How govt can expand mental health workforce in Nigeria

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Azubike Aliche is the Secretary of the Board of Trustees of the Nigerian American Institute for Mental Health. He is a licensed clinical social worker and psychotherapist. Aliche, who is also the president of the Nigerian Mental Health Practitioners, USA, in this interview, spoke about the launch of the institute, the need to licence social work and psychology, as well as ways to tackle barriers to quality mental healthcare delivery in Nigeria.


What is mental health?

Mental health can be described as the condition that many times originates or has a relationship with the brain or emotions. It is different from physical health. If you break your leg or you have fever, it is considered physical health, but if you have depression or anxiety, or become psychotic, or have schizophrenia that will be considered mental health.

What is your assessment of mental health care services in Nigeria?

Most people will tell you that it is woefully inadequate. And it is built around psychiatrists. I am not challenging that. Many times psychiatrists are leaders in the mental health field. But they can’t do everything.

There is so much to do that you cannot leave it to psychiatrists alone. Some estimates I find say about 10% to 20% of Nigerians are suffering from some form of mental illness.

When it comes to the number of psychiatrists in Nigeria, some estimates say there are about 100 or 150. But no estimates say there are more than 250 psychiatrists right now in the country.

So that reflects a sorry state of affairs. That is why the Nigerian American Institute for Mental Health would like to intervene. We might not be able to do a whole lot but we are trying to raise awareness, particularly with government officials, and legislators, the laws need to change. You can’t just come up one day and say you are a psychologist or a clinical social worker, if there are no enabling laws for licensing. Because everyone needs to be licensed to go through some form of education and be licensed for the safety of the community and the public.

You don’t just ask anybody to go take care of people who are mentally sick. So what we’re trying to do is to raise awareness, and call attention to say, this is not good enough.

Right now, so many people, with some level of mental illness, have a tendency to go to traditional healers or churches to be cured; sleeping there for one year.  But the results are not showing that they can do it well.

 Many times by the time they go for orthodox medicine it is too late.

When they go for orthodox medicines, they usually go to places close to them like general hospitals and community health centres.   That is why we are targeting these health facilities, and even doctors in the private sector, to equip them with skills to at least assess, do observations or be able to refer to people who have the skill. Some people might be able to administer medication if the doctor has already prescribed the medication. So we want to see a change.

The basic infrastructure for mental health care in the country is inadequate. Some people may say, oh, are you trying to use the models in America? But the reality is, we just don’t see anything on the ground. We are not saying transform Nigeria to America in one day in terms of mental health, but the building blocks have to be laid. It doesn’t seem like that’s a sustainable foundation at this time.

The mental health bill was passed into law last year. Is there any other specific mental health related law you think should be amended or changed?

It took over 10 years of advocacy before the Mental Health Act was passed. That is the attitude that we essentially want to change- that reflects the low level of importance attached to mental health care.  One law cannot address everything and the history of implementation of policies in the country is not what to celebrate.

The level of awareness goes beyond what the government can do. Many times governments don’t act on their own. It is the people who put pressure on the governments to get things done. Professional associations should also lobby the National Assembly on things that they think is the way forward, because let’s face it, many of these politicians are not actually equipped to propose legislation that can make a difference.

That is why we are trying to work with people at the grassroots to train different cadres of people to know that there are obstacles, and even about understanding what mental health is and how it can be addressed. We are also trying to look for partners in order to get the message across that this needs to change.

Can you briefly tell us about the Nigerian American Institute for Mental Health?

The best way to understand it is to first of all understand the association called the Nigerian Mental Health Practitioners USA. It is a group of Nigerians who practice mental health care in the United States of America.

So our goal as a group is to help with developing mental health care in Nigeria, because of the poor state of mental health care in Nigeria. Because we are far away, we consider it difficult to help with mental health care here unless we have people on the ground, doing it on our behalf, or with us.

So that’s how we decided to register an organisation here, called the Nigerian American Institute for Mental Health. It is meant to be the vehicle that we use from the US to help the practice of mental health care in Nigeria. So it is a nongovernmental organisation established in 2022.

