Perspective Chapter: Theoretical Paradigm for Mental Health and Family Therapy within the South African Context – An Overview

Abstract

This chapter places focus on family therapy within the African and more specifically South African context. It attempts to sketch a context on a continental level, highlighting and describing the theoretical paradigm through which contextually appropriate theory and literature is being developed. A brief overview is given of mental health within the content. A more specific South African context is then described. Whilst also engaging with limitations and obstacles, also highlighting developments within the context.

1. Introduction

This Chapter will focus on my personal clinical experience, exposure and training in family therapy, within the South African context. This having been in both the private and state sector, from a primary to tertiary level of healthcare. However, with this contextual limitation kept in mind, considering that Africa is a continent, made up of 54 countries, and that diversity will exist on geographical, political, economic levels of resource and perhaps most importantly culturally. It is within these limitations I will attempt to sketch the current landscape of family therapy within the continent.

Whilst having highlighted the disparities which exist, there are also similarities, embraced in the concept of Pan African Humanness. This concept argues that there exists a greater level of commonality amongst the people of Africa, as opposed to the differences [1]. It is through the use of this concept that a theoretical framework has come to be, in which cultural and intellectual developments have taken place [1, 2]. As a result, we have seen the developed and subsequent rise of an African-centred paradigm, which has allowed for Africans to not only have been given a voice, but allowed for that voice to be heard, with regards to life experiences, ancestry, history and tradition [1, 2].

In response to this, the chapter will initially expand upon the African paradigm, setting the context with regards to culture and worldview of Africa. An attempt will then be made to sketch the landscape of mental health within this context. Finally, there will be a specific focus on systemic family therapy within this context, examining the challenges and developments within the field.

2. African epistemology

Western Cultures hold the underlying assumption that humans are innately flawed, with challenges of self-control, manifesting itself in phenomena such as “original sin”, which will guide us in the direction of these impulses [3]. However, within African beliefs people are born innately good, and that through interpersonal relationships, they are able to develop their humanness, in a constructive and positive manner [4]. In this regard, being a good member of your community is of greater value as opposed to the accumulation of goods or wealth [5]. The inverse is possible, should actions be viewed as not in keeping with the interests of community, and rather self-serving in nature, they can be viewed as the cause of pain and or misery for others [6]. For this reason, it is argued that African morality is relational [4].

Whilst there is an obvious pluralism and diversity within cultural experience and history, across the continent, it is argued that there is a metaphysical unity and central worldview which exists amongst all Africans [7]. This is highlighted in the stance that nothing is absolute and that the relationship between the natural and supernatural order is governed by the principal of complementary opposites [7].

The Afrocentric paradigm refers to the ideology and the epistemology through which contemporary African-centred practice is rooted, so as for the worldview of Africans, as well as the philosophical assumptions, which are underpinning this, to be acknowledged and given voice [8]. Grounded within African epistemological reflections would be the mindset of commonality and centredness, which builds the frame of the process of knowing within this context [1].

The African context places focus on a collectivistic orientation as opposed to individualistic one [5]. This is thought to be a corner of African thought and life. From this perspective it assumes that everyone belongs and that there is no-one who does not belong [9]. Here the individual is not of lesser importance than the group [5]. As such it can be argued that neither is placed in a hierarchal order. Thus, a person remains a person regardless of their status in life and that their value as a human being is seen to be just as important as another person [9]. The manner in which an individual obtains their own good, is through the good of the group [5].

One such concept to have emerged from this paradigm is the concept of “botho /ubuntu”. This concept of “botho /ubuntu”, is South African of origin, and has attracted significant attention within several fields. It has usually been described in terms of values, respect, compassion, humility, which are believed to have been rooted within culture, which are collectivist in nature [10]. This concept is considered to have been made up of four key elements, these being African spirituality, personhood, interconnectedness and communalism [10]. These values are thought to be innate to all human beings [5].

