Clergy as collaborators in the delivery of mental health care: An exploratory survey from Benin City,Nigeria

Abstract

The paucity of skilled manpower in sub-Saharan Africa limits the delivery of effective interventions for the mentally ill. Individuals with mental disorders and their caregivers frequently consult clergy when mental symptoms cause distress. There is an urgent need for collaboration with nonprofessionals in order to improve mental health care delivery and close the widening treatment gap. Using a cross-sectional descriptive method, we explored clergy’s (Christian and Muslim) aetiological attributions for common mental illness (schizophrenia and depression) from Benin City, Nigeria, as well as their willingness to collaborate with mainstream mental health services. We observed that a majority of clergy surveyed were able to correctly identify mental illnesses depicted in vignettes, embraced a multifactorial model of disease causation, and expressed willingness to collaborate with mental health care workers to deliver care. Clergy with a longer duration of formal education, prior mental health training, and Catholic/Protestant denomination expressed a greater willingness to collaborate. Educational interventions are urgently required to facilitate this partnership.

Keywords

clergy collaboration mental illness Nigeria

Introduction

In sub-Saharan Africa, beliefs about a spiritual aetiology for severe mental illness are common (Ezeobele, Malecha, Landrum, & Symes, 2010; Quinn, 2007). In Nigeria, religion is central to psychosocial and economic interactions. Odejide, Sanda, Olatawura, and Oyeneye (1978) note that educational status does not deter beliefs in supernatural or preternatural causes for mental illness. Individuals with mental illness, as well as their caregivers who hold these beliefs, seek treatment or a “cure” from traditional and religious institutions (Campbell-Hall et al., 2010). Resources for mental health care are scarce, exemplified by a poor ratio of psychiatrists to country population in this region of the world (Jenkins et al., 2010). Psychiatric services in the country are underdeveloped and confined mostly to the urban areas (Gureje & Lasebikan, 2006). Traditional and religious institutions are however easily accessible and receive greater patronage (Makanjuola, Adelekan, & Morakinyo, 2000).

There exists a treatment gap between the proportion of individuals in the community with mental health problems and those who seek appropriate care (Patel et al., 2010). The gap is wider in sub-Saharan Africa (Wang et al., 2007). The World Health Organization’s (WHO) Mental Health Gap Action Program (mhGAP) aims to scale up effective interventions in resource-poor settings and reduce morbidity from common mental, neurological, and substance use disorders. The objectives of this program involve equipping nonmental healthcare professionals at the primary care level with the skill and competency to manage these disorders (Patel, Goel, & Desai, 2009). However, additional interventions are required in low- and middle-income countries to channel individuals with severe mental illness who present to religious institutions to appropriate mental health services.

In North America and Western Europe, collaboration exists between the clergy and specialised mental health services to improve service utilisation (Farrell & Goebert, 2008). In contrast, some mental health workers in sub-Saharan Africa see the clergy as barriers to effective care for the mentally ill (Adeponle, Obembe, Suleiman, & Adeyemi, 2007). In view of their continued patronage, perhaps it is time to harness the potential of the clergy in this environment as “gatekeepers” if the burden from mental illness must be reduced.

This paper reports on an exploratory survey of clergy’s conceptualisation of mental illness, their ability to correctly identify common disorders depicted in vignettes, and their willingness to collaborate with specialist mental health services in delivering appropriate care.

Methods

Study setting

We conducted this study between June and July, 2011, in Benin City, the administrative capital of Edo State in Southern Nigeria. The city has a population of approximately 800,000 persons and is cosmopolitan in nature (National Population Commission, 2006). It is home to the Benins, though several other ethnic groups have settled here over the years. No official data on population distribution by religion are available; however, it is generally assumed that the city is predominantly Christian, followed by traditionalists, then Muslim adherents.

Participants

We recruited a convenience sample of clergy belonging to the Muslim and Christian faiths for this survey. Clergy must have been working in a ministerial capacity for a least 1 year and be resident within the city.

