Writing the history of postcolonial and transcultural psychiatry in Africa

Universalism and ‘culturalism’

Kilroy-Marac’s is the first English-language history of the Fann psychiatric clinic, established in 1956 in Dakar, which developed an experimental and innovative approach to the intellectual conundrum regarding the role of cultural factors and symbols in psychiatric and psychotherapeutic work. This approach was famously espoused by French military psychiatrist Henri Collomb, who took control of Fann in 1960 and remained the clinic’s director for nearly 20 years. Collomb’s research team aimed to initiate a truly ground-breaking interdisciplinary collaboration between transcultural psychiatrists, medical anthropologists, philosophers, ethnologists, and anthropological psychoanalysts. What set this group of practitioners and researchers apart was their openness to local cultural psychotherapeutic systems, and to exploring local systems of belief and practice regarding psychological pathology: they strove to put modern Western psychiatry in conversation with traditional forms of healing and therapy. Their theoretical framework and methodology were by necessity complex; they were also constantly plagued by intellectual tensions between universalist epistemological systems, such as psychoanalysis, and cultural relativist approaches. Collomb and his close collaborators opened the clinic to traditional healers and built solid and long-lasting professional relationships with many of them; like Thomas A. Lambo’s Aro village in Nigeria, the Fann hospital combined psychiatric and psychoanalytic clinical practices with some important local social traditions and healing rituals, incorporating them and adapting them to the Westernised hospital environment (Heaton, 2013).

This was perhaps one of the best-known and most far-reaching attempts to establish the discipline of transcultural psychiatry in its most idealistic sense: as a literal communication channel between (Western European) clinical psychiatrists and West African traditional healers. Moreover, as Kilroy-Marac demonstrates, in the early decades of Fann, local cultural interpretations and expressions of mental suffering were not seen as reducible to superficial outer layers of some imagined universal pathology; nor were they immediately (and simplistically) translated into the ‘universal’ clinical languages of Western medicine. At the same time, however, Collomb and Fann’s experiment remained riddled with internal tensions over the (in)commensurability of these different approaches and traditions, and Impossible Inheritance can serve as a starting point for a broader discussion on the different political meanings of psychiatric universalism. The Fann school was arguably unique in the postcolonial psychiatric context in that it probed the theory of universality most explicitly and from a decidedly anti-colonial perspective. Still, the work of Fann’s early clinicians and researchers demonstrated and possibly never resolved the theoretical contradictions inherent in this balancing act, as they struggled with difficulties in defining some minimal common ground that would allow for communication and mutual understanding between different cultural systems. Even in Marie-Cecile and Edmond Ortigues’ L’Oedipe Africain – one of the most important, nuanced, and complex contributions of the Fann school – psychoanalysis still ultimately functioned as a universal psychiatric language, of decidedly European origin, which was to interpret other cultures’ symbols, meanings, and relationships (Ortigues and Ortigues, 1984).

Even though Collomb’s insistence on culture was respectful and egalitarian, it was difficult for Fann to overcome the complex links between cultural relativism and the colonial legacies of racist reifications of cultural difference. As Stefania Pandolfo points out in relation to postcolonial Moroccan psychotherapy, ‘The study of culture in general, and of “traditional therapies” in particular, is viewed as carrying the legacy of a psychiatric rhetoric systematically seeking in the culture, and especially in the Islamic religion, the roots of North African psychopathology’ (Pandolfo, 2000). In other words, within the long history of colonial psychiatry, one was hard-pressed to find clinical conceptualisations in which cultural differences were not explicitly linked to notions of hierarchy and worked into theories of the inferiority of colonised societies (Vaughan, 1991). But even in the second half of the 20th century, European mental health professionals regularly struggled to define the psychiatric importance of ‘culture’ in terms that were not at least implicitly hierarchical or evolutionary, and an excessive focus on cultural specificities and ‘traditions’ frequently evolved into reifying and exoticising interpretations. This further complicates our understanding of the historical relationship between colonial interpretive frameworks and the ideology of universalism. Despite the many ways in which universalism – in psychiatry as well as in other fields, such as human rights – perpetuated colonial tropes, at this precise historical moment it could also serve an explicitly anti-colonial political function, to provide medical evidence to support and reaffirm the equality and universal rights of all people, whose differences were to be accorded less significance. Even within Senegal’s emerging psychiatric profession, educated by Collomb and his close associates, questions emerged in the course of the 1970s over whether such an emphasis on cultural specificities and differences could succeed in liberating West African psychiatry from its colonial legacies and hangovers. Without believing in a universal, thoroughly cross-culturally comparable human psyche, could there be a truly postcolonial psychiatry, and did Collomb’s brand of transcultural psychiatry fundamentally depart from colonial norms? (As one of Kilroy-Marac’s Senegalese interviewees argues, in relation to colonialism Collomb’s project was ‘much more a mutation than a revolution’; Kilroy-Marac, 2019: 147.)