African reality has been described as having been made up by three hierarchical, interrelated and not oppositional worlds. These are the microcosmos, which is made up of the immediate perceptible world; the mesocosms which has been made up of the intermediate world of spirits, which are beneficial or malevolent in nature; the third realm is that of the Devine or macrocosmos which is made up of ancestors and spirit beings [1]. Thus, it is believed that within the African structure there is a constant interactional relationship between those who dwell within, these realms and the realms of reality themselves [1].

How do these realms interact and engage? Ancestors operate as a conduit, between the living and God, allowing for communication to take place [10]. Traditional healers are believed to possess the abilities to engage with the spiritual world, able to communicate with the ancestors. As a result, they are often highly regarded members of their respective communities [10]. Within the African context, when a person experiences troubles and or challenges within their life, spiritual healers are often the first port or call. The purpose of which is to establish the nodal cause of the challenge, which is done through their spiritual powers [10].

It is believed that spiritual relationship between the living and ancestors, is not only vertical but also horizontal [11]. What this means is that the quality relationships amongst people as well as their relationship with God and the ancestors will impact upon their personhood.

Mental illness within the Afrocentric paradigm, is rooted within the African cultural and worldview that there are interconnected worlds which influence one another. In this regard it can emanate from any of the realms previously described. For this reason, those who are able to communicate with spiritual forces are often employed, so as to determine the root cause and the intention with which those have become ill [8].

3. Psychopathology from this paradigm

Taking into mind the cultural formulation which has been outlined. One can understand the cultural barriers which exist and limit, if not dissuade individuals from seeking treatment for mental health conditions, from mental health care practitioners, trained in Western-based medicine. For this reason, this stigma or fear needs to be understood [12]. This as it could also be considered a cause for the defaulting of treatment [12]. An example of this, was highlighted in a study conducted in Nigeria, where it was frequently believed that mental illness was a result of moral failing or wickedness [12].

It can and has been argued that the manner in which psychopathology is constructed and understood, and as a result approached in a vastly different manner within Afrocentric and Eurocentric paradigms [8]. For this reason, greater value is often placed in consultation with alternative healthcare providers, such as faith healer and indigenous healers, as opposed to consultation with medical health professionals [13]. Consultations occurring across varying health systems, can be complex, due to the epistemological foundations are quite different which can make collaborative engagements quite challenging [13]. However, this should be effectively managed that it can yield very positive and beneficial outcomes.

In order to achieve this level of collaboration, it would be considered to be of value to understand psychopathology through an African lens. From an African perspective, psychopathology is viewed as an aspect of social drama, which can be experienced as two kinds of dramatic experience, social drama and stage dramas [14]. Social drama can be understood as a breach, from which a crisis develops and requires a remedial process or redress intervention [14]. Whilst stage dramas are socially based, with the aim being to depict approaches which can be engaged with to overcome real social dramas of existence, which can then be effectively overcome [14]. Thus, psychopathology can be seen as a breach in the normal routine of a person’s existence, which their inner and outer equilibrium, move towards illness and distress, as opposed to that of harmony and peace [8]. It is believed that ancestors have the ability to grant rewards to the living, whilst also in cases can insight bad luck or illness if unappeased [10].

It is important to hold this formulation in mind. When western psychiatric perspectives have been administered, and have not resulted in a curative response, in which there has been a complete resolution of illness and or symptomatology. The challenge can be that there is an assumption from an Afrocentric paradigm that a hidden message is carried by the illness, which is required to be understood, before a curative intervention can be implemented [8]. It is important to then shift focus to who is speaking through the illness and then the next aspect would be what is expected to be done, so as for a resolution to take place [8]. As such psychological illnesses can be approached as meta-communications, which are rather to be interpreted or “read” as opposed to classified and categorised, as is the case in the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM5) [8]. For this reason, if the two views are held as mutually exclusive, it may result in greater levels of non-adherence to western medical interventions. Allowing for the two to coexist, allowing for greater levels of autonomy and a more active engagement in the treatment process [15].

