Research on help-seeking for mental illness in Africa: Dominant approaches and possible alternatives

Category 1: Knowledge-belief-practice survey approach

The most prominent approach to studying help-seeking for mental illness in Africa seeks to understand the pathways people will take to seek help and the potential barriers that prevent or delay people from accessing services, through the administration of large-scale, quantitative surveys. The central focus is on exploring people’s beliefs about the causes and symptoms of, and appropriate forms of treatment for, mental illness. As such, the notion of “belief,” and particularly cultural beliefs, emerges as a fundamental category mediating interpretations within this research tradition.

Indeed, the large majority of studies within this approach assert that people in Africa tend to hold “traditional beliefs” in “magic” and the “supernatural,” and as such, understand mental illnesses as “spiritual illnesses.” For example, in their study amongst people attending primary health clinics in Dar-es-Salaam, Ngoma, Prince, and Mann (2003, p. 353) assert: “In Africa, mental disorders . . . are perceived as a source of misfortune; ancestors and witches are believed to have a crucial role in bringing them about.” Similarly, in a study of students’ beliefs about the causes of mental illness in South Africa, Samouilhan and Seabi (2008, p. 75) note:

In African culture, religious and spiritual beliefs inform all other beliefs, behaviours and practices . . . The African worldview subscribes to the idea that mental illness is caused by witchcraft, by a failure to connect spiritually with the ancestors.

These quotations capture dominant sentiments across the majority of studies, with an abundance of statements such as: “the majority of the Ugandan population still harbours cultural beliefs about mental illness” (Ndyanabangi, Basangwa, Lutakome, & Mubiru, 2004, p. 54); “Traditional notions . . . are widespread” (Deribew & Tamirat, 2005, p. 157); and, “The belief system of bewitchment/sorcery is still entrenched in the way of thinking and lifestyle of the African people” (Mkize & Uys, 2004, p. 67). This apparent widespread belief in the supernatural is widely emphasized as the key reason for the pervasive patronage of “traditional” forms of care in Africa. As unequivocally stated by Bekele, Flisher, Alem, and Baheretebeb (2009, p. 481) in their research into the pathways to psychiatric care in Ethiopia:

Seeking care from traditional healers for mental illness is a reflection of the prevailing belief among the Ethiopian population that mental illnesses are caused by supernatural forces . . . As such patients usually resort to modern mental health-care services only after receiving traditional treatments.

These kinds of claims are ubiquitous throughout this type of research, with widespread comments such as: “People in Africa consult traditional healers because of cultural beliefs” (Mirza, Okitapoy, & Jenkins, 2006, p. 143); “Due to cultural beliefs about the causes of mental illness the mentally ill will consult a traditional healer first” (Ndyanabangi et al., 2004, p. 55); and, “The cultural background of an individual determines who and where to go for help” (Mkize & Uys, 2004, p. 67).

A very particular understanding of human action, including care-seeking, is embedded in these assertions, one which assumes that people behave in essentially predictable and rational ways, shaped primarily by a set of beliefs held by the care-seeker. Moreover, these propositions are assumed to be determined almost exclusively by supposed traditional African “culture.” What is striking about these quotations is how the notion of African “culture” is conceptualized as a homogenous entity, comprised of clear and unchanging social boundaries. All Ethiopians, all Nigerians, all Senegalese people, all Africans for that matter, are bound together, with the underpinning assumption that they ultimately share the same kinds of beliefs and practices. Not only are African “cultural beliefs” constructed as internally monolithic, they also tend to be represented as being in direct opposition to Western biomedical knowledge. For example, Burns, Jhazbhay, and Emsley (2011, p. 539) in their study of help-seeking in South Africa assert: “While studies in high-income countries show that both psychotic patients and their relatives attribute their illnesses to biological or natural causes, it appears that their counterparts in low- and middle-income countries (LMICs) invoke spiritual and traditional explanations.”