Some of these dilemmas are further complicated by more recent developments in cross-cultural psychiatry. In one of her most fascinating chapters, Kilroy-Marac explores the organisation and proceedings of the First Pan-African Conference on Mental Health, which took place in Dakar in 2002. Coordinated by the Fann clinic, the conference aimed to both draw on the symbolic capital of Collomb’s legacy and legitimise the significantly different medical outlook of the new generation of Fann practitioners. Kilroy-Marac masterfully analyses the multiple tensions inherent in this project, and explores the Senegalese psychiatrists’ ‘strategic ambivalence’ towards Fann’s layered history. As the organisers attempted to promote a new identity for the clinic and finally step out of Collomb’s long shadow, their choice of the controversial French psychoanalyst Tobie Nathan as the keynote speaker was particularly contentious. As Kilroy-Marac rightly points out, Nathan’s idiosyncratic brand of ethnopsychiatry appears to have a lot more in common with Collomb’s culturalist approach than with Fann’s recent biomedical universalism, but Nathan’s view of culture as ‘static, monolithic, and timeless’ was indeed much more rigid and reifying. Nathan’s cultural essentialism meant that he completely rejected psychiatric universalism of any kind and in any degree, and it was this rejection that resulted in his insistence on otherness and on the irreducibility of cultural difference. Didier Fassin critiqued Nathan’s ethnopsychiatric clinics, arguing that they exacerbated discrimination of minority and immigrant communities in French society, and led to their further isolation and othering (Fassin, 2011). The question remains whether Nathan’s approach simply took Collomb’s culturalist assumptions and concerns about universalism to their logical conclusion. Psychiatric universalism has rightly been criticised for its Eurocentric tendencies, marginalising local voices and reinforcing existing power hierarchies, but does its complete rejection ultimately lead to cultural essentialism and further divisions (Mills and Fernando, 2014; Summerfield, 2008)?

Moreover, as Kilroy-Marac observes, Collomb’s investment in in-depth cultural explorations and descriptions seemed to go hand in hand with a particular lack of interest in other aspects of environmental influences on mental health, such as political factors or massive sociological transformations, which changed the face of Senegal in the 1950s and 1960s: ‘None of Collomb’s publications…hinted at a political consciousness on his part, nor did they reflect the social transformations taking place as struggles for decolonization erupted across Africa’ (Kilroy-Marac, 2019: 233). Moreover, his depoliticised understanding of ‘culture’ as a concept in psychiatric theory and practice possibly made it even easier for some of his opponents to criticise his innovations, and to argue that the Fann school of transcultural psychiatry did not really reflect on its links to colonial psychiatry, or on Collomb’s own position within the old colonial system. One of Kilroy-Marac’s interludes invites readers to think about an alternative Fann – to imagine how the clinic might have developed without Collomb and under the leadership of Frantz Fanon, who allegedly sent a letter to the first Senegalese president, Leopold Senghor, expressing interest in the position of its director. Fanon was a pronounced critic of Senghor’s brand of Negritude, and Kilroy-Marac asks readers to consider how his involvement in the development of Senegalese psychiatry would have transformed the history of the discipline (and of the definition of Senegalese modernity as a whole). It is indeed intriguing to imagine how the work of the Fann clinic would have advanced if its terms of engagement with the outside world and Senegal’s own history had been less depoliticised, or infused by Fanon’s radical political consciousness. Kilroy-Marac’s brief reflection on Fanon’s unanswered letter to Senghor puts Collomb’s legacy in sharp relief.

