International Review of Psychiatry, October 2014; 26(5): 579–584

Globalization of psychology: Implications for the development of psychology in Ethiopia

RACHEL SWANCOTT, GOBINDERJIT UPPAL & JON CROSSLEY Clinical Psychology Unit, University of Leicester, Leicester, UK

Abstract The present article reports on the variation of mental health resources across the globe and considers the merits or otherwise of the process of globalization in low- and middle-income countries (LMIC), with a specific emphasis on Ethiopia. Although globalization has gained momentum in recent years, there is a concern that the globalization of Western mental health frameworks is problematic, as these concepts have been developed in a different context and do not accommodate the current diversity in understanding in LMIC countries. The importance of understanding the mental health frameworks of LMIC like Ethiopia, prior to considering if and how aspects of high-income countries (HIC) conceptualizations may be appropriately imported, is therefore reflected upon. Traditional approaches in managing mental health difficulties and possible reasons for the limited engagement with clinical psychology in Ethiopia are considered. Current developments within the fields of mental health and clinical psychology in Ethiopia are discussed, and the need to develop more local research in order to increase understanding and evaluate treatment interventions is recognized. Further consideration and debate by Ethiopian mental health professionals as well as those from HIC are recommended, to promote both reciprocal learning and new local discourses about mental health.

Introduction The variation in the provision of mental health facilities across the world is considerable. It is estimated that more than 90 per cent of global mental health resources are located in high-income countries (HIC) (WHO, 2005), while approximately 80% of the world’s population live in low- and middle-income countries (LMIC) (Saxena et al., 2006). In order to address this inequality, there have been calls for the scaling up of mental health services in LMIC, with the aim of providing effective, affordable and morally justified services (Lancet Global Mental Health Group, 2007). The intuitive appeal of the globalization of mental health systems and services is based on the premise of universal biological causes for mental health difficulties and universal effective treatments, for which there is a considerable and well established critique (e.g. Read et al., 2009; Whitaker, 2002). The desirability of the straightforward globalization of mental health frameworks and services has therefore been questioned (Watters, 2010; White, 2013). Understandings of ‘globalization’ Globalization has been defined as ‘a process in which the traditional boundaries separating individuals and

societies gradually and increasingly recede’ (Bhugra & Mastrogianni, 2004, p.10). This process has gained momentum in recent years as changes in media, travel and technology have allowed aspects from across the world to be more accessible and therefore integrated into people’s lives (Prilleltensky, 2012). Many questions have been raised about globalization generally, and both positive and negative elements have been identified (Bhugra & Mastrogianni, 2004). One of the fundamental questions about the globalization of mental health frameworks relates to variations in the definition of mental health difficulties across the world, and concerns that globalized concepts do not account for the current diversity in understanding. The concept of mental health difficulties can be understood from multiple perspectives, and over time particular discourses become privileged in specific contexts for a multitude of different reasons, such as political influence or clinical effectiveness (Kirmayer, 2006). Consequently, the understanding of mental health difficulties is intrinsically linked to the prevailing context and culture. This cultural perspective subsequently influences accounts regarding appropriate treatment and successful treatment outcome (Watters, 2010; White, 2013). Throughout this fluid, enduring process,

Correspondence: Jon Crossley, Clinical Psychology Unit, University of Leicester, 104 Regent Road, Leicester LE1 7LT, UK.  0116 223 1639. E-mail: jpc18@ le.ac.uk (Received 10 March 2014; accepted 9 April 2014) ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.917610