Similarly, Ngoma et al. (2003, p. 353), mentioned above, claim: “Traditional medicine and biomedicine differ in their concept of the nature and causes of mental illness. In Africa . . . such disorders may be viewed in terms of magical and religious causes, but rarely as diseases within the Western biomedical paradigm.”

Analogous sentiments are expressed by Adewuya and Makanjuola (2009, p. 124) in their research on the treatment for mental illness among Nigerians: “A strong belief in supernatural causation may imply that offering Western medical care would be futile.” In the same vein, Gureje and Lasebikan (2006, p. 48) based on their research in Nigeria conclude: “Belief in the supernatural causation of mental illness . . . is likely to make persons with mental illness unwilling to seek formal services for mental disorders.” Similarly, Samouilhan and Seabi (2008) referred to above proclaim, “A strong belief in traditional ideology could lead to the rejection of formal mental health services,” whilst Coleman, Loppy, and Walraven (2002, p. 381) in their study of epilepsy in rural Gambia conclude, “In most parts of sub-Saharan Africa, notions about epilepsy are rooted not in a medical model but in a spiritual model.”

In this research, a line of demarcation is therefore constructed between Africa and the West, between traditional African healing systems and beliefs and Western biomedical frameworks of knowledge and care. This bifurcation evolves further as it appears to produce a proliferation of negative assumptions about African people and their way of life. Apparent African beliefs and practices are represented as inherently primitive, irrational, and damaging, as opposed to Western biomedical truths which are valorized as essentially sophisticated and modern. For example, Osungbade and Siyanbade (2011, p. 428) conclude in their paper on help-seeking in a rural Nigerian community: “The dominant tendency to use traditional treatment over modern [emphasis added] medicine in many African countries is common and worrisome [emphasis added] as it amounts to denial of prompt and appropriate [emphasis added] treatment.”

In a similar manner, Selassie (2008, p. 1645) in his analysis of the management of epilepsy in sub-Saharan Africa proclaims:

The causal link of epilepsy to natural spirits has neither scientific basis [emphasis added] nor allows rational approach [emphasis added] for intervention. To the contrary, it wastes valuable time and the meagre resources of the patients by interfering with a possible link with biomedical care providers until too late.

These assertions are hardly value-free. Apparent traditional cultural beliefs and practices are given an inevitable appearance of primitiveness and inferiority, in stark contrast to supposedly enlightened, Western scientific truths. Indeed, these value-judgements are most pertinently revealed in the kinds of recommendations put forward by many of the studies, where it is explicitly asserted that interventions need to focus on “correcting” false cultural beliefs and behaviours so they are more in line with a biomedical system of knowledge and practice. It is widely emphasized that there is a need for education and awareness-raising campaigns, “aimed at modernizing general population causative models and attitudes” (Ohaeri & Fido, 2001, p. 498). It is asserted that such programmes must “teach people about the real symptoms, causes and treatment of mental health problems” (Deribew & Tamirat, 2005, p. 153); “sensitize residents to Western knowledge” (Sharkawy, Newton, & Hartley, 2006, p. 211); and “encourage utilization of modern treatment” (Osungbade & Siyanbade, 2011, p. 428). This is seen as essential in order to “change irrational perceptions” (Deribew & Tamirat, 2005, p. 153), or else “those in need are likely to continue using the traditional pathways to care in preference to a new alien service” (Eaton & Agomoh, 2008, p. 557). Not only is there a strong emphasis on educating African communities, there are also widespread calls for the training and education of traditional healers. As Bekele et al. (2009, p. 482) argue:

It is important to train them [traditional healers] about early detection and timely referral of psychiatric patients . . . This will reduce the risk of disability and economic burden to the individual and country, especially by avoiding undue delay [emphasis added] of treatment and expenditure on non-effective treatments [emphasis added].

Or in the most unambiguous words of Mkize and Uys (2004, p. 68):

Health professionals should embark on educating [emphasis added] traditional healers in the concepts of mental illness . . . and the recognition of signs for referral to health professionals, thus shortening the clients’ journey to proper [emphasis added] health.