‘Africanising’ African psychiatry

Pringle’s book does not place these political-medical tensions between universalism and cultural specificity at its centre – in fact, it spends surprisingly little time on these discussions, concluding that Uganda’s postcolonial ‘psy’ professions adopted universalist principles and therapeutic and diagnostic concepts, thereby integrating themselves in the broader global trends in mid-20th-century transcultural psychiatry. But Pringle’s work focuses on a related and very important issue: the relationship – and cultural and clinical misunderstandings – between patients and psychiatric practitioners in Uganda. Her book engages critically with the frequent pre- and post-independence calls for the ‘Africanisation’ of African psychiatry, and for increasing the number of local Ugandan psychiatrists, who were deemed to have a better innate understanding of the ‘African patient’s’ mental world. But this was hardly an ideal solution: even local psychiatrists were most often educated in Western Europe or the US, and the social, linguistic, and cultural gap that existed between them and their patients was no less significant because they supposedly possessed some mystical and ‘intimate’ cultural understanding of the local population’s thinking and characteristics. The very argument for Africanisation, writes Pringle, hinged on a colonial and essentialist interpretation of cultural and racial differences between Europeans and Africans. Even in the context of Uganda’s fairly straightforward psychiatric universalism, such a reification of the notion of cross-cultural contact was widely used to justify the state’s efforts to train a larger number of Ugandan mental health workers. It was in the discussion around Africanisation that intellectual continuities between colonial and postcolonial psychiatry were perhaps least expected but clearly visible. This exposed yet another seemingly unresolvable tension in postcolonial psychiatric universalism: Ugandan psychiatrists, both local and Western, believed in the universality and cross-cultural comparability of the human psyche, but also reinforced the idea that there existed some powerful barriers between different cultures and races, which could not be overcome. ²

The figure of the African doctor (or psychiatrist) – and his/her position within national and global professional hierarchies – emerges here as a core theme in postcolonial psychiatry in both Senegal and Uganda. Arguably, one of the most difficult challenges facing the new field of transcultural psychiatry was the need to transform hierarchical relationships between European and non-European experts, and to accept psychiatrists from the decolonising world as equals. This was an essential component of the unfinished decolonisation project. In the course of the 1950s and 1960s, a number of non-European and non-Western mental health experts became very influential figures in global psychiatry: psychiatrists such as Thomas Lambo, Tigani El-Mahi, Tsung-yi Lin, and Emmanuel Forster achieved outstanding success and managed to shape the core paradigms and policies, and the institutional infrastructure, of transcultural psychiatry (Wu, 2015). Still, on the global level, the discipline was dominated by Western figures and clinical frameworks, and in the decolonising countries themselves, expatriate psychiatrists often held the most influential positions. In Senegal, Collomb was celebrated as the greatest friend of African culture and psychiatry, but, as mentioned above, he and his close associates rarely reflected on his own position within the colonial and postcolonial hierarchies. Moreover, Kilroy-Marac’s book sheds light on the complex relationship Senegalese psychiatrists had with Collomb’s legacy, and their attempts to adjust his ‘traditional’ model to their more conventional ‘biomedical’ psychiatric framework. In the Senegalese context, it was the local psychiatrists who eventually reinforced the universalist – ‘scientific’ – approach to mental illness, constantly translating local cultural idioms and expressions into the supposedly superior ‘universal language’ of Western psychiatry, and rejecting Collomb’s inclusion of traditional healers in the psychiatric process. In the Ugandan case, local psychiatrists struggled to achieve equality with foreign white psychiatrists, under whose supervision and tutelage they were expected to work. As the Africanisation argument was based on the idea of fundamental cultural differences, its limited effects on dismantling hierarchies within the profession were unsurprising. On the other hand, local Ugandan psychiatrists such as Benjamin Kagwa rarely differed from their Western colleagues in their clinical practice and interpretations, and their understanding of local conditions and idioms of distress could be just as reductive and reifying.

