et al. 5
followed by initial independent coding of three sample tran- Facilitating factors included four broad themes, namely:
scripts to develop a tentative coding framework through dis- (1) interpersonal relationships between healers and health
cussion and review of codes. Deductive codes were workers; (2) intrapersonal characteristics; (3) health
developed based on the research literature and research ques- systems support; and (4) community resources. Each of
tions alongside inductive codes developed from the data. these had various sub-themes as shown in Figure 1 below.
With this tentative framework, the remaining interview tran- Barriers to successful collaboration included: (1) leg-
scripts were split among threemembers of the team for initial acies of distrust; (2) competition for inadequate resources;
analysis, with each transcript given to at least two coders. and (3) ethical dilemmas. Figure 2 outlines the themes
Subsequently, themes were developed based on inter-coder and sub-themes of barriers to collaboration.
agreements and discussion of differences and triangulation Each of the themes and sub-themes are discussed in the
with observational data from the film footage and fieldnotes. sections below and are illustrated with quotes, ethnographic
In this article, we present data on the themes relating to observations and photographs where appropriate.
factors that were identified as facilitating collaborative part-
nerships between the healers and mental health workers, as
well as some of the challenges. Factors that facilitated successful
collaboration
Findings Interpersonal relationships between healers and
We identi ed several factors that facilitated collaborations health workersfi
between healers and mental health workers, as well as Establishing good interpersonal relationships was key to the
factors that served as barriers to collaboration. success of the collaborations. This was achieved through
Figure 1. Thematic map of facilitators for collaboration between healers and health workers.
Figure 2. Thematic map of challenges to collaboration between healers and health workers.
6 Transcultural Psychiatry 0(0)
several key factors – demonstrating mutual respect, recog- (Read, 2017). In order not to perpetuate these historical ten-
nising mutual goals, and acknowledging shared beliefs. sions, the mental health workers consistently and explicitly
emphasised their respect for the healers. When visiting with
‘Respect is the key attitude’: demonstrating mutual respect. An members of the nursing teams we witnessed the ways in
important interpersonal factor that health workers discussed which they interacted with the healers, visibly demonstrating
as imperative for building successful collaborations deference and remaining non-confrontational – both of which
involved recognition of the healers’ positions of authority are culturally expected behaviours when interacting with
and expertise within the communities in which they people in authority. Health workers followed accepted proto-
worked and an avoidance of explicit criticism which cols in forms of address and gestures. For example, when visit-
might lead to confrontation. George, a mental health ing Nana Duodu, an ɔkɔmfo with whom George and the team
nurse in Nkoranza explained: worked, at his shrine, we observed how George approached
him in a deferential manner, bowing in greeting (Figure 3).
You cannot go to someone’s house and tell the person, ‘Do Health workers were careful to acknowledge the healers’
this, do [that]’. I am not going there to condemn what he is expertise, recognising that they each approached healing
doing there. I am going there with a purpose, so I must from different perspectives. They explicitly acknowledged
respect him as a person and respect what he is doing. to the healers with whom they sought to partner that they
Respect is the key attitude. had no expertise in spiritual matters and were coming in a
spirit of collaboration rather than competition. They empha-
Traditional healers are considered cultural leaders within sised that professional training in mental health could com-
their communities owing to their perceived connections to plement the healers’ spiritual insight. Sister Regina2, a
the spirit world. The authority and power of traditional pioneering community mental health worker in the region
healers have historically been ridiculed or dismissed by colo- who mentored the younger novice nurses, stated it this way:
nial administrations (J. Roberts, 2021) and these attitudes
have persisted among many health service providers who I will always tell them, ‘Nana [lit. grandfather, honorific
often criticise such practices as ‘backward’ and ‘superstitious’ term used to address traditional healers], I can’t see
Figure 3. Nurse George bows to greet traditional healer Nana Duodu as a sign of respect for his cultural position.
Kpobi et al. 7
beyond my nose so I am always after the physical3. But you A church elder corroborated this, saying ‘When it is
know the spirit, so you will also do your spiritual part’. We beyond our abilities, we call them’.
talk this out with them and they are calm. They know you This dual approach was particularly evident when
have given them respect. patients4 brought to healers were behaving in ways which
could be perceived as dangerous or disruptive. On visits
Similarly, some Christian healers recognised that there to Sofo Ketewa’s prayer camp we interacted with several
may be some things that were not spiritual in nature and men who were very agitated, angry and argumentative,
required biomedical intervention. In such cases, they shouting at their mothers and sometimes threatening
expressed appreciation for the expert intervention of the them. On one visit, a patient accused his mother of
health workers. An elder at a prayer camp in the market putting something in his food (this is commonly believed
town of Techiman where mental health nurses conducted to be a way of enacting witchcraft) and so he refused to
regular visits explained: eat when she cooked for him. Another young man was
moving around, restlessly, giggling and behaving in sexu-
…when it happens to be spiritual, the prophet is able to deal ally suggestive ways. The camp attendants usually
with it very well. For the physical ones we call the experts, responded to these behaviours by putting the person in
the doctors, to come. We call the doctors to check their chains or shackles. In these difficult situations, nurses
blood, their strength, how they are faring, their appetite, took an important role negotiating with the healers and
to aid in taking medication. We realised that we couldn’t family caregivers to administer sedatives and remove the
treat them with our knowledge; it gets to a point where chains (see Figure 4). Sister Regina echoes the elder in
the doctor’s knowledge is above ours. So while we take describing their methods as complementary in these situa-
care of the spiritual aspect, we call them to take care of tions. After medication is administered then the pastor’s
the physical part. interventions such as prayers can continue: ‘maybe we’ll
give a sedative before you [the healer] also continue from
With this mutual respect for differing expertise, healers where we stopped’. In this case, as Read reports elsewhere
and health workers were able to separate out their respective (2019), chains and sedating medication are often viewed as
domains to avoid conflict and acknowledge the potential for achieving similar ends, to calm and ‘cool’ the patient and
their respective complementary roles. enable them to resume spiritual treatment as well as fulfil
social roles.