Measures

We used the Clergy Perceptions of Mental Illness Questionnaire (CPMI; Farris, 2005), which we slightly modified to adapt it to the setting of our study. The CPMI is a 45-item questionnaire comprised of vignette statements of individuals with common mental disorders (depression, schizophrenia) and substance use disorder. It also contains a control vignette (a healthy person) and tests the ability of clergy to correctly identify these illnesses, as well as aetiological attributions, and willingness to refer and/or facilitate care. The questionnaire captured item responses using a combination of binary, multiple, Likert scales, and unstructured open-ended statements. We removed racial descriptions for the hypothetical persons in each vignette to make it suitable for our study, as the population in the city is almost exclusively African. We also included a common aetiological attribution for mental illness in this environment: “spiritual attack.” The term “spiritual attack” often refers to a disturbing influence of malevolent evil forces (demons, devils, or evil spirits) or acts of individuals who seek to harm others by placing curses or hexes on an unsuspecting person. A team of psychiatrists, psychologists, and clergy reviewed the adapted version and found it to have good face and content validity. A sample depression vignette statement with representative questions is illustrated below:

Mary is a civil servant. For the past two months, Mary has been feeling really down. She wakes up in the morning with a heavy feeling that stays with her all day long. She isn’t enjoying things the way she normally would. In fact, nothing gives her pleasure. Even when good things happen, they don’t seem to make Mary happy. She pushes on through her days, but it is really hard. The smallest tasks are difficult to accomplish. She finds it hard to concentrate on anything. She feels out of energy and out of steam. And even though Mary feels tired, when night comes she can’t go to sleep. Mary feels pretty worthless, and very discouraged.

In your opinion, what might Mary be experiencing?

Alcohol use disorder [ ] Depression [ ] Schizophrenia [ ] A drug problem [ ] No problem [ ]

How serious would you consider Mary’s problem to be?

Very serious [ ] Somewhat serious [ ] Not very serious [ ] Not at all serious [ ] Undecided [ ]

In your opinion, how likely is it that Mary’s situation might be caused by?

A chemical imbalance in the brain

Very likely [ ] Somewhat likely [ ] Not likely [ ] Not at all likely [ ] Undecided [ ]

Stressful circumstances in her life

Very likely [ ] Somewhat likely [ ] Not likely [ ] Not at all likely [ ] Undecided [ ]

A mental illness

Very likely [ ] Somewhat likely [ ] Not likely [ ] Not at all likely [ ] Undecided [ ]

If Mary approached you for help with this situation, at what level do you feel that you would be able to provide assistance?

I can handle this situation alone (I have adequate training to handle situations of this sort) [ ]

I could provide major assistance in conjunction with properly trained professionals [ ]

I could provide minor assistance in conjunction with properly trained professionals [ ]

I am not trained to handle situations of this sort other than to refer to professionals [ ]

A copy of the modified questionnaire is available on request from the authors. This report does not present findings from the vignette on substance use disorders.

Procedure

There was no comprehensive or valid database of clergy for the city. For Christian clergy, we approached state branches of their umbrella associations (Christian Association of Nigeria and Pentecostal Fellowship of Nigeria) for permission to carry out the study and to access their members. We distributed questionnaires to captive audiences at their monthly meetings. For large denominational groups (Baptists, Catholics, Anglicans, and large Pentecostal churches) we also distributed questionnaires through the heads of these churches. For Muslim clergy, we approached ministers at two of the largest mosques in the city and administered questionnaires. To increase the representation of the Muslim clergy, we employed a snow-ball technique: Muslim clergy who had completed the questionnaires helped identify other clergy within the city to whom we also delivered questionnaires. All members of the clergy were allowed a week to complete the questionnaires and return them to an identified collection point. We sent reminders on two separate occasions 1 week apart to clergy who did not return the questionnaires within the specified time frame to improve participation rates.

Ethical considerations

The Ethics and Research Committee of the Federal Neuro-Psychiatric Hospital, Benin City, Edo State, reviewed the study protocol and gave approval. We assured all participants of full confidentiality and collected no identifying data. Participation was entirely voluntary and we informed clergy who declined of no untoward results if they did so. The questionnaire booklet contained a page detailing the nature and purpose of the study. Each respondent provided written informed consent.

Data analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS) software Version 17. Data were summarised using descriptive statistics and presented in tables. We tested the association between the independent variables of age, gender, years of experience, congregation size, level of education, denomination, attending a Bible or Quranic school, and previous mental health training against the dependent variables of correctly identifying the depression and schizophrenia vignettes, as well as level of confidence to collaborate with mental health professionals. We used the chi-squared test for categorical variables and the student’s t test for continuous variables. For the purpose of analysis, level of education was grouped into ≤12 years (primary, secondary) and >12 years (college, university, postgraduate degree). Level of confidence to collaborate was also grouped into “No” (manage alone, unsure, undecided) and “Yes” (provide major or minor assistance with professionals). Level of significance was set at p < .05.