But even outside the lingering colonial hierarchies, Ugandan and Senegalese psychiatrists found that they needed to legitimise their own position and establish their authority in the face of fierce competition from local traditional healers. As both Kilroy-Marac and Pringle demonstrate, when Ugandans and the Senegalese turned to psychiatrists for help, this almost always meant that Western psychiatry was only one of many alternatives they were exploring, and often not their first choice. Patients were frequently following the advice of both traditional healers and psychiatrists, and whenever psychiatric hospitals or clinics were struggling to provide adequate care or achieve desired results, patients would readily return to traditional therapies and beliefs. Collomb’s Fann strove to deal with this by developing innovative collaborations with traditional healers and including them in the clinic’s world. Nothing comparable happened in Uganda, but traditional models of healing provided an important service during the country’s prolonged and devastating political crisis from the 1970s onwards.

Another important theme, which pervades Pringle’s book, is the development of transnational connections between psychiatrists on the African continent. Pringle briefly discusses the multiple initiatives and attempts to bring together a variety of African experiences, practices, and systems of psychiatric knowledge, to define shared features and characteristics of African mental health sciences, and to address common challenges faced by African psychiatrists. Collomb was an important actor in such pan-African efforts, projects, and conferences, and the worlds of the two books fleetingly come together in Pringle’s descriptions of African psychiatric transnationalism. More than anything else, Pringle’s brief engagement with this theme is a reminder that this is a field in urgent need of more systematic research. It is important to explore in greater detail the networks and circulation of knowledge that developed outside the established Western frameworks, rather than focusing primarily on relationships and exchanges between the decolonising world and Western expertise. By looking more closely at pan-African initiatives and psychiatric networks, historians of transcultural psychiatry can prioritise innovative local conceptualisations of and responses to the challenges posed by decolonisation, development, and poverty.

Psychiatry and politics

Kilroy-Marac stresses the political significance that Collomb’s Fann school of transcultural psychiatry had in post-independence Senegal. As she demonstrates, Collomb’s conceptualisation of cultural difference in psychiatry and his prioritisation of African culture in his therapeutic project was fully congruent with Senghor’s vision of a ‘distinctly Senegalese modernity’ based on his distinctive brand of Negritude. In that sense, despite its deliberate lack of interest in the broader political context as a factor in mental illness and healing, Collomb’s Fann was deeply embedded in Senegal’s complex political relations, and Collomb ‘had Senghor’s ear’ (Kilroy-Marac, 2019: 107). Moreover, the president saw the Fann hospital as ‘an exemplary institution of the nascent Senegalese state’.

It is striking, however, that, in Pringle’s interpretation, the overall political influence that Uganda’s postcolonial psychiatry was able to wield was comparatively extremely limited. As Pringle herself states, the theme of the profession’s marginality and marginalisation pervades and binds together all of the book’s chapters, and indeed marks the history of psychiatry in Uganda throughout the 20th century. Marginality remains an important trope in broader histories of psychiatry, of course, and limited material resources and low prestige have long characterised the position of the psychiatric profession in both medical and political contexts. In Uganda’s specific case, the marginalisation was reflected in an at times shocking lack of financial resources and personnel, as well as in the independent state’s reluctance to increase investment in the ‘psy’ disciplines, in terms of either infrastructure or education. This was despite the fact that, in late colonialism and after independence, Uganda served as the centre of medical and psychiatric education in Eastern Africa, and that it trained and hosted some very influential and globally renowned psychiatrists and mental health experts. However, Ugandan psychiatrists were still deeply embedded in their political context, and played important roles in political developments and relationships. As Pringle demonstrates, psychiatrists and psychiatric hospitals were complex and ambiguous actors in local and national politics before and after 1962 – psychiatry was ‘no straightforward tool of “social control” wielded by the colonial government’ and could be subversive of colonial authority, while the political turmoil of the 1970s and 1980s demonstrated that psychiatrists could be deeply involved in political conflicts and divisions (Pringle, 2019: 83). In the 1960s and 1970s in particular, Ugandan psychiatrists sought for themselves the role of social and political advisers, and aimed to engage in broader discussions about development, modernisation, and their effects on the nation’s mental health. In these earlier decades, the WHO also sought their help and advice in shaping international policies for developing countries.