Pulling these threads together, the knowledge produced by this research tradition is underpinned by a host of interrelated assumptions and meaning-codes about the supposed nature of human action, about culture, and about medical science. These particular assumptions take on a “natural” and self-evident quality with this research, ultimately “black-boxed” within the supposed normalized categories of science, culture, and belief. And yet these categories are far from natural or given, having been the subject of much critique by STS, postcolonial, and anthropological scholarship.

For example, the assumption within this research tradition that human action, including care-seeking, is inherently stable and rational, based upon the beliefs that people hold, has been rigorously disputed. Much critical work has demonstrated how, far from operating in a mechanical, law-like, cause-and-effect manner, human action is profoundly complex and unpredictable, mediated by an array of contextual processes (Law, 2008; Mol, 2008). Indeed, in his analysis of some of the central epistemological presuppositions implicit in what he calls an “empiricist theory of medical language,” Byron Good (1994) highlights how the notion of “belief” has come to function as a key analytical term within medical science discourse. He shows how this concept of “belief,” which is deeply rooted in a rationalist philosophy of science, reduces all of the contingencies and vicissitudes associated with illness and related behaviours to a set of propositions held by individual actors in their minds. According to Good, such reductionism has in turn so often led to misleading accounts of how and why people behave in the ways that they do, and inappropriate forms of medical practice.

The inherent assumption embedded within the knowledge-belief-practice tradition of research that “culture” is a monolithic and distinct entity, comprised of tidy and unchanging social boundaries, has also been widely destabilized. For example, it has been argued that identities, cultures, and structures of knowledge, including those on the African continent, are neither homogenous nor static. Rather, these are complex and disjointed social constructs which are constantly in flux, having assimilated and mutated over centuries (Comaroff & Comaroff, 2012). As critical social anthropologist Lesley Green (2008, p. 148) argues: “To suggest that ‘culture’ has existed without internal differences of opinion, innovation, or contact with new ideas throughout human history is demonstrably false . . . The idea that ‘a knowledge’ can be wholly ‘indigenous’ to ‘a people’ . . . is just not a complete picture.”

The work of sociologist of knowledge Arun Agrawal (1995, 2002) is particularly illuminating in this regard. He demonstrates how the demarcation between Africa and the West, between traditional “African” systems of knowledge and “Western” knowledge frameworks, is unsubstantiated. Providing diverse examples, he shows how over the last several centuries, “African” and “Western” forms of knowledge have experienced much contact, exchange, and transformation, leading to extensive overlap between them. Agrawal (1995) unpacks in great detail three major themes that presumably separate “African” systems of knowledge and “Western” knowledge frameworks: substantive differences, methodological and epistemological differences, and differences related to context. Drawing on a diverse range of theoretical traditions he shows how none of these claims have substantial grounds: “attempts to draw a strict line between Western and African knowledges on the basis of method, epistemology, context-dependence, or content . . . are ultimately untenable” (Agrawal, 2002, p. 293). Ultimately, he shows how in conceiving “culture” as a homogenous and distinct entity, all the multiplicity and dynamism of identities and systems of knowledge and practice are made invisible and erased.

Furthermore, the assumption deeply embedded within this research tradition that supposed “traditional” African cultural beliefs and practices are inherently primitive and irrational, whilst Western biomedical truths are intrinsically rational and superior has been the subject of much critique by various STS and postcolonial researchers (e.g., Comaroff & Comaroff, 2012; Connell, 2007; Latour, 1991). According to such scholars, our identifications of “rational” and “superior” forms of knowledge and practices are never given or self-evident, but rest upon all kinds of values and assumptions around what “the modern” comprises. For example, in his book We Have Never Been Modern (1991, p. 76), Bruno Latour argues that things are never inherently “modern” or “premodern”; only by means of a “harsh disciplining” and the “work of sorting out, cleaning up and dividing up” are certain entities compelled to become modern, and others designated as archaic or irrational. For Latour, then, in constructing the modern we have been caught up in a process of classification and reclassification and, as such, if we change the “classification principle,” we can get a “different temporality on the basis of the same events” (Latour, 1991, p. 75).