‘Working towards one goal’: recognising mutual aims. Another
supporting factor for promoting collaborative interpersonal ‘We also believe in the spiritual aspect’: acknowledging shared
relationships was a recognition that both parties were beliefs. Although community mental health workers had
working toward a mutual goal. In their engagements with received training in biomedicine and a scientific approach
healers, health workers sought to show the healers that it to mental illness, they occupied a liminal space in their
could be in the interest of both parties if they worked identification with their professional training on the one
together. As Abu, a mental health nurse in Techiman, hand, and cultural beliefs and values similar to those of
emphasised, the important aspect was not the method but the healers on the other. Despite their medical training,
the result: health workers acknowledged the co-existence of their
own belief in the potential for spiritual forces to influence
We are all working towards one goal. We all want people to health. As Sister Regina put it: ‘I am a Christian, I
be getting well. So whether you are using orthodox [medi- believe in God. I believe God created human beings and
cine] or you are using traditional [medicine], the important he cures illnesses’. Although there is a great deal of vari-
thing is for them to get well. ation in what Christian nurses believe is acceptable,
dependent on their particular form of Christian practice,
In these instances this pragmatic approach appeared to be nurses were adept in emphasising shared beliefs and mini-
effective because the healers were receptive to the health mising points of difference, whatever their personal misgiv-
workers, in most cases welcoming them warmly when they ings. Abigail, a mental health nurse, described this process
came to visit. Sofo Ketewa, who led the prayer camp in in relation to a prophet with whom she was attempting to
Techiman, acknowledged the potential for faster recovery establish a collaboration and who practised a form of syn-
when the two methods of healthcare were combined: cretic Christianity which many other Christians tend to
view with suspicion:
We have a lot of knowledge, but it is also right that we learn
from your knowledge. That will be helpful. Because I sat there with him and all he could tell me is that he has
healing is not only spiritual, there is also the physical. So seen a vision about me and some stars. That I had a bright-
if the spiritual and the physical treatment join together, it ening star covered with some darkness and he knows that
works better. there are some spiritual forces behind it and so he will
8 Transcultural Psychiatry 0(0)
Figure 4. Nurse Kingsford speaks to healer Sofo Ketewa about a patient’s care.
pray for me and I should also pray. And I said ‘Ooh, he that we also believe in the spiritual aspect. But we want to
shouldn’t worry, I am also a Christian and I pray a lot so give the physical treatment. Maybe you are thinking that
that won’t be much of a problem’ […] in fact, I had to your condition is spiritual, but [for all] you know, it is phys-
take all that, just so that he wouldn’t … I had my plans ical. And maybe we are thinking that it is physical, [for all]
for going there. I just wanted to nail it. I wanted to just you know, it is a spiritual [condition]. So we are not against
… establish that rapport with him. [the spiritual].
Attending church services with the nurses, we saw how Such statements highlight how successful collaboration
was built by identifying shared beliefs and values
they actively took part in prayers and other aspects of the ser-
vices and how their faith informed much of their approach to between healers and health workers and using these as a
their work as a service, not only to the people of Ghana, but bridge to find joint pathways for providing care.
to God. The goal of collaboration was therefore not to
change causal beliefs about mental illness, but to advocate Intrapersonal characteristics
for the inclusion of biomedical interventions alongside spir-
‘You need to be selfless’: personal commitment. Other facili-
itual treatment. George described this as follows: tating factors that helped to sustain the collaborative relation-
ship between the healers and health workers were reflected in
… the mental health officers who are giving treatment, we the personal characteristics of the nurses and the healers. It
are Christians, one way or the other, [or] Muslims. Meaning was clear that the particular commitment and drive of the
Kpobi et al. 9
mental health workers in this study contributed to the success medicines or help patients set up small businesses. During
of the collaborations5. They demonstrated a focused dedica- the course of fieldwork, for example, the nurses used a
tion to seeing community mental healthcare thrive in their public holiday to donate a mattress, clothing and other
respective districts. We saw evidence of their passion to items to a young woman who was formerly homeless, in
ensure that as many people as possible who required help an attempt to reintegrate her into her family and set her
were reached, such as working long hours and responding up with a livelihood.