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mental well-being is consistently being defined and re-defined and is far from a universal, stable concept. A recent article identified seven different conceptual definitions of positive mental health by looking crossculturally (Vaillant, 2012). Without consensus about mental health difficulties and well-being across the globe, HIC conceptualizations that are exported to LMIC will inevitably be partial and parochial. The need to integrate LMIC concepts is apparent, in order to avoid minimizing the value of traditional LMIC understanding. Indeed it has been argued that there is actually a moral obligation to first understand more about mental health in different countries, in order to provide effective treatments (Patel & Prince, 2010). Therefore, it is necessary to proceed with caution in the exportation of mental health concepts and systems from HIC to LMIC, in order to ensure the transportation is valid, sustainable, and brings added value to the countries (White, 2013). To encourage a more detailed debate regarding the merits or otherwise of globalization, it is helpful to focus on specific contexts, in order to examine whether the process increases equality and leads to better standards for all in that setting, or whether it impinges on indigenous ways of working. This paper considers this debate in relation to Ethiopia in East Africa, by reviewing the literature on mental health pertaining to this area, and by considering the recent changes that have been observed in the way mental health is conceptualized and practised. The potential impact of the development of clinical psychology in Ethiopia, as part of the wider process of the globalization of mental health frameworks, is thereby explored.

Clinical psychology in Ethiopia Typically, changes in mental health provision in LMIC have involved input from HIC, and the continent of Africa is no exception. Clinical psychology, as an academic discipline, was introduced into Africa largely by ex-colonists, Caucasian psychologists in South Africa and elsewhere, who were invited to undertake teaching and research at the request of host governments (Abdi, 1975). This was partly in response to a discourse of the neglect of clinical psychology within the continent that was prevalent in some academic circles towards the latter end of the 20th century; ‘little is known about the role and status of Psychology in Africa. Like the rest of the world, Africans need to be recognised and helped’ (Abdi, 1975, p. 227). Initial research enterprises often involved non-African psychologists utilizing their own frame of reference to analyse ‘African problems’; however, this led to

the promotion of Eurocentric thinking, with African scholars neglecting their own values and cultural positions (Nsamenang, 2007). This process was exacerbated by the absence of culturally and linguistically matched psychological and psychiatric terms (Fekadu et al., 2007). As a result, the development of clinical psychology and mental health provision in Africa has been a patchwork and partial venture. Although there is a paucity of literature documenting the introduction of clinical psychology in Ethiopia specifically (Tsegaye, 2011), it is clear that there have been a number of factors that have caused it to be a very gradual, tentative process. One of the foremost inhibiting factors has been the absence of a clear pathway for the practical application of clinical psychology in Ethiopia, due to the dominant influence of traditional understanding. Prior to the advent of Western influences the concept of ‘psychology’ was relatively unknown, and there was no recognition of the need for psychiatrists or psychologists in Ethiopia (Baasher, 1967). With the traditional system aetiology is often attributed to supernatural causes with the onus placed on the person for having done something wrong (Alem et al., 1995; Mogga et al., 2006). Traditional classification of mental health difficulties denotes the severity of the condition and the level of responsibility that the individual holds (Alem et al., 1995). Severe symptoms typically need to be present before a person is considered to have a mental health difficulty (Alem et al., 1999). Symptoms of depression are often perceived as the least important mental health difficulties, whereas symptoms of psychosis are seen as the most severe (Alem et al., 1999). Families are likely to care for those with mental health difficulties and rarely seek additional help (Mogga et al., 2006). If help is sought, traditional healing methods are usually the first option, as this generally links most closely to the family’s understanding of the causes of the difficulties (Alem et al., 1995). Treatments are likely to be provided by a spiritual healer, a magical healer or a herbalist (Alem et al., 1996; Kibour, 2010) and include rituals, herbal remedies, holy water and adorning amulets, as well as exorcism (Alem et al., 1995). If traditional methods are unsuccessful and more acute difficulties develop, families may keep the person with mental health difficulties under restraint due to uncertainty about alternative ways of coping. If there continues to be no improvement, the family may choose to ask the person to leave the family home. Given that they are likely to be experiencing significant difficulties, finding alternative accommodation will often be challenging, thus the likelihood is that the person will become homeless (Alem, 2004). Given this traditional paradigm, the application of