Research on help-seeking within this tradition thus appears to be underpinned by a host of questionable and Eurocentric assumptions. These assumptions coalesce around a very particular way of classifying the social world, one which tends to demarcate the world into homogenous entities and binary oppositions: “cultural beliefs” versus “biomedical truths”; “Africa” versus “the West”; “traditional” versus “modern”; “primitive” versus “civilized.” This system of ordering is indeed one of the most powerful and stubborn forms of classification buried in the “black box” of the modernist/colonial inherited archive, including colonial medicine (Connell, 2007; Green, 2012; Said, 1978). As most pertinently demonstrated by Edward Said (1978) in his Orientalism, through the metalanguage of colonialism and modernity, imaginary lines were drawn and homogenous identities were constructed. In legitimizing tropes of otherness and polarizations of difference, these binaries served to unambiguously distinguish Europe from other societies, and validate its supposed “positional superiority” (Said, 1978, p. 7).

Colonial medicine was indeed intimately entangled with this kind of thinking, characterized at least in part by the struggle between supposed “rational” Western science and “primitive” “traditional” therapeutics (Comaroff, 1993; Vaughan, 1991). In its imaginary, “Western” medical science embodied the highest form of rationality and modernity, in contrast to the supposed backward and superstitious nature of “indigenous” cultural beliefs and practices. Put bluntly, medical modernization of African populations entailed attempting to drive out supposed “primitive” traditional therapeutics, and promoting forms of care which were based solely on medico-scientific theories and practices.

Category 2: Indigenous-knowledge-system approach

I term the second dominant body of research which seeks to understand help-seeking for mental illness in Africa, the indigenous-knowledge-system approach. This approach draws heavily on the “new cross-cultural psychiatry” tradition, and in particular Arthur Kleinman’s (1980, 1988) “explanatory model” framework. In the late 1970s and 1980s, Kleinman and colleagues criticized the tendency of epidemiological research worldwide to assume that Western psychiatric models and taxonomies are universally applicable. Heavily influenced by medical anthropology and sociology, these scholars condemned psychiatric research for assuming the inevitable superiority of Western biomedical frameworks and classification systems. Advocating a conceptual distinction between disease and illness, such scholars asserted that “disease” is the malfunctioning of the body, whereas “illness” comprises the lived experience of suffering (Kleinman, 1980, 1988). And this subjective understanding of disease, according to such scholars, is mediated by people’s “explanatory models,” which are “shaped by cultural factors governing perception, labelling, explanation, and valuation” and which play a fundamental role in determining how people understand and respond to disease (Kleinman, Eisenberg, & Good, 1978, p. 252). For these scholars then, different cultures will have unique explanatory models that are distinct from, but equally legitimate to, Western psychiatric nosology.

Drawing on this “explanatory model” framework, and most commonly using qualitative methodologies, the second dominant research tradition focuses on exploring local people’s explanatory models, and how these shape their help-seeking behaviours. In line with the “explanatory model” framework, it is commonly asserted within this body of research that African people have their own explanatory models, and own forms of healing, which are inherently different from Western views. For example, Crawford and Lipsedge (2004, p. 143) conclude from their research amongst Zulu-speaking South Africans: “Models of Western psychiatry tend to locate the source of psychological disturbance within the individual. In stark contrast, the Zulu tradition locates both the source of individual psychological distress and responsibility for its treatment firmly within the community.”

Relatedly, based on their research on the “explanatory models” of mental illness in Ethiopia, Teferra and Shibre (2012, p. 1) assert: “There is a dichotomous belief regarding what causes severe mental disturbance: people living in western countries tend to focus on biological and psychosocial factors; whereas in non-western countries the focus is mainly on supernatural and religious factors.”