How does the institute intend to build the capacity of mental health practitioners in Nigeria?

That is why we included the word institute in the name of the organisation because we think that we can help with training people who can practice mental health care other than psychiatrists. So the capacity building is building the manpower base that is lacking in Nigeria.

I am a licensed clinical social worker. There are not many of them here. But we need equivalents of that. We are not psychiatrists but in the United States, licensed clinical social workers are the largest number of mental health care providers, more than psychiatrists, and psychologists.

At the level I am licensed, I can evaluate, diagnose and treat mental healthcare, and people who have mental illness. The only thing I cannot do is to prescribe medicine. That is meant for doctors, and advanced practitioners. Those are people who can prescribe, even in many states in the US, psychologists do not prescribe medicine.

So we all work together to make sure that people who have mental illness have care. To build capacity here, we are looking at non psychiatrists who can intervene, work with people to help restore their mental health.

We are going to make a formal launch and presentation of the institute on April 13 in Enugu State. So, the primary partners we have on the ground for the launch is an organisation called Umuada Igbo Nigeria and diaspora, but over there, we have a group of nurses in South Carolina and North Carolina who are partnering with us.

We are gradually building more networks and connections and also becoming part of the mental health providers in this country.

How will the diaspora be involved?

It will be involved but indirectly. The institute is a Nigerian organisation, the diaspora or the American part of it, is the Nigeria Mental Health Practitioners USA, which is the parent body and sponsor. So, since we are the sponsors, whatever they are doing, we are interested in it, we are supporting and can finance it.

With recent advances in technologies in education, we can provide training from there. We can set up structures and provide telehealth training for Nigeria America Institute for Mental Health. We can also send people here to conduct training.

We are just trying to join people on the ground to contribute where we can.  We have a vision where people who have mental health conditions, can walk into a primary health facility, or the nearest hospital around, and get some kind of screening, and then be referred to an appropriate place.

That is not readily available now for someone suffering from depression, or any of the major mental health problems for instance, so we want to close that gap.

So it is all about access. Access to mental health care is very much lacking compared with access to physical health. So we want to narrow that and one way to narrow that is to use the people who are already on the ground, providing physical health care to do some level of screening and probably treatment, or at least refer to the right people. Whether those people are psychiatrists or not.

What is your take on stigma for mental health in the country?

We are also working towards reducing stigma and some other issues that make it difficult for people to either understand or take advantage of services.

In some cases, there are services available, but people don’t believe in it or don’t think it will work. Or people have been discriminated against, locked in a room, their freedom denied just because they show some signs of mental illness. Attitude needs to change.  Many cultures discriminate against people suffering from mental health disorders. All of these need to change.

People need to be aware that there’s really nothing evil or evil spirits about mental health issues. It is a change in how the brain functions. In many cases, it is a change in the chemicals in the brain and those can be balanced, you know, with some medication or even meditation and other things people could do to restore that balance.

We need support to carry out these activities. The America in the name of the institute does not mean the American government is involved. Right now, it is not involved. It is just that regular American citizens like us, who are also Nigerian citizens, are looking at the state of mental health care in Nigeria, and we’re saying, hey, we can do something because we’ve been lucky to get some training. This is really such a gigantic work that no one person or organisation should be left alone to do it.

I must say that there has been some progress. The Nigerian government also made some progress like the passage of the mental health bill. When I left the country 25 years ago, hardly any university in this country was doing a degree in either psychology or social work. At the time I graduated in 1986, social work was only a course in sociology but today many universities are offering it even up to PhD level. But we need more universities to introduce more courses in psychology, social work and counselling so they relieve psychiatrists of the burden of having to see everyone who has mental health and so what the government needs to do now is to create opportunities for psychologists to be licensed, do more, maybe through National Universities Commission to encourage more universities to offer these courses.

I also know that many professionals, units in some hospitals have been closed because psychiatrists have left. So the government should create opportunities for people who started psychology or social work to be licensed- to get additional professional training and be licensed. So those are the kinds of things needed to expand the capacity of the mental health workforce in Nigeria.


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