Results

A total of 200 questionnaires were distributed, with 120 returned (60% participation rate). We discarded 13 incompletely filled questionnaires. The ages of the 107 respondents ranged between 21 and 71 years. The mean age (SD) was 43.3 (9.7) years. A majority were males (n = 95; 88.8%), and had received formal training in a religious institution (seminary, Bible, or Quranic school; n = 91; 85%). Most had obtained at least a college or university degree (78.8%). The average duration (SD) of clergy in ministry was 12.01 (8.06) years. Concerning numbers of members in their congregations, estimates ranged between 10 and 8,000 members, with a mean (SD) of 809.6 (1,472.1) members. About a third (33.6%) reported receiving some form of mental health training during the course of their work.

Identification of vignettes

Over half (64.4%) of the participants were able to correctly identify the schizophrenia-related vignette. In terms of the assessment of the severity of the case described in the first vignette, a majority (91.7%) correctly indicated it was very/somewhat serious. In terms of aetiological attributions for the schizophrenia vignette, clergy endorsed multiple factors (biomedical, psychosocial, and spiritual), as illustrated in Table 1. Over a third expressed willingness to provide major assistance with trained professionals (39.6%), though a small proportion believed they could handle the situation alone (13.9%) or were not adequate to help (12.9%).

Table 1.

Clergy aetiological attributions for mental illness.*

Schizophrenia:	Depression:	No problem:
Aetiological groups	n = 107 (%)†	n = 107 (%)†	n = 107 (%)†
Biomedical
Chemical imbalance	37 (34.6)	43 (40.2)	29 (27.1)
Genetic	47 (43.9)	34 (31.8)	34 (31.8)
Nervous breakdown	47 (43.9)	65 (63.1)	54 (50.5)
Psychosocial
Bad character	25 (23.4)	29 (27.1)	33 (30.8)
Poorly raised	21 (19.6)	20 (18.7)	35 (32.7)
Stress	52 (48.6)	82 (76.6)	61 (57.0)
Spiritual
“Spiritual attack”	63 (58.9)	51 (47.7)	28 (26.2)
Crises of faith	26 (24.3)	35 (32.7)	31 (28.9)

Respondents chose multiple aetiological factors.

†

Percentages are proportions of the total sample who endorsed a particular aetiology per vignette.

The second vignette described a hypothetical case of depression, which a majority of the clergy (85.3%) were able to correctly identify. A similar proportion (87.3%) rightly indicated that the case in the vignette was very/somewhat serious. Most endorsed multiple aetiological factors as responsible for the disorder (see Table 1). Over half of the clergy surveyed expressed willingness to provide major (43.6%) or minor (24.8%) assistance to individuals with depression, in conjunction with trained professionals. A slightly higher proportion (20.8%) compared to the schizophrenia vignette indicated they would be able to handle the case alone (see Table 2).

Table 2.

Clergy level of confidence to handle mental illness.

Variable	Schizophrenia: n = 101 (%)	Depression: n = 101 (%)	No problem: n = 101 (%)
I can handle alone, I have training	14 (13.9)	21 (20.8)	32 (31.7)
I can provide major assistance with trained professionals	40 (39.6)	44 (43.6)	36 (35.6)
I can provide minor assistance with trained professionals	30 (29.7)	25 (24.8)	23 (22.8)
Not adequate to help	13 (12.9)	8 (7.5)	8 (7.5)
Undecided	4 (4.0)	3 (2.8)	2 (2.0)

The third vignette described a young male with minor somatic complaints and occasional worry and irritability. Most of the respondents wrongly indicated that the hypothetical case described a mental disorder (77.2%), with only 18 respondents (22.8%) correctly identifying that the individual had no problem (major mental disorder). Furthermore, most respondents indicated that psychosocial factors were responsible for the individual’s worry and sleep problems (see Table 1). Almost a third (31.7%) expressed confidence in handling the situation in this vignette alone, though a slightly higher proportion (35.6%) indicated requiring major assistance in collaboration with mental health professionals (Table 2).

Less than a quarter of respondents (n = 24; 23.1%) indicated that they worked in a ministry that provided dedicated services for the mentally ill. Over half (60.7%) were aware of facilities in their community for managing mental illness (n = 25; 23.4%), and 14 (13.1%) were unaware of or unsure about such facilities.

A majority (n = 77; 76.2%) were comfortable referring an individual with symptoms indicative of a mental illness to a psychiatric hospital. However, 24 (23.8%) respondents were not comfortable referring. Most (61.8%) were willing to receive training in mental health, compared to those who were undecided (n = 23; 21.5%) or not interested (n = 16; 15.0%).