The legacies of African psychiatry

Another common theme in the two books is the fate of African psychiatry following the damage of the structural adjustment programmes and escalating political violence on the continent. In this context, Pringle tells a poignant story of a struggling yet hopeful and ambitious profession that was then severely impaired by Idi Amin’s dictatorship and the long civil war, as well as by the late 20th-century financial restructuring. With their discipline severely underfunded and their lives sometimes under threat, international and many local psychiatrists left Uganda in the 1970s and 1980s. When the country reinserted itself in the networks of international mental health in the 1990s, the innovative legacies of Uganda’s experimentation with and expansion of psychiatric services seemed all but forgotten: ‘It remains a central irony within psychiatry in Uganda that it has needed to seek WHO advice on an approach that Uganda helped pioneer’ – that is, the integration of psychiatry in primary healthcare services (Pringle, 2019: 169). When Uganda became one of the first global sites for war trauma research, these psychiatric initiatives were led mainly by Western organisations and individuals, and largely ignored local psychiatric knowledge and experiences. In Senegal, many of Collomb’s early collaborators felt embattled and ignored by the 1980s and 1990s. The country’s neoliberal economic restructuring and its attendant financial restrictions and dramatic budget cuts drained the Fann clinic of valuable resources and personnel, and both staff and patients were struggling to keep their heads above water. Moreover, as mentioned above, the post-Collomb era saw the reorientation of the Fann psychiatric staff away from culturalist preoccupations; these young Senegalese psychiatrists pushed for the clinic’s full integration in modern Western psychiatry with its biomedically informed universalism. In that sense, the peculiar intellectual and therapeutic tradition of Fann became increasingly marginalised and actively ‘forgotten’ by the new generation of mental health experts in Senegal, who did not consider cultural difference an important factor in devising therapy and treatment.

Given this complex and difficult situation at the end of the 20th century, both books indirectly raise the question of the legacies of early (pre-1980s) transcultural psychiatry from Africa. In the post-independence years and decades, psychiatric professionals from Senegal, Uganda, and many other African (and Asian) countries transformed the face of global psychiatry, and pioneered therapeutic approaches and clinical practices that were particularly well suited to addressing the mental health needs of developing countries. Both Kilroy-Marac and Pringle ask whether there ever was a distinctively African model of psychiatry – and some important characteristics emerge, such as the extensive use and training of lay and support mental health staff, rural outpatient clinics, village settlements, collaboration with traditional healers, and so on. There are also substantial indications in both books of why many of these projects faced severe difficulties or failed. How does the current field of global mental health and global psychiatry remember these foundational figures, initiatives, and traditions? Are these experimental attempts to conceptualise the importance of cultural difference in mental health and overcome cultural barriers between patients and psychiatrists still relevant as the world struggles with mental health crises in the Global South? Now that the world of global psychiatry appears much less pluralist and diversified, how can these postcolonial experiences be utilised for both historians and clinicians?

Pringle’s and Kilroy-Marac’s books cannot be expected to answer these complex questions, but they open a window onto the incredibly rich, if often troubled, world of the Senegalese and Ugandan post-independence psychiatric professions, their earnest efforts to grapple with local and global challenges, and their innovative contributions to international discussions of mental health. These two monographs are models for how to write and conceptualise histories of postcolonial psychiatry, and they will hopefully serve as inspiration for future researchers interested in exploring these and many other important, difficult, and still open questions in this nascent field.