The value and positive impact of social relationships, on both physical and mental health have been well documented in the context of the global north [16, 17]. Within the African context, this has the added benefit of social capital [18]. Whilst also having cultural significance, specifically within collectivist cultures, which are rooted in the interconnected nature of people [18]. For this reason, it is argued that in order to understand the African episteme, all of these realms must be considered [1].

4. Mental health within the African context

It is believed that mental health is an essential aspect of human health, however if we are to achieve humane and effective treatment of mental health conditions there needs to be an increase in the social, financial and human resources allocated to it [19].

Currently it is estimated that mental health disorders account for 37% of healthy life years lost through disease [12]. Global data suggests that in low to middle income countries that there are insufficient resources, along with an inequity of distribution of these resources [19]. For example, there is only one neuro-psychiatric hospital within the Niger Delta of Nigeria, which services a population of over four million [12]. As such it is estimated that less than 20% of persons with mental illness are able to receive treatment within Nigeria [12].

The current stance is that a balance between hospital-based and community-based services would be the most effective means of provision of mental healthcare [19]. Though this only appears to be the reality within a few of the high-income countries on the continent, with the provision of mental health services outside of the hospital setting only being available in about half of African countries [19]. Patterns of consultation are thought to vary depending on cultural groups and the types of services available or accessible [13].

It is important to note that political instability and general unrest have negatively impacted upon access to as well as the availability of mental healthcare services. The result, a fairly obvious one, is that in areas of conflict, more especially those in which are regularly occurring or frequent, there is a notable absence of mental healthcare professionals [20]. Even though these services are most likely to be more crucially required, as a result of the political and historical context.

Currently we are faced with a lack of awareness, regarding the magnitude of the challenge of mental health, compounding this is a lack of reliable information, with regard to the prevalence of disorders within the communities [21]. Whilst we are seeing ever increasing numbers of Africans seeking out formal mental health services [22].

5. South African context

South Africa remains one of the world’s most unequal countries, with areas in which people living still remaining racially divided, even after 25 years of democracy [23]. The result of this division is that there are two economies which coexist in South Africa, the first being one which is not all together dissimilar from that of the global north and then that which is rife with poverty and limitations of access [24]. It would make sense then that the vast majority of South Africans who belong to this second economy would depend on state healthcare. Not dissimilar to many post-colonial societies South Africa has ageing infrastructure within many of its state owned and subsidised sectors. Some of the challenges faced by this sector are not dissimilar to those seen in other parts of the continent such as inconsistent planning for healthcare infrastructure and inadequate allocation of funds [25].

6. Provision of mental health within the South African context

On the continent health is generally poorly funded, and in comparison, to other areas of health, mental health is often more poorly developed [21]. Within Sub-Saharan Africa, mental health services are generally limited to hospital-based services, within the major urban areas. However, within these settings human resources are often limited, with a large population depending on access to these services [20].

It is currently estimated that within the South African context approximately 5% of the health budget is spent specifically on mental health [26]. The vast majority of this budget is spent on curative interventions as opposed to preventative interventions [27]. As such managing healthcare in a reactive as opposed to proactive approach. When these figures were examined on a provincial level, it was found that only a few of the better functioning provinces were keeping within the National allocation of funds for mental health, with some provinces allocating far below this percentage.

There have been several arguments which have been made that some of these provincial departments of health have been struggling to maintain their basic services let alone their infrastructure [28, 29, 30]. In some instances, to support these views, it has been highlighted that staff have been failed, in terms of not having received the basic equipment required so as to do their jobs and to conduct their work safely. An example highlighted by [31] was that in Port Elizabeth, one of the largest cities in the Eastern Cape, there is only one state ambulance currently in operation. As highlighted challenges exist with the provision of basic services, which are essential to save lives. As a result, it could be assumed that more specialised and less acute healthcare services could prove to be more difficult.

Again, this is the life experience of the second economy, which is wildly different from that of the former economy. In which we see better patient to staff ratios, newer and well-maintained infrastructure and staff being more appropriately equipped, with required equipment and safety equipment. For this reason, it is important to understand the manner in which people make sense of and experience their worlds.