In a similar fashion, Okello and Musisi (2006, p. 70) conclude from their research amongst Bagandan Ugandans, “Although the symptoms of depression were seen as constituting an illness, its conceptualization, name, causation and treatment were not deemed to fit into conventional western biomedical psychiatry.” By the same token, Mosotho, Louw, and Calitz (2011, p. 447) and Mbanga et al. (2002, p. 69) emphasize respectively that an important finding from their research in South Africa “is the marked variation in manifestation of the symptoms of the anxiety among Sesotho speakers in comparison with Westerners” and that “Attitudes towards and beliefs about schizophrenia . . . differ substantially from those described in previous work in the West.”

What tends to emerge within this research is that these local explanatory models are not only distinct from, but are also just as valid as those arising in the West, or as Okello and Musisi (2006, p. 61) put it, are of “equal value to western biomedical psychiatry.” Such assertions of equality are most pertinently revealed in the recommendations put forward by many of the studies. Rather than stressing the need to educate people and modify their beliefs, as was characteristic of the previous research tradition, it is widely asserted that the onus lies on service providers, who need to better appreciate local explanatory models. As Johnson, Mayanja, Bangirana, and Kizito (2009, p. 276), drawing from their research on depression in Uganda, argue: “It is neither appropriate nor effective to simply transport Western-based methods of conceptualizing and treating mental illness to African countries … professionals in Uganda and elsewhere should be educated about cultural conceptions.”

Similarly, Mosotho et al. (2011, p. 447) in their study of anxiety among Sesotho-speaking South Africans proclaim: “There should be no room for cultural arrogance, as Africans are neither Americans nor Europeans. African people should be treated within the framework of their culture and belief systems.”

Thus, traditional beliefs are categorized as entities that should be recognized and celebrated, rather than disparaged and modified. Supposed “traditional” healing practices are classified in a similar light. Many scholars within this research tradition praise the work of traditional healers, portraying them as competent care-providers. For example, Mosotho et al. (2011, p. 446), quoted above, assert: “Spiritual and/or traditional healers have played a significant role in combating a range of diseases that have affected African people for centuries . . . they therefore deserve a place next to mental health professionals trained in the western tradition.”

Similarly, Crawford and Lipsedge (2004, p. 143) argue: “Traditional healers are highly respected members of the community and provide great stability… [They] have a deep understanding and knowledge of the Zulu peoples’ historical, religious and cultural beliefs.”

According to the large majority of studies within the indigenous-knowledge-system approach then, there may be ways of understanding and responding to mental illness that are different from biomedical frameworks, but which are not necessarily inferior. Research within this approach thus seems to complicate the content of what falls under “the modern” and “the premodern,” refusing to place “African” cultural beliefs and healing systems in one column and “Western” biomedical knowledge and practices in the other. And yet the knowledge produced within this approach is in fact structurally very similar to the previous tradition. Although the values have changed, the logic has not.

Once again, help-seeking behaviour is understood to be determined first and foremost by people’s cultural beliefs. Like the first research tradition, human action is thus assumed to be essentially predictable and rational, determined primarily by cultural beliefs. And once again, this notion of “cultural belief” tends to be construed in monolithic terms. Essentialist claims are widely made within the studies, with common phrases such as: “the African people” (Mosotho et al., 2011, p. 447); “the Zulu peoples’ cultural beliefs” (Crawford & Lipsedge, 2004, p. 143); “African people should be treated within the framework of their culture and belief systems” (Mosotho et al., 2011, p. 447); or as Okello and Musisi (2006, p. 61) explicitly state, “People from different cultural contexts and traditions define and experience reality in very different ways, including their views about mental disorders.” Thus, as with the previous research tradition, “Africa” tends to be classified as a homogenous entity, with the subjectivities and systems of knowledge prevailing on the continent bound seamlessly together.