to late night phone calls on their personal mobiles from fam- Stigma towards mental health within the wider health
ilies needing help. As Eric, another mental health nurse, sector is widespread as the nurses reported. Abigail was
described: ‘Patients have my number so they can call me told by the health workers in her clinic that she had to
at any time they want’. One Sunday for example, a day keep her ‘mad’ patients away from other patients, and
which was officially his day off, George described how he nurses were commonly referred to as abodamfo (mad
had been called to administer sedative medication to people’s) nurse. This spurred them to develop their own
someone who had become psychotic. This drive pushed professional networks, both formal and informal, to
them to persist despite the low status of mental health sustain their morale and gain support. WhatsApp groups
within the health system, as George explained: and in-person meetings were important means of strength-
ening their professional identity and mutual learning.
As soon as you become a [community mental health Mental health teams supported each other through periodic
worker], if you want to do the work to touch the lives of debriefing meetings, making decisions about care or family
people, then you need to be [selfless] because it is a part interventions together, and pooling their resources to pur-
of the profession that has been neglected. chase medication and fuel to visit healers and families. As
George described:
The healers in turn were impressed by the hard work and
patience that the health workers demonstrated. This made Richard has been handling more than ten patients. He buys
them more willing to work with them. Nana Duodu them medication every month. Abigail and I have been
remarked: doing the same here. We have been buying for the patients.
Liberty, the same thing. The issue is, sometimes you’ll see
When I met George, I could see he was very serious about them, and the little [money] that you are getting, you need
the work he was doing. He was focused on his work. to use some to support these people, because you are afraid
Someone who works hard and pushes himself to see the otherwise they will relapse.
growth of the nation, I always want to partner with you.
[…] He rides his motorcycle and comes here, and we In this way, they sought to strengthen their morale and
talk. Some days, when I go to town, I meet with him and pride in their professional identity, which was particularly
we talk. important in a widely stigmatised field of healthcare.
These quotes illustrate the personal commitments of both
healers and mental health workers to building and sustain- Health system support
ing collaborative partnerships. A further crucial factor that supports collaborations
between healers and mental health workers in Ghana is
‘My work is important to me’: professional identity and values. the support from local, national and international health
Both healers and health workers took pride in their profes- policy and systems. This system-level support was highly
sional role, and this was reflected in their personal ethos of valued by mental health workers in this study as lending
care. The collaboration, therefore, worked because it was credibility and reinforcing their efforts to establish partner-
mutually beneficial for building or sustaining their respect- ships with healers.
ive professional identities. Nana Duodu stated:
Municipal and regional support. Nurses in Nkoranza South
…my work is important to me. I am not a lazy person. My and Techiman emphasised the value of support from the
work is very important to me. So when I see that the work is municipal health directors in enabling their work. As
also important to you, then we can work together … it will George put it, the director of health was ‘another collabor-
benefit all of us. ator’ because of the assistance he gave in many ways, from
promoting their work in the municipality, to making
The mental health workers’ attitudes also demonstrated resources available and even making a substantial personal
personal moral principles, which influenced their profes- donation. This contrasted with other districts where health
sional behaviour. We witnessed how they often went managers could be less supportive and indeed obstructive;
‘beyond their mandate’ to meet the needs of people under for example, withholding resources that mental health
their care, such as using their own funds to purchase workers needed to do their work or deploying them in
10 Transcultural Psychiatry 0(0)
other areas of health such as disease control. However, Through the data recorded in the registers, the health
George emphasised that as more mental health workers workers could identify nearby health facilities in the
are posted to primary healthcare, health managers are start- service users’ local community and provide referrals if
ing to see ‘massive improvements’ and so realise ‘that we needed. In this way, even when the spiritual care provided
too have something [to offer]’. by the healers had been completed, biomedical treatment
In addition, new regional mental health co-ordinators, could continue.
appointed as part of the implementation of the Mental
Health Act, provide a focal point for mental health
workers across the region and organise training and super- International initiatives. Mental health workers were also
vision. Through this and other informal mechanisms, nurses able to tap into wider global initiatives through the activities
developed networks with other mental health teams by of international organisations in Ghana. This included train-
which they gained practical and emotional support, peer ing on human rights and collaborative ways of working
learning, and assistance with fundraising activities. such as WHO QualityRights (Moro et al., 2021), which
Training workshops, often offered by NGOs active in was being rolled out across the country during the time of
mental health and organised through the regional mental the research. All of the nurses were undergoing or had com-
health co-ordinators, enabled nurses to share experiences pleted training in human rights as part of this initiative, with
and reinforced a rights-based approach to their work. Abu and George additionally trained to be trainers. George
explained how this had helped to transform his approach to
National policies and guidelines. As described above, collab- care and treatment, particularly in relation to reducing coer-
orative relationships are explicitly promoted by the Mental cive practices:
Health Authority (MHA) to meet the mental health needs
of the country and prevent human rights abuses. The I was fortunate because I was among those who went for the
mental health workers in this study are part of a shift to national training. One thing I have seen about
community-based mental healthcare in Ghana, which fol- QualityRights is that it is very, very good, very helpful.
lowed the passage of the Mental Health Act in 2012. To The aspect I like most is the human rights. […] the day
meet the requirements of the Act, mental health workers we started the training, I felt sad because I realised that
are advised to establish working relationships with trad- we think we are helping the patients, not knowing that we
itional and faith-based healers in their community. To help are causing more harm forcing treatment on these patients
fulfil this mandate, the MHA has developed policies and against their will, especially when they are aggressive.
guidelines and trained mental health workers in building And sometimes, when the patients say something, we
and sustaining relationships with healers and monitoring doubt it.
for potential human rights abuses.