Globalization of psychology: Implications for the development of psychology in Ethiopia applied psychological approaches developed in HIC may have appeared incompatible, and the study of psychology may even have been considered something of an indulgence. Other factors that will have certainly limited engagement with clinical psychology are the ongoing difficulties of hunger, poverty and disease, with Ethiopia being one of the poorest countries in Africa. There is growing evidence that poverty increases the likelihood of mental health difficulties and this affects a person’s ability to contribute to the economy, highlighting the way in which poverty and mental health difficulties are often intrinsically linked in a vicious cycle (WHO, 2008). Despite the potential merit of clinical psychology to illuminate such relationships, the use of psychology is likely to have been considered a ‘luxury’ and the resources to develop the discipline will not have been prioritized while much of the population’s basic needs were not being met. Despite widespread poverty, some researchers have suggested that mental health difficulties are not as common in Ethiopia as in many HIC, which could further account for the limited role of clinical psychology. Kibour (2010), for example, claimed that the rate of mental health difficulties is higher in America than Ethiopia. Prevalence rates of mental health difficulties in Ethiopia have been estimated at around 11–12% of the population (Alem et al., 1995; Giorgis & Sime, 2013); in England it has been found that 17.6% of adults have at least one common mental health difficulty and a similar proportion has symptoms which do not fulfil full diagnostic criteria (McManus et al., 2009). Lower prevalence rates would be consistent with the well-established finding, that mental health difficulties are associated more strongly with relative rather than absolute poverty (Wilkinson & Pickett, 2009). Another influence is the substantial diversity within the estimated population of 82,950,000 (WHO, 2009). Amharic is the official language, although up to 90 languages have been identified (Wagaw, 1999). Over 80 ethnic groups have been recorded (WHO, 2006) and the main cultural influences include both Christianity and Islam, as well as traditional thinking (Alem et al., 1996). The successful application of clinical psychology would therefore have needed to consider how concepts might fit effectively in Ethiopia’s dense and complex cultural background. It is likely that a combination of the factors discussed above have played a role in positioning both clinical psychology and mental health service provision marginally within Ethiopia, traditionally providing populations with little choice but to rely on their indigenous knowledge.

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Current developments Until recently there has been limited debate around mental health issues in Ethiopia initiated by Ethiopian academics and mental health professionals. In 2011 the first International Mental Health Conference was held in Gondar, with professionals invited from around the world as well as those practising in Ethiopia. The Ethiopian Federal Ministry of Health has also recently published the National Mental Health Strategy (Giorgis & Sime, 2013), the first of its kind in the country. The strategy is a detailed document that acknowledges the widely observed relationship between poverty and mental health and outlines the importance of the ‘development of accessible, affordable and acceptable mental healthcare for all Ethiopians’ (p. 1). It recommends that treatments for mental healthcare will need to be provided by a range of mental health professionals and, consistent with the beliefs of many Ethiopians, should also include traditional healers. It focuses on presentations such as ‘depression’ and ‘schizophrenia’, which have been rated within the top ten most burdensome conditions in the country, and considers ways to address them. These recent developments may encourage an exploration of the cultures and timeless traditions of Ethiopia as sources of enrichment when thinking about the appropriate use of clinical psychology within this population. It is likely that the application of clinical psychology is currently based in academic settings in Ethiopia and has not yet been translated into practical knowledge, primarily due to the low numbers of professionals working in mental healthcare. A total of 40 psychiatrists, 14 psychologists (not trained in clinical psychology but with PhDs in psychology), three social workers and an unknown number of 461 qualified psychiatric nurses are working in mental health currently in Ethiopia (Giorgis & Sime, 2013). Changes in the provision of mental health services have already been identified. In the 1940s, Amanuel Hospital in the capital, Addis Ababa, was converted from a general hospital into a mental asylum (Alem, 2004); currently services are being taken to communities, increasing access to those that have not previously received government resources. Eaton et al. (2011) described a model used in Ethiopia whereby mental health nurses prescribed psychiatric and anti-epileptic medication and also provided counselling and teaching about mental health to communities. Thus, it seems that there is an increasing willingness to use a mental health framework to identify and address difficulties. As well as the Ministry of Health aiming to increase knowledge, reduce stigma and advocate that individuals should not be discriminated against due to mental health