7. Family therapy within the South African context

In South Africa to become a Psychologist, one has to complete an undergraduate degree, an Honours Program and a Master’s degree, after which it is required for you to complete a year internship, board exams and potentially a community service year, depending upon which stream you enter [32]. South Africa currently has five categories in which one can register as a psychologist with the Health Professions Council of South Africa (HPCSA).

Given the duration of time and the associated direct and indirect costs of training, it can already be assumed that the those coming from more resourced backgrounds would be more likely to become psychologists, within the field. Whilst in contrast, the majority of those whom they will attempt to provide services to, even if only in their community service and internships, will be from the aforementioned second economy, which is far less resourced. This experience has been expressed by some authors, that the life of privilege which they have lived had left them feeling isolated from and experienced difficulty in connecting to disadvantaged communities [33].

It has been argued that the development of psychological services for non-white populations was severely stunted by some real and some imagined obstacles [34]. Like the vast majority of psychotherapeutic modalities, family therapy was developed within the Western World and was subsequently imported to the African context [35]. One of the dangers argued in so doing, is the inappropriate application of this model. This potential for inappropriate application is based on imposition of universalism [36]. This universality is grounded in the belief that only one humanity is in existence, and thus there is only one psychology, one philosophy and as such only one way of being [34]. For Morkel [33], she felt that her training had also failed in preparing her to bridge that gap, between her formalised Western training and the needs of the community which she would service.

Whilst the inability to speak client’s first languages and to have an intimate first-hand knowledge of their customs and beliefs would be challenging, it can be argued that these would not stop the therapist from being able to provide a level of assistance and or intervention in the here and now [34]. To counter act this, it was suggested that therapist attempt to bring “pscyhotheraputic contexts” to the clients, by attempting to see the world through their lens as opposed to that of a Western one [37]. There has been an argument that South Africa, as a result of its diversity requires a deviation from traditional systemic interventions.

Perhaps this is the most important and valuable stance to have. So as to avoid falling into traps of our own preconceived biases, regarding race and culture, which undoubtedly were influenced by our current and historical context, which we live in currently and grew up in. This is because in apartheid South Africa we were taught to believe that culture is pure, static and unwavering [34]. The result of which was to reproduce and reinforce ethnicity and perpetuate a false ideology of cultural determinism [38]. This as the cultural boundaries which were more clearly defined along racial lines are less clearly defined, in this multicultural society [39, 40].

Considering the mental health and family health needs of the continent, it is believed that family therapy and by extension of this family therapists would be well-suited to intervene, treat and assist [35]. However, as already highlighted there are some real and perceived impediments to the application thereof.

The provision of psychological services and specifically that of family therapy, is limited within the African context [41]. This underdevelopment of these services, are thought to often be similar to other aspects of underdevelopment found in these African countries [22]. However, with the limited number of trained professionals available, this number decreases when we examine the number of therapists who are adequately trained to adapt these skills to the contextual needs of the populations which we service [42]. Whilst we are seeing ever increasing numbers of Africans seeking out formal mental health services, these challenges will need to be addressed in order for these needs to be met [22].

At present there is no registration category of Family Therapist [35]. For this reason, the vast majority of professional practicing family therapy will be psychologists and social workers, who have all undergone various levels of training on the topic. It should also be noted that family therapy is a relatively young field, within the context of Africa, with interest only becoming prevalent in the 60s and 70s in South Africa [35]. This challenge is not unique to South Africa and is rather a challenge seen throughout the continent with no registration category for family or couples’ therapists being present throughout the continent, the result of this, is a contribution to the lack of cohesion amongst family therapist on the continent [35].

The question can then be posed, as to whether or not the inefficiency of therapy can be attributed to the family, which is failing to respond, or to the therapist, who is failing to adapt to the family [43]. This could potentially be as a result of the greater focus on the consistency, of application of learned theories, as opposed to the ability to adapt, to the needs to our clients [44].