As part of the implementation of this policy, the MHA
now provides patient registers which mental health Community resources
workers are tasked to give to healers to record sociodemo- Aside from this institutional level support, mental health
graphic information about the people who use their ser- workers also drew on resources available in the local com-
vices. In practice, the registers are also useful for helping munity to support their attempts to build collaboration with
the mental health workers keep track of the people who healers. Although the government gave policy support, this
visit healers in their community, particularly as many of was not always backed up with resources, such as transport
these people may have come from elsewhere. By support- and fuel, and so mobilising support from civil society such
ing the healers to use the registers, the mental health as NGOs and local philanthropists was crucial. The activ-
workers were able to follow up and, if necessary, refer ities of national and international NGOs operating in the
people for further care once they left the healers to return field of mental health in Ghana have increased significantly
home, as George describes: over the past decade, specifically in relation to livelihood
support and protecting human rights (Cohen et al., 2012;
So [when] the Mental Health Authority gave us the register, Yaro et al., 2020). As part of this, they have run training
we were happy. I gave the register to [the healers], and [told workshops for healers and mental health workers, including
them], ‘Any patient who will come to the […] prayer camp in the Bono East Region, as well as establishing livelihood
or to the facility, make sure you register the person. [Write] support initiatives such as mushroom farming. They fre-
the one who is responsible [for them], take their contacts’. quently work in partnership with local community mental
So, as soon as the people are discharged… we [try to] trace health workers who engage in training and refer their
them with the information that has been written in the regis- patients to livelihood programmes and are thus aware of
ter and try to call them to follow up. Because most of them the resource challenges. Indeed, NGOs invariably need to
are not [from]here. Most of them are coming from other address these before they can implement their projects. It
parts of Ghana. is therefore not uncommon for NGOs to purchase logistics
Kpobi et al. 11
such as motorcycles or medication, and some nurses are are working beyond what they are required to do. There
active in lobbying for these. are many in the community who treat people with mental
The extent of this patchwork of support was evident illnesses as outcasts, they are not useful to anyone. But
when we visited Eric in his dilapidated office in the local when they see us drawing close to such people, it makes
health clinic. Notes were stacked haphazardly on a bench them realize that they are also worthy.
because he had no cupboard or filing cabinet and, he told
us, the bench and even his desk had been donated. A
number of tubs of Challenges to effective collaborationfluoxetine, an anti-depressant, had been
provided by another NGO, as had his motorbike. Thus, We have identified factors that helped to strengthen colla-
by making mental healthcare possible, albeit limited by borations between healers and health workers in this
the sporadic and short-term nature of NGO projects, these setting but there were also several challenges to initiating
donations directly and indirectly supported mental health and sustaining these relationships.
workers to fulfil their mandate to collaborate with healers.
The mental health workers also actively sought partner-
ships with influential people within their communities. Postcolonial legacies of distrust
These included entrepreneurs and a journalist at the local As mentioned earlier, traditional healing was banned during
commercial radio station who could assist with fundraising the colonial era as it was considered primitive and harmful.
and awareness-raising activities. For instance, mental health By contrast, biomedicine was promoted as progressive, sci-
workers in Nkoranza periodically received donations to entific and more efficacious (J. Roberts, 2021). As a result,
support with buying medication for patients staying at there was much disdain for indigenous healing within elite
healing centres or to pay for fuel costs for visits to educated circles in Ghanaian society, and people who used
healers. AskGod, a prominent local philanthropist in their services were considered unenlightened (J. Roberts,
Nkoranza, loaned his vehicle to the team to visit distant 2021). Such sentiments regarding the two health systems
communities and provided work opportunities in his con- have remained in postcolonial times. Sensationalist
struction business to support the recovery and rehabilitation reports of chaining or beating by traditional healers
of people who had been treated by the mental health team reinforce a view of healers as primitive and barbaric and
(see Figure 5). He described how this helped to challenge many are widely viewed as ‘charlatans’ or ‘quacks’ who
stigma and support social inclusion: are focused solely on making money (Read, 2017). This
suspicion extends to Christian pastors who may fear
Sometimes I use my pick-up [truck] and then we all go. losing their livelihoods and reputation for healing power
When we do that, it helps the community to see that they (Kpobi & Swartz, 2018a). As a result of this negative
Figure 5. Local philanthropist AskGod employs people with mental health problems in his construction business.