Moreover, rigid polarizations and binary oppositions similar to those found in the knowledge-belief-practice survey research approach appear to be strongly retained. Once again, strong lines of demarcation are constructed between supposed Western biomedical models and apparent indigenous African healing and belief systems. There is ubiquitous talk in the studies about “models of Western psychiatry . . . in stark contrast to the Zulu tradition” (Crawford & Lipsedge, 2004, p. 143), or assertions that “Traditional beliefs should be given equal value to western biomedical psychiatry,” and “Western-based methods of conceptualizing and treating mental illness” should not be “transported to African countries” (Johnson et al., 2009, p. 276). Indeed, the primary focus of research within this tradition is to distinguish apparent African traditional understandings and healing systems from those which supposedly reside in the West, in an attempt to legitimize and celebrate the former.

At the same time, the explanatory model approach upon which these studies are based is structured by an inherent distinction between disease and illness. That is, at the core of this approach is the assumption that “real” and objective disease is distinguishable from the “subjective” experience and meaning of illness. This dualism of objective disease and subjective experience of illness has been the subject of much critique by critical STS and anthropological scholars (Craffert, 1997; Good, 1994; Mol, 2008). According to such scholars, this binary, now at the heart of most subspecialities of medicine, is deeply rooted in the shifts that occurred in medical science during the 18th century and the rise of the “medical gaze.” More specifically, with the discovery of autopsy and the rise of modern pathology, it became possible for the physician to identify disease in a way totally independent of the patient’s experience of it. From this point on, disease was increasingly seen as autonomous from patients’ experienced sense of affliction, and the patient’s capacity for self-knowledge and interpretation were isolated from the functioning of the body. As such, disease entities were conceptualized as resident in the physical body, whether grossly evident, as the widely reproducing cells in cancer, or more subtly evident through their effects, as in the disordered thoughts and feelings of schizophrenia or major depression. Put differently, disease was assumed to be biological, universal, and ultimately transcending social and cultural context. Although the experience and understandings of illness may vary by social and ecological context, real disease or pathology does not.

And yet this dualism has frequently been found to be incongruous with what critical STS and anthropological researchers observe in the field (Craffert, 1997; Good, 1994; Mol, 2008). Such research reveals that people do not just represent and make meanings of disease through sociocultural processes. Rather, the very nature of disease, and associated signs, symptoms, and definitions are constituted by the complex socialcultural milieu in which people live. As such, disease and illness are essentially intermingled, at once biological, moral, spiritual, emotional, social, cultural, and political. Ultimately, as revealed by such researchers, abstracting of the world of physical objects and physiological processes from social and meaningful phenomena has frequently led to distorted forms of medical understanding and practice.

In sum, although the second research approach attempts to destabilize many of the Eurocentric assumptions of the first tradition, in retaining the same form of classification, one which is based on essentialized categories and rigid binary oppositions, it ends up reproducing the very epistemological frameworks it seeks to contest. This in turn ultimately limits the possibility of an effective subversion of the modernist/colonial epistemological order and its many questionable assumptions. As Green (2012, p. 4) most pertinently articulates, “In uncritically accepting the conceptual structure of modernity, the capacity to offer different thought is curtailed.” To use her analogy, “transposing the colours on the chess board does not change the frame.”

An alternative approach?

The question then is, can we find other ways of understanding help-seeking for mental distress in Africa based on alternative kinds of systems of classification which are neither Eurocentric nor Afrocentric? Might we be able to change the frame, rather than just the content, of conversations on help-seeking? And could this transform the ways in which we understand how people seek support for mental illness in Africa?