There were no significant associations between correctly identifying the depression vignette and age (t = 0.70, p = .49), number of years in ministry (t = 0.40, p = .69), congregation size (t = 0.34, p = .72), gender (p = .65), having received mental health training (p = .93), or denomination (p = .99). However, clergy who correctly identified the schizophrenia vignette were significantly more likely to be Catholic/Protestant (p < .05), and have a smaller congregation size (t = −0.96, p < .04). There were no significant associations with level of education (p = .43), gender (p = .38), age (p = .10), number of years in ministry (p = .42), or prior mental health training (p = .08).

Clergy who were willing to collaborate with mental health services in managing depression were significantly more likely to have >12 years of formal education (p < .04) and to have attended Bible or Quranic school (p < .03; see Table 3). Clergy who had more than 12 years of formal education (p < .05), of Catholic/Protestant denomination (p < .03), or who had prior mental health training (p < .05), were also significantly more likely to collaborate with mental health services in managing schizophrenia (see Table 4).

Table 3.

Comparison of willingness to collaborate in managing depression and sociodemographic variables.

Variables	Willingness to collaborate		Statistic
Variables	Yes	No	χ²	p
Gender
Male	64	31	.02	.96
Female	8	4
Level of education
>12 years	56	24	4.07	<.04
≤12 years	7	9
Attended Bible/Quranic school
Yes	65	26	4.74	<.03
No	7	9
Denomination
Orthodox	24	7	2.08	<.35
Pentecostal/ syncretic	37	21
Islam	11	7
Received mental health training
Yes	23	13	.28	.59
No	49	22

Table 4.

Comparison of willingness to collaborate in managing schizophrenia and sociodemographic variables.

Variable	Willing to collaborate		Statistic
Variable	Yes	No	χ²	p
Gender
Male	74	21	2.22	.14
Female	7	5
Level of education
>12 years	55	25	3.64	<.05
≤12 years	7	9
Attended Bible/Quranic school
Yes	61	28	.02	.87
No	12	6
Denomination
Orthodox	25	5	6.97	<.03
Pentecostal/syncretic	34	25
Islam	14	4
Received mental health training
Yes	20	16	4.02	<.05
No	53	18

Discussion

The study has important limitations. The participation rate was low. Although we made several efforts to improve this rate, with frequent reminders and redistribution of questionnaires to members of the clergy who might have misplaced the questionnaires, this resulted in only a small return rate, which limits the inferences we can make from this study. Furthermore, there is the possibility of a sampling bias, whereby clerics who were “propsychiatry” responded and those who were “antipsychiatry” declined to complete the questionnaires. In spite of this, this study is the first of its kind and provides a starting point for further research in this area. Secondly, though the instrument had good face validity, we did not undertake further objective assessments of its validity and reliability, given the adjustments made to the original questionnaire and the fact that it had not been previously used in this environment. Thirdly, participants were aware of the fact that the researchers were from a mainstream mental health service and this might have introduced some response bias. Lastly, the response to vignettes may not reflect participants’ actual practice or behaviour in real-life situations; thus our findings may not fully capture participants’ true attitudes or practices (Hughes & Huby, 2002).

We observed that a large majority of clergy were able to correctly identify schizophrenia and depression as depicted in the vignettes, but not the control question for an individual with no problem. This moderate to high sensitivity and poor specificity might be attributable to the bias created by the knowledge that the researchers were from a local psychiatric facility. This “negative halo effect” might have influenced their responses, such that they believed that all the vignettes were about individuals with a mental disorder. We had earlier hypothesised that detection rates for the schizophrenia vignette would be low because the term “schizophrenia” is poorly understood as a disease concept outside mental health settings and is often still misconstrued to mean a “split personality.” Perhaps the high identification rate we observed was due to the effect of education; we note that a majority of our sample had at least a tertiary level of education. However, the ability to correctly identify the schizophrenia vignette was not significantly associated with level of education in our sample. The higher identification rate for the depression vignette contrasts with that from a representative population-based survey in Switzerland, where rates of recognition for schizophrenia were far higher when compared to those for depression (Lauber, Nordt, Falcato, & Rossler, 2003).