12 Transcultural Psychiatry 0(0)
regard, mental health workers reported that many healers And when that motorbike came, [there was] nobody to fuel
were initially suspicious of their intentions for seeking part- [it]. I will have to buy fuel, George will have to buy [medi-
nerships with them. Kingsford, a mental health nurse in cation] and then, we were on the field. And on the days that
Techiman, recalled: I don’t have [money], George will buy fuel and we will go.
The pastors… initially they wanted to refuse us, they did not This quote highlights the absence of logistic support and
want us here. But when we came here, we sat the pastor the community health workers’ use of their own meagre
down and explained that this is the situation on the ground, resources to visit healers and provide treatment. With the
we wanted to work with them, we want us to come together absence of ring-fenced support for mental healthcare in
so that we will do our part and he will do his part. the community, the nurses often have to compete for
limited resources with other public health programmes.
Against this backdrop, the health workers needed to work Occasionally, they joined other better-funded and more
carefully at overcoming the healers’ suspicions in order to highly prioritised public health activities, such as neonatal
gain their trust and build working relationships. As Sister care, to be able to conduct community visits.
Regina explained, some healers feared that health workers
would take their patients, and thus their livelihoods, away: Ethical dilemmas in care
Initially when you go, they think you want to hijack their Alongside these logistical challenges, mental health
patients. So we tell them, ‘We are not here to hijack but workers encountered ethical dilemmas, which impeded
to collaborate with you. If you will permit us, we would the progress of the collaboration.
like to know what you do, then you also know what we
can do. We are not here to challenge your powers’. Use of physical restraints. The use of chains to restrain people
in healing centres in Ghana has been heavily criticised by
What is evident in these responses is that mental health- human rights organisations (HRW, 2020). Although chain-
care operated within a political economy (Kong et al., 2021) ing is banned in Ghana, both in the constitution and more
where healers often felt short-changed by the dominant bio- explicitly in the 2012 Mental Health Act, as described
medical healthcare system. There were concerns that the above we witnessed chains and shackles in use in traditional
presence of biomedical interventions within their healing healing centres and prayer campswhere the nurses were con-
spaces could potentially damage their client base. To over- ducting visits. This was used to control disruptive and
come these fears, as we have described above, the health aggressive behaviour or to prevent people leaving and poten-
workers (who initiated most of these relationships) had to tially getting lost or using drugs. Although mental health
cultivate trust in the healers by proving their desire for part- workers are tasked to ensure that chaining is stopped com-
nership, not dominance. pletely, this has been difficult to accomplish in practice as
they find themselves in a conflicting role when visiting
healers – acting as a form of state-sponsored surveillance
Competition for inadequate resources while also requesting partnership. This reinforces the hier-
Although community mental healthcare is being promoted archical relationships between biomedicine and healing
through legislation and policy in Ghana, as described described above and thus creates distrust, which can threaten
above, there is a general low priority of mental health in hard-won relationships, as Abu describes:
the national health discourse and financing. As a result, to
date there is no provision of ring-fenced funding to The first time we came here, […] we met patients in chains
support community mental health activities and very and shackles … It wasn’t easy. We faced some challenges
limited support at a primary care level. Consequently, the and rejections and other difficulties, but we kept pushing
mental health workers have to grapple with an absence of and then at long last, they came to understand that we
resources to facilitate their work, including inadequate have to work together … They felt we wanted to monitor
infrastructure and logistics, as Eric’s situation described their activities and then report on them.
above illustrates. Furthermore, although mental healthcare
is meant to be freely available at public community-based Asdiscussed earlier, althoughmental healthhasbegun tobe
health facilities, there is usually an inadequate medication provided within primary care clinics, there are very limited
supply. Thus, the community health workers often have facilities to provide acute inpatient care in the region.
to purchase medication and bear transport costs from their Conversely, traditional healing shrines are numerous and can
own pockets, as Sister Regina explained: provide a means of confining people who may be perceived
to be a threat to the community, as described in the case of
We needed a motorbike to go out [but there were] no Sofo Ketewa’s prayer camp. Faced with this reality, some
means. Then MIHOSO [a local NGO] gave us a motorbike. mental health workers described feeling helpless, unable to
Kpobi et al. 13
provide a humane alternative if chains were removed and sceptical of the biomedical system and therefore rarely
highly agitated people from shrines or prayer camps were sought toworkwith them.However, once the initial relation-
brought to their clinic. To overcome this challenge, the nurses ship had been established, the healers contacted the health
negotiatedwith thehealers to allow themtocommencepharma- workers whenever they received new patients who appeared
ceutical treatment while the person remained restrained at the to need psychiatric interventions.
healing centre. Once the person was calmer, they could use
this as an argument for the healer to permit them to unlock
the chains. Abu described the dif culties of this situation Discussionfi
when hemet a person in chains at Sofo Ketewa’s prayer camp: In this article, we have discussed facilitating factors and
barriers in developing collaborative care between mental
I couldn’t stand it but there was nothing I could have done health workers and healers, drawing on a visual ethnog-
at the time. It was a very difficult situation. I couldn’t have raphy of examples in Ghana. The findings of this study
intervened in any way. We normally argue or advise that highlight that successful collaboration between healers
they remove the chains before we give medication. But in and health workers is dependent on several multi-layered
his case, we cannot argue that much. We do it gradually. conditions being consistently provided and reinforced.
