A clinical psychologist in Ghana

Starting work at the inpatient unit was a baptism of fire. I walked in assuming that I would have an easy day of induction, only to have sessions with seven patients in quick succession. All of the patients were experiencing psychosis, three floridly so. I was propped up behind a fat desk like a physician and rang a bell on the wall when I was ready for the security guard to bring the 'next one' in. However – despite vernacular English or, indeed, translation – familiar problems were aired, stories took shape and I became exhilarated.

Over the last six months, I've worked in inpatient and outpatient settings with the core client groups – children, adults, older adults, and people with learning disabilities. I've counselled marriages; facilitated support groups for substance abuse and staff; solicited funds for, and designed and implemented, a programme of rehabilitation and reintegration for former child soldiers from the Liberian conflicts; run psychology outreach workshops for teachers and church groups; coordinated psychological intervention for people living with HIV/AIDS and their families; and am working towards certification in NTU, an Afrocentric relational psychotherapy.

Most of this variety springs from the youthfulness of the discipline and the huge number of issues to address. Support and guidelines are limited, but work is creative. I am involved at levels not often open to those newly qualified in the UK. The child soldier work, for example, has involved meetings with ministers about the security situation; my involvement with those who are drafting and lobbying for a Psychologists Act has enabled me to think more critically about statutory regulation in the UK.

CPD and ethical guidelines are a challenge, because I would like whatever I do to inform both my Ghana- and UK-based practice. It is a constant challenge reconciling UK-based values, boundaries and professional structures with need in Ghana. Internet-based peer supervision is a real help.

Clinical psychology in Ghana

Although a handful work within it, clinical psychologists are not officially recognised by the Ghanaian healthcare system – the (stalled) Psychologists Act seeks to rectify this. There is an MPhil course at the University of Ghana, Legon, and clinical psychology is primarily an academic concern. Interestingly, some people working in the field are doctors who have retrained to address the psychology shortfall. MPhil graduates are finding work, but in nontraditional settings, such as NGOs, the police force and the military.

Despite this situation, demand for clinical psychology is growing, especially from affluent, outward-looking Ghanaians who are familiar with Western cultural mores. However, many Ghanaians remain uninformed. I have been regarded variously with puzzlement, disapproval or the deference usually reserved for a doctor.

The flipside of the professional freedom is a lack of established protocol and structures, which can be daunting. Services are often presided over by a paterfamilias through whom everything is relayed, and hierarchy is felt keenly. Ghanaian professional culture is bureaucratic and it's often difficult to get things done. There is also a seeming insouciance that tips into the irksome and absurd when engagements start hours after schedule due to 'Ghana time'.

A small group of psychologists and organisations, such as the WHO, are raising public understanding of psychological distress and the importance of addressing it. Much of this work falls under the rubric of stress-diathesis or the 'biopsychosocial' approach. People are becoming aware of the deleterious effects of chronic stress and are sympathetic to those who suffer. However, there is a sharp divide between stress-related illness and sheer 'lunacy'. The term 'lunatic' is reserved for those who evince the more severe forms of psychological disorder. People experiencing, for example, psychosis – more specifically, poor people experiencing psychosis – are perhaps the most marginalised group in society; shunned by their families and, sometimes, psychologists, keen to avoid the stigma. Patients want to be seen by those who deal with the stressed, not the insane. This area is the preserve of psychiatry and the Western medical model.

Many Ghanaians achieve health through indigenous healing methods. Some of these are questionable, but something is felt to be working. Perhaps the common, nonspecific factors that have an important, if undervalued, role in effective psychological therapy are at play here too. There is an opportunity to tease these out and start to frame psychology in Ghanaian terms. Instead of a bearer of outside invention, I feel that I could be a part of Ghanaian psychology becoming more culturally appropriate. 

The extended family is still the most important functional component of Ghanaian society. So much of what we call health- or social care falls within the remit of the family, and clinical work has to be relational and systemic almost by default.

Ethnicity and power

Anyone from the UK wanting to work here should be prepared to be reminded regularly about his or her 'whiteness' – whether he considers himself to be so or not! Many are keen to see the 'white' doctor – such experience can be wearing, but working in a profession which seeks  to help the marginalised,  it has been incredibly valuable to try and get by in the shadow of my otherness.

I find it paradoxical. On an everyday level, Ghanaians seem to hold an esteem that must make them among the happiest and most resilient people on the planet. Yet there seems to be such an inferiority complex in relation to the 'white man'. This stems surely from the systematic dehumanisation of Africans during slavery, which has been internalised.

One disparity I am trying to reconcile is between my training, a lot of which was about reducing the power imbalance in therapy, and the approach here, which couldn't be more top down and paternalistic. I don't work that way, but I've noted some tension, coming more often than not from patients, who have expectations shaped by the culture.

A colleague speculated that psychological consultation flowed from that with elders, herbalists or spiritualists, where a supplicant approaches an expert, looking to be told exactly what to do to cure his or her ills. There are heartening moments, however – some of my substance-abuse patients have responded positively to the fact that my therapy deviates from the 'drugs are bad – take your medicine' approach, and others have found my psychodynamic interpersonal approach refreshing.

At the same time, I've come to accept that perhaps we have more of a responsibility to be expert than we like to admit or at least more forthcoming about what we know and believe.

The future

There is much to be done here in removing the myths about mental health and popularising psychology. We must identify need, and psychology will flourish depending on whether this need can be met. With the recent discovery of oil off the coast, the drive to become a middle income economy by 2015 with a burgeoning, outward-looking middle class, it seems to me that Ghanaian society is becoming more individuated, isolated and prone to existential crisis. These appear to be optimal conditions for the growth of psychology and  .I sometimes feel like we're harbingers of a more unhappy society. I dearly don't want Ghana to lose so much of what makes it special. I wonder whether the profession has the power to point out and pre-empt these trends, rather than being only reactive to them.