Robertson (2006) argues that, among traditional healers, collaboration with mental health service providers is difficult because their understanding of the aetiological factors for mental disorders is at variance with mainstream or Western medicine. In a syncretic denomination in Lagos, Nigeria, the clergy was reluctant to refer persons with mental illness to psychiatric services (Agara, Makanjuola, & Morakinyo, 2008). Our findings contrast these earlier reports. Perhaps informal, alternative, or complementary forms of mental health services in sub-Saharan Africa should be viewed nonhomogenously. Faith-based organisations are seeing increasing numbers of their ministers come with a high level of formal education. This subset of clergy may have already fused Western biomedical disease models with traditional and spiritual models of disease aetiology. A significant majority of participants in this survey expressed willingness to collaborate with mental health professionals, refuting long-held stereotypes that clerics in Africa are unwilling to collaborate. Leavey (2010) explains that Western-educated clergy exposed to secular biomedical concepts are more likely to embrace a biomedical model of disease based on regular exchanges in scientific and sociopolitical discourse. This was evident in our sample, as clergy in Catholic/Protestant denominations who were very open to collaboration were largely Western-trained. The endorsement of a “bio-psycho-socio-spiritual” model of disease is perhaps one reason why individuals with mental illness or symptoms prefer being seen by their clergy over a professional mental health worker. Recent reports indicate that patients would like their physicians to talk about religion or spirituality as it relates to their illness (D’Souza & George, 2006; Ehman, Ott, Short, Ciampa, & Hansen-Flaschen, 1999).

Overall, clergy in this study expressed willingness to collaborate with professional mental health services in the delivery of psychiatric care to their members. Though a third reported receiving mental health training of some kind, this study did not enquire as to the specific types of training received or its duration. This willingness to collaborate provides a window for the exchange of ideas and presents an opportunity for mental health workers to train nonprofessionals in the detection and referral of the mentally ill in our society. Skilled workers in this environment are few, and the willingness to collaborate would not only improve the numbers of individuals who receive appropriate care, but also reduce the stigma that is a major barrier to receiving adequate care (Adewuya & Makanjuola, 2008).

On the other hand, though a majority of the clergy identified the cases in the vignette as severe, some were still confident in managing the cases alone. This is a cause for some concern and may reflect an underlying resistance or stereotype by the populace concerning the treatment of mental illness in mainstream settings (Makanjuola, 2003). Furthermore, if they believe the conditions described to be wholly of a spiritual aetiology, they are unlikely to see the benefits of collaboration. Yamada, Lee, and Kim (2012) observed that in a sample of Asian clergy, respondents who had received some mental health education were more likely to refer members with mental health symptoms to appropriate services. Consequently, improving collaboration between clergy and mainstream mental health services in our setting might require educational interventions targeted at clergy. Mental health professionals need to prioritise collaborations with clergy because religious institutions continue to play a central role in worship and healing in Nigeria (Agara et al., 2008). Collaboration is even more pressing as the impact of natural disasters and man-made conflicts in several parts of the country is resulting in psychological trauma for victims for which the clergy are needed to play a significant role in the healing process.

Conclusion

In this study in Benin City, Nigeria, clergy surveyed demonstrated a fairly high identification rate for schizophrenia and depression. They endorsed a multifactorial model for the aetiologies of these disorders and were willing to collaborate with mental health workers to deliver mental health services. Educational interventions are required to facilitate collaboration and dispel myths and stereotypes about available mental health resources within the community.

Footnotes

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Biographies

Bawo Onesirosan James, FWACP, FMCPsy, is a consultant psychiatrist at the Federal Neuro-Psychiatric Hospital (FNPH), Benin City, Edo State, Nigeria. He also holds an associate lecturership position in psychiatry at the Igbinedion University, Okada, Edo State, Nigeria. He currently manages the addiction services program at the FNPH and is keen on researching into the beneficial aspects of spirituality in coping for persons with mental illness as well as its utility in addiction treatments.

Joyce Ohiole Omoaregba, FWACP, is a consultant psychiatrist and Associate Lecturer in Psychiatry at the Federal Neuro-Psychiatric Hospital (FNPH), Benin City, Edo State, Nigeria and the Igbinedion University, Okada, Edo State, Nigeria respectively. He runs the emergency and assessment services at the FNPH and has research interests in religion, sexuality, and mental health

Nosa Godwin Igbinomwanhia, MWACP, is a chief resident of the residency program in psychiatry at the Federal Neuro-Psychiatric Hospital, Benin City, Nigeria. He is an ordained clergy and seeks evidence-based approaches to improving collaboration between orthodox mental health care systems and the clergy in Nigeria

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