As others have identified, collaborations have not been
sustainable because of deep distrust and suspicion
Treatment interactions. Another dilemma faced by mental between practitioners of different healing paradigms
health workers was in relation to the danger of drug interac- (Abdullahi, 2011; Green & Colucci, 2020; Krah et al.,
tions. In several healing centres, including some healing 2018). The mental health workers in this study recognised
churches, plant-based herbal medication is given to this problem. By purposefully emphasising mutual recogni-
patients. These herbal treatments could potentially have tion of and respect for the authority and expertise of trad-
dangerous interactions when taken together with psycho- itional and faith-based healers, they were able to
tropic medication. Although the mental health workers cooperate and work toward mutual goals for the benefit of
request that patients staying with healers only take pharma- people in their care. This was also facilitated by the fact
ceuticals provided by the nurses, this is not always accepted that the mental health workers shared at least some
by the healers. As explained by Kingsford: aspects of their cultural and spiritual beliefs with the
healers. Intrapersonal characteristics were also fundamen-
Sometimes we will prescribe drugs for them to take. But tal, as without the flexibility, commitment and dedication
[the healer] will also instruct them not to take it, or to of the mental health workers and the healers, the partner-
start with [herbal medication] then later continue with ships could not have been initiated or sustained.
ours. So it became […] a bit of confusion. We sat [the Identification with a professional role and its attendant obli-
healer] down and tried to let him know that […] their medi- gations, whether as a healer or a health worker, was also
cation and our medication cannot… we can’t combine both crucial in motivating individuals to establish and maintain
of them for the client [because of] the side effects. successful collaborations.
However, individual motivations and interpersonal rela-
In addition, in the early days of their collaboration, the tionships are seldom sufficient on their own. These findings
nurses noticed that there were instances when the healers reflect the importance of structural support from local and
would buy psychotropic medications themselves to give national level health systems and policies (Gureje et al.,
to their patients. This was usually for people who were dis- 2015). By making room for traditional healing within the
ruptive or aggressive as they desired the rapid sedating formal mental health system, a process of equal regard
effect of psychotropics. In such cases, the nurses lost and mutual capacity can be cultivated. This is a crucial dif-
control over the administration of drugs that can have ference from attempts at collaboration which emphasise
highly dangerous effects, particularly if given in too high task-shifting, where the healers’ roles are typically limited
a dose. The nurses reported that they had to explain the to providing support for psychiatric interventions
dangers to the healers and negotiate to retain their control (Mendenhall et al., 2014; Musyimi et al., 2017). The
in dispensing psychotropic medication. approach adopted by participants in this study allowed the
It is important to highlight that the above barriers were expression of cultural norms and not merely co-opting
related by the mental health workers and not the healers. healers’ cultural authority for the purposes of handing
This is likely because it was the mental health workers who over their patients to psychiatric treatment (Gureje et al.,
were required to seek out healers to initiate partnerships as 2015). Alongside health system support, informal support
part of their work. In this study we found that it was only harnessed from community level actors, such as NGOs
after being approached by the nurses in the first instance and philanthropists, helped overcome chronic resource
that some healers then went on to call them of their own vol- challenges that could prevent collaborations being estab-
ition. As explained above, many of the healers were initially lished and sustained.
14 Transcultural Psychiatry 0(0)
Challenges to collaboration discussed by the participants the data for this visual research project were collected
reflect the low priority of mental health in Ghana. over a relatively short period. Further planned visits to the
Inadequate facilities, few mental health professionals and field site could not be conducted within the funding timeline
shortages of psychotropic medication are factors that have owing to the outbreak of COVID-19. Therefore, it was not
been identified as problematic in the delivery of mental possible to consistently follow participants over time to
healthcare in Ghana and other LMICs for several years determine the success of the partnerships in the longer
(M. Roberts et al., 2014; Saxena et al., 2007). Despite the term, particularly from the perspective of caregivers and
recent advances made in community mental health services patients who often came from outside the communities
in Ghana, there is clearly still a need for dedicated and sus- where the healers were based. Third, because of the time
tained funding and resources to support mental health at the limitations and the reluctance of some participants to be
community level. Although community-based support has filmed, we were not able to speak to many people with
been helpful, this is often piecemeal and short-term. lived experience of mental health conditions to determine
Without dedicated and sustained funding, progress in build- their experiences with and views on collaborative care.