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difficulties, families with members with mental health difficulties have formed a group to increase awareness of mental health and identify ways to maintain mental well-being (Giorgis & Sime, 2013). Education and research The scaling up of services has also included educational programmes that have been developed within Ethiopia, which include the recent establishment of an Institute of Psychology in Ethiopia. Furthermore, the inclusion of a master’s degree programme in clinical psychology at the University of Gondar has provided students with the opportunity to develop culturally appropriate models and undertake meaningful research, working towards shaping the mental healthcare delivery system. It is also encouraging to note the development of the Ethiopian Psychologists Association, which was established in 1992. The development of these educational programmes in Ethiopia has shone a spotlight on mental health provision in the country. In July 2012 the PanAfrican Psychology Union was established in Cape Town with representatives from 11 African countries coming together to discuss the development of psychology in Africa. This may indicate progress in the increasing appreciation of how clinical psychology can be applied to Ethiopian populations. This increase in education may also be helpful in addressing one of the well-known difficulties in developing clinical psychology and mental health facilities, namely the loss of resources. Ethiopian students have often been educated outside Ethiopia and have not returned back, due to the greater prospects in other countries (Hanlon et al., 2006). Hence an advantage of providing teaching in Ethiopia is that there is a greater likelihood that students will remain in the country upon qualification, thereby increasing the number of people providing mental health support (Hanlon et al., 2006). Consistent with this notion is the recent finding that the majority of the 27 graduates from the psychiatry training in Addis Ababa University are now working in mental health services in Ethiopia (Giorgis & Sime, 2013). Although some have questioned whether the teaching on the recently established educational programmes takes sufficient account of Ethiopian culture (Begouignan & Lajonie, 1969), to omit information about mental health practices in HIC could also be damaging by disadvantaging Ethiopians within the worldwide community. With a broad awareness of theory and practice from HIC, it will be possible for Ethiopians to integrate this information with local knowledge to further develop services that are relevant to their culture (Hanlon et al., 2006). It would nevertheless seem important that outside organizations give due consideration to encouraging Ethiopians to

address their own issues and epistemologies, rather than accepting imposed ‘solutions’ that do not fit with their own cultural frameworks and knowledge. The recognition that ‘imported disciplinary organisation of psychological knowledge may not be appropriate at all times and everywhere’ should not be discarded (Danziger, 2006, pp. 269–275). Interestingly, during the recent International Mental Health Conference in Gondar, studies reported on the treatment of a range of mental health difficulties including psychosis and depression by drawing upon measures developed in HIC; for example, one study investigated the effect of cognitive behavioural therapy on post-traumatic stress disorder (PTSD) and depression in sexually abused children in Ethiopia (Hailu, 2011). Measures used in this study included those such as Rosenberg’s Self-Esteem Scale and the Children’s Depression Inventory. The validity of these measures with Ethiopian populations was unreported, however. Nevertheless, other research has started to contemplate the importance of sociocultural practices on health beliefs (Hanlon et al., 2010). Furthermore, it is important to consider the research that influences the decisions about appropriate treatments for mental health in Ethiopia, and the barriers to local research being prioritized. There are several obstacles that are immediately apparent. Firstly there is ‘publication bias’, where certain studies are more likely to be published than others, for example studies where the results are statistically significant (Easterbrook et al., 1991). Secondly, there is generally a paucity of research published from LMIC, reportedly as low as 6% (Patel & Sumathipala, 2001; Saxena et al., 2006). This type of evidence base is likely to give rise to an incomplete view of global mental health. Given that research from Euro-American countries, namely Western Europe, North America, Australia and New Zealand, is most widely reported, it is not surprising that classification of mental health from these areas has become increasingly dominant (Kirmayer, 2006; Watters, 2010). As a consequence, reports suggest that there are changes in the understanding of mental health and that certain classifications of mental health (e.g. depression, PTSD and anorexia nervosa) are growing in countries where the American conceptualization of mental health has been introduced (Watters, 2010). It is apparent that research that is driven both by the values of LMIC and by local conceptualizations of mental health is desperately needed (Cohen et al., 2008; White, 2013). It is important that this research is also subsequently regarded as valid and disseminated. The development of more local research to increase understanding and evaluate treatment interventions is a priority of the Ethiopian Mental Health Strategy. Currently what is deemed as good evidence

Globalization of psychology: Implications for the development of psychology in Ethiopia minimizes the value of local knowledge as the standards have been based on Euro-American countries standards which often require resources that are not available to LMIC (Kirmayer, 2006).