Two particular studies, grounded in more critical and constructive perspectives and employing in-depth ethnographic methodologies, may offer a potentially fruitful terrain for engagement. First, Ursula Read (2012; Read, Adiibokah, & Nyame, 2009) conducted 14 months of ethnographic research amongst people with mental illness and their families living in rural communities in Kintampo, Ghana, which included inter alia an exploration of help-seeking behaviour. She found that people with mental illness drew upon and experimented with a kaleidoscopic range of healing modalities and therapeutic resources in diverse but fundamentally pragmatic ways. In particular, her research revealed that a preference for one form of treatment over another was driven less by beliefs about the nature of illness and its causation, than by a practical attempt to restore well-being and attain positions in which valued forms of subjectivity could be exerted. Importantly, these subjectivities emerged as multiple, frequently based upon potentially conflicting rationalities and deeply entangled with socially meaningful processes.

For example, Read found that many people discontinued antidepressant or psychotropic medications not because they did not know about the potential benefits, but because such treatments frequently led to adverse effects that disrupted their ability to work, created dependencies, and contributed to all kinds of family conflicts. Similarly, the widespread patronage of traditional healers was often less about “cultural beliefs,” than the manner in which the treatment provided by such healers incorporated some fundamental and irreducible aspects of wellness and healing for many people. Ultimately, Read’s research suggested that a focus on “beliefs,” defined in generic terms, tends to obscure the many crucial aspects of wellbeing and recovery that are important to patients and their families and which shape the therapeutic choices they make.

In a similar manner, René Devisch, Dimomfu, Le Roy, and Crossman (2001) explored the dynamics surrounding help-seeking practices, including those related to mental health, of residents living in Kinshasa, Congo. They found that help-seeking was inherently idiosyncratic and fragmentary, consistently shifting between a plurality of therapeutic settings. Service users and their families tended to visit and consistently move between both biomedical treatments and indigenous healing practices. Both of these healing systems were seen to provide partial and transitory solutions, functioning as sources of both constraint and opportunity; comfort and discomfort. Through the choices made, the health-seeker attempted to find solutions that “fit” with his or her identities and moral landscapes. Importantly, such subjectivities and value hierarchies were intimately shaped by local conceptualizations of community and personhood, understandings which were, in turn, deeply embedded in the spiritual, the corporeal, and the social community. Ultimately, Devisch and colleagues argue that without a complex understanding of how relatedness and intersubjectivity shape conceptualizations of “wellness” and “recovery,” it is hard to grasp the logic behind the therapeutic itineraries that people follow.

These two studies employed careful ethnographic methods to build up a detailed familiarity with the social life and practices of those studied. Rather than focusing solely on “cultural beliefs,” these scholars attempted to tap into the tremendously complex political, social, and structural environments in which help-seeking arise. Moreover, rather than assuming a kind of homogeneity and distinctiveness of entities which can be captured through rigid categories, such research was premised on the assumption that identities and actions are fluid and interdependent. People were understood to move between multiple healing modalities, to hold diverse beliefs and values, and to possess an assortment of needs and priorities, none of which could be fully understood or spelled out in rational terms. Understandings and behaviours thus materialized as multiple and circumstantial matters that were difficult to pin down and generalize precisely because they were interdependent and involved sociopolitical questions about multifaceted individuals in complex social milieus. Similarly, all healing practices surfaced as partial and limited, as diverse entities with both gaps and contradictions. No one mode of healing was assumed to be inevitably superior to another, but all healing systems were understood as ultimately incomplete and indeterminate.

As such, this research resisted bounded and totalizing accounts of how people seek support for mental illness. No simple explanations and definitive solutions were provided. Rather, what emerged most strongly through this research was the need for in-depth and provisional understandings of local circumstances and conceptualizations of wellbeing and recovery, for more partial forms of categorizing, and ultimately more nuanced kinds of recommendations. Accounts such as these therefore have crucial implications for the prospects of building understandings of help-seeking for mental illness that are more robust, more localized, and are indeed more connected to local histories and relationships. In changing the ways in which sociocultural influences were categorized, this research begins to shift the grounds on which questions about the nature of help-seeking may be posed and explored. Ultimately, such research holds great potential for articulating help-seeking for mental illness in postcolonial Africa through more appropriate configurations and possibly along new epistemic lines.