ing collaborations and their long-term viability is threa-
tened. Furthermore, the absence of adequate logistics also
affects those facing an acute mental health crisis, as there Conclusion
are very few alternative inpatient facilities, especially This study is one of few that illustrates how collaborations
outside the major urban centres (Nyame et al., 2021). between mental health workers and healers are working in
Rather than focusing on transforming traditional healing everyday practice, rather than within the restricted context
practices alone, changes are also needed on the part of the of a research intervention. The findings suggest how colla-
formal health system. borations can be successfully established not only in Ghana,
Given these challenges, the real driving force for suc- but also in other contexts. The factors that contributed to the
cessful collaboration was in the interpersonal relationships success of these collaborations included individual and rela-
between healers and health workers and the mutual tional characteristics as well as support from communities
respect for their domains of expertise (Read, 2019). and the health system. However, inadequate resources
Because of shared cultural beliefs, mental health workers resulted in ethical dilemmas that had to be carefully navi-
did not feel threatened by the healers’ worldview but recog- gated. By strengthening the facilitating factors and mitigat-
nised the value of spiritual connectedness as important for ing against identified barriers, these partnerships show
healing. They did not find this to be in conflict with their promise for developing community mental healthcare in
biomedical training, but instead identified a complementary Ghana and other settings into a more holistic system with
role for religious faith and spiritual belief in their approach benefits for enhancing care and protecting human rights.
to collaboration. As Mathauer and Imhoff (2006) suggest,
religious identities foster cognitive and motivational
Acknowledgements
responses, including those based on how values and
norms are expressed in other areas of the individual’s life. We acknowledge the contribution of the participants, the Ghana
We saw this in the acceptance of the place of spiritual inter- Advisory Group and the Steering Committee members of the
Together for Mental Health project.
ventions by the health workers, and in the personal ethos of
care displayed by both healers and mental health workers.
Although our study identified important factors for Declaration of Conflicting Interests
building sustainable collaborations, there were some limita- The authors declared no potential conflicts of interest with respect
tions. The first is that the experiences of successful collab- to the research, authorship, and/or publication of this article.
oration that we observed are not necessarily a reflection of
what collaborative care is like in other contexts, including Funding
in other parts of Ghana. Indeed, there were particular The authors gratefully acknowledge the support of the United
factors that made these collaborations successful, such as Kingdom Research and Innovation Economic and Social
the personalities and motivations of the nurses, which Research Council (UKRI ESRC) and the Global Challenges
may not be present in other attempts. We also recognise Research Fund (GCRF) [grant number ES/S00114X/1] in
that the factors that facilitated success in these communities funding the research. The content of this paper is the sole respon-
may be different elsewhere, and that success is a product of sibility of the authors and does not necessarily represent the offi-
positive engagement from all parties involved. Our aim in cial views of the UKRI ESRC or GCRF.
this project was, however, to show that collaboration is
indeed possible and can be mutually beneficial. The ORCID iDs
second limitation is the fact that, although LK and UR Lily Kpobi https://orcid.org/0000-0002-7074-5804
have longstanding fieldwork experience in this context Ursula M. Read https://orcid.org/0000-0002-9482-7898
and maintain contact with participants in the field sites, Erminia Colucci https://orcid.org/0000-0001-9714-477X
Kpobi et al. 15
Notes Badu, E., O’Brien, A. P., & Mitchell, R. (2018). An integrative
1. See https://movie-ment.org/together4mh/ review of potential enablers and barriers to accessing mental
2. Regina Ayishatu Ali sadly passed away in 2020 before editing health services in Ghana. Health Research Policy & Systems,
of the ethnographic documentary was completed. A short video 16(1), 1–19. https://doi.org/10.1186/s12961-018-0382-1
of the lm footage featuring Sister Regina was made in Baheretibeb, Y., Wondimagegn, D., & Law, S. (2021). Holy waterfi
her memory and can be found at https://movie-ment.org/ and biomedicine: A descriptive study of active collaboration
together4mh/ between religious traditional healers and biomedical psychiatry
3. Healers are believed to be able to see into the spiritual realm in Ethiopia. BJPsych Open, 7(3), E92. https://doi.org/10.1192/
which is invisible to the ordinary person. Sister Regina is refer- bjo.2021.56
ring to the fact that as a health worker she does not possess this Braun, V., & Clarke, V. (2006). Using thematic analysis in psych-
insight but is limited to what is physically visible to the human ology. Qualitative Research in Psychology, 3(2), 77–101.
eye. https://doi.org/10.1191/1478088706qp063oa
4. We recognise the importance of avoiding stigmatising lan- Campbell-Hall, V., Petersen, I., Bhana, A., Mjadu, S., Hosegood,
guage when referring to people with lived experience of V., & Flisher, A. J., & MHaPP Research Programme
mental illness and have consulted with people with lived Consortium. (2010). Collaboration between traditional practi-
experience in Ghana regarding preferred terminology in tioners and primary health care staff in South Africa:
English and Ghanaian languages. In this article we refer to Developing a workable partnership for community mental
people who were believed to be experiencing or to have experi- health services. Transcultural Psychiatry, 47(4), 610–628.