ICD-10 An attempt to account for diversity across the globe is the International Classification of Diseases (ICD). This is a document that aims to be used worldwide, accounts for diversity and seeks to actively include a diverse range of professions and people. Although there are some cultural aspects in the ICD-10, these appear only to be linked with those classifications that are non-Western, such as koro, noted to be local variants of anxiety disorder (White, 2013). It is important to note that the proportion of contributors was not representative of the global environment with only two of the 47 psychiatrists who contributed to the ICD-10 coming from Africa (White, 2013).

Joint working Given the recent movement towards greater dialogue and shared approaches within the field of clinical psychology and mental health in Ethiopia, which has helped to raise the profile of these areas, it is important that joint work with different countries is approached fairly and flexibly. Whilst financial resources are necessary, the involvement of other professionals from different countries should not hinder the potential for indigenous and authentic solutions to Ethiopia’s current challenges. Leicestershire Partnership NHS Trust (LPT) has established links with Gondar based on mutual respect, development and support. In conjunction with LPT, community health workers in Gondar have started working in local villages, offering home visits for children. These workers offer a wide range of support including physiotherapy for children with cerebral palsy, reading and sign language for deaf children and their parents, as well as helping those with a learning disability with activities of daily living. Referrals for this community rehabilitation team are obtained via word of mouth, with their continued and successful work raising the profile of mental and physical health whilst attempting to reduce stigma in the community. Similarly, with the help of LPT, a twelve-bedded psychiatric ward has been built and inaugurated in the teaching hospital of the University of Gondar. In addition, the Mother Theresa Missionaries of Charity acts as a substitute mental health ward in Gondar, with as many as 40 clients and one nun per ‘ward’. This would be an ideal location for placements for nursing, medical, and

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psychology students offering real-life application of taught principles closer to home (only Addis Ababa currently has an inpatient unit in Ethiopia). Interestingly, this was an idea suggested by the nursing students themselves, allowing them a setting in which to provide information and psycho-education that could be very valuable to the nuns currently supporting the many that live there.

Conclusions The process of globalization within the fields of mental health and clinical psychology offers potential advantages to countries with limited mental health resources. However, there are also many threats and hidden dangers. It would be naïve not to recognize the vested interests in the wholesale import of Western models of mental health difficulties and treatment to LMIC, not least from pharmaceutical companies, for example. This paper has considered this debate in relation to Ethiopia, where there has recently been the introduction of a number of education and government initiatives focused upon mental health, including a clinical psychology training programme and the National Mental Health Strategy. These enterprises have helped to create a space for dialogue about the way that mental health approaches, developed in the West, may be integrated alongside more traditional methods of care. Given the precedence attached to research findings in the current hierarchy of evidence, which therefore paves the way to definitions and conceptualizations of mental health, it seems crucial that research that draws attention to the local context is both carried out and widely disseminated. This will help to keep the local perspective in the forefront, promote opportunities for integrating traditional approaches with more recent developments, and limit the extent to which decontextualized findings and remote conceptualizations dominate and usher in an unsophisticated process of globalization. The promotion of such education and research requires consideration and debate by Ethiopian mental health professionals as well as those from HIC. However, HIC should not engage in the process merely to provide knowledge to Ethiopian colleagues, but also to be open to reciprocal learning. It is hoped that this will promote critical reflection on HIC mental health, allow greater recognition of the effects of culture on mental health, and create opportunities for new discourses about mental health to emerge. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Globalization of psychology: Implications for the development of psychology in Ethiopia.

The present article reports on the variation of mental health resources across the globe and considers the merits or otherwise of the process of globa...
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