enced mental illness as ‘patients’, in recognition of the fact that https://doi.org/10.1177/1363461510383459
most were receiving treatment at the time from healers or health Cohen, A., Raja, S., Underhill, C., Yaro, B. P., Dokurugu, A. Y., De
workers. ‘Patient’ is also used to translate the Twi term yarefo Silva,M.,&Patel,V. (2012).Sittingwithothers:Mental health self-
[literally ‘sick person’] which is widely used by healers and help groups in northern Ghana. International Journal of Mental
families. Health Systems, 6(1), 1. https://doi.org/10.1186/1752-4458-6-1
5. We acknowledge that we selected nursing teams for our Colucci, E. (2016). Breaking the chains: Ethnographic filmmaking
research that were generally highly motivated and engaged in mental health. The Lancet Psychiatry, 3(6), 509–510. https://
and that the examples we give here cannot be taken as illustra- doi.org/10.1016/S2215-0366(16)30034-7
tive of mental health workers’ practices in Ghana as a whole. De-Graft Aikins, A. (2005). Healer shopping in Africa: New evi-
We are aware that dif cult working conditions, lack of dence from rural-urban qualitative study of Ghanaian diabetesfi
resources and stigma towards mental health workers can also experiences. BMJ, 331(7519), 737. https://doi.org/10.1136/
be demoralising and disincentivising. However, we have wit- bmj.331.7519.737
nessed nurses taking similar proactive approaches in other Draicchio, C. (2020). Extraordinary conditions” and experiments
parts of Ghana such as Tamale and Kintampo and Cecilia with collaboration in “zones of social abandonment”. Mental
Draicchio reports similar ndings from her eldwork in health care between psychiatry and prayer camps in ruralfi fi
Western Ghana (Draicchio, 2020). Ghana. Politique Africaine, 157, 165–182. https://doi.org/10.
3917/polaf.157.0165
Esan, O., Appiah-Poku, J., Othieno, C., Kola, L., Harris, B., Nortje,
G., Makanjuola, V., Oladeji, B., Price, L., Seedat, S., & Gureje,
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Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). lessness and mental health in Ethiopia, Ghana and Kenya.
Resources for mental health: Scarcity, inequity, and ineffi- She is also leading ethnographic and participatory research
ciency. Lancet, 370(9590), 878–889. https://doi.org/10.1016/ into partnerships with traditional and faith healers to
S0140-6736(07)61239-2 improve the care of people living with psychosis in
van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Bangladesh and Nigeria for the NIHR TRANSFORM
Othieno, C., Harris, B., Oladeji, B. D., Esan, O.,
project. She has published on experiences of mental illness
Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O.
(2017). Collaboration between biomedical and complementary and care within community settings, traditional and faith-
and alternative care providers: Barriers and pathways. based healing facilities and mental health services drawing
Qualitative Health Research, 27(14), 2177–2188. https://doi. on extensive ethnographic research in Ghana.
org/10.1177/1049732317729342 Roberta Kekle Selormey, MPhil, is currently a clinical
World Health Organization (2019). WHO global report on trad-
psychologist intern at the Eastern Regional Hospital psych-
itional and complementary medicine 2019.
Yaro, P. B., Asampong, E., Tabong, P. T., Anaba, S. A., Azuure, ology unit, Koforidua Ghana. Her research in mental health
S. S., Dokurugu, A. Y., & Nantogmah, F. A. (2020). focuses on the wellbeing of vulnerable populations, espe-
Stakeholders’ perspectives about the impact of training and cially the abused. She is a volunteer blogger, researcher
sensitization of traditional and spiritual healers on mental and counsellor at Dialogue Genitalia, a social advocacy non-
health and illness: A qualitative evaluation in Ghana. governmental organisation. Additionally, she volunteers at
International Journal of Social Psychiatry, 66, 476–484. the Orange Support Centre, United Nations Populations
https://doi.org/10.1177/0020764020918284 Fund, as a psychosocial care provider. She worked as a
research assistant on the Together for Mental Health
project and is committed to demystifying and destigmatising
Lily Kpobi, PhD is a Research Fellow at the University of mental health in Ghana.
Ghana and adjunct faculty at the Alan J. Flisher Centre for
Erminia Colucci, PhD is Professor in Visual and Cultural
Public Mental Health, South Africa. Her research and pub-
Psychology at Middlesex University London (UK) and a
lications have focused on traditional and faith healing in
Visiting Professor at Gadjah Mada University (Indonesia).
community mental health in Ghana, exploring help-seeking
She is currently leading a British Academy writing work-
pathways for mental health interventions, and more recently
shop award on qualitative and visual mental health research
exploring using creative arts for mental health advocacy
and qualitative workstream lead on a Medical Research
and activism including through partnering with mental
Council study on psychological therapy for Pakistani ado-
health peer researchers. She has worked as co-investigator
lescents with a recent history of self-harm. She is also one
and collaborator on several research grants and was post-
of the founders of the Arts & Humanities Research
doctoral fellow for the Together for Mental Health project.
Council-funded Research Network on creative arts for
Ursula Read, PhD is Senior Research Fellow at the mental health advocacy and activism in Ghana and
University of Warwick. Dr Read is currently Principal Indonesia. Her focus is on suicide prevention, human/
Investigator on a UK Research and Innovation grant to women rights and mental health, faith-based and spiritual/
develop a network to explore the potential of creative arts traditional healing, first-hand stories and arts-based/visual
for mental health advocacy and activism in Ghana and methods. She is the founder of Movie-ment and Co-chair
Indonesia, and co-Investigator on the National Institute for of the World Association of Cultural Psychiatry Special
Health and Care Research (NIHR) HOPE project on home- Intertest Group on Arts, Mental Health and Human Rights.