Family therapy has been noted to have been growing around the world, with Africa being no exception to the global trend [35]. Family therapy places its focus on how to liberate and empower clients [45]. It has been argued that it’s collectivist orientation, results in it being considered as contextually appealing to the continent considering the shared cultural collective orientation.

Some models have been adapted to be used within and adapted to the South African context. For example, Seedat and Nell [46] argued that the most appropriate model of family therapy available was that of Jay Hayley’s problem-solving therapy [47]. They argued for a six-step intervention, which they believed would be easy to teach, readily accepted by families and practical in its application. These steps would be: Greeting; Socialising; Problem Identification; Bringing the problem into the room; Goal Setting and Contracting, all to be conducted in a session of one hour. It was believed that this would result in the psychologist being able to explore social, psychological and somatoform complaints with the family. The result is a model which lends itself effectively the biopsychosocial model, in which a therapeutic context is generated which holds practical value for both the family and the therapist. Problems become mutual, with the family’s views and experiences becoming resources, and being of value. There is also a level of empowerment which occurs, as the family are ultimately developing their own solutions to problems.

Whilst in contrast there have been models which have been developed within the South African context. One such example of this is the Interactional Pattern Analysis (IPA). The underlying assumption is that the quality of our mental health is causally related to the quality of our interpersonal relationships [16]. Emphasis is placed on that which can be observed in the interaction between the individual and their environment [48]. As such an inter-psychic stance is adopted, in which the observable interaction between individual’s is the focal point [16]. Bateson [49] argued that interpersonal interactions were based on a trial-and-error system, in which a feedback loop would result [49], with behaviour being modified as a result, leading to self-correction within the system. As a result of this it was argued that individuals would have preferred or more frequently engaged with interactional styles, which could be observed during their interactions with others [50]. As a result of this, the tool of the IPA (Interactional Pattern Analysis) has been designed to guide the psychotherapeutic process whilst also identifying nodal points of the client or patient’s interactional style [51] which need to be engaged with so as to result in change from the perturbing of them [52]. It is postulated that this should take place that there will be observable changes in the client or patient’s observable behaviour and that there will be a subjective experience of relief for the presenting complaint [48]. This as it is argued that the presentation of symptomatic behaviour, is conceptualised as an adaptive function, within a relational context, which serves the function of maintaining the system [53]. Thus, within this approach the symptomatic behaviour is seen as a function of the individuals’ relationship or relationships.

This psycho-diagnostic tool examines sixteen interpersonal variables, from which a description of the observable behaviour will be established, which will allow for the sketching of an individual’s interpersonal style [51]. The intervention would then be the link between the clients’ patterns of behaviour and their presenting complaints. Based on this connection, relevant and appropriate psychotherapeutic interventions can be implemented [17].

This tool has spawned research focusing on the evaluation and contrasting of the effects of incubator care and kangaroo mother care [54]. It also saw the extensions of it into the realm of child psychotherapy, with the development of Teddy Bear Therapy [55]. This approach has been highlighted to have been effective and of benefit to children who have experienced traumatic events, which can be thought to occur relatively frequently within the South African context [56].

It has also been used to conceptualise and treat Functional Neurological Symptom Disorder (Conversion Disorder), from a systemic and interactional approach [53]. This could be considered putting into clinical practice that which Du Plooy [48] postulated with regards it being used to conceptualise and treat psychologically, mental health conditions.

It has also been used in a preliminary study to assess the incapability of separated couples [57]. Whilst inversely it was also used to assess the subjective levels of marital satisfaction, in a correlational study [58]. It has also been used to assess the effectiveness of therapeutic intervention in preventing the breakdown of partner relationships [59].

8. Conclusion

Family therapy from an African perspective is in a developmental phase, and for this reason limited attention has been paid to families within this context [22]. However, with that having been said African authors are frequently involved in collaborative studies and projects with international academics and clinicians [35]. As highlighted within this chapter there are developments within the field, in Africa. Whilst perhaps these have not been as well published as work originating from the global north, this should also serve as a reminder that whilst implementing and conducting the work that we do, the important role that publication has to allow for this to better known and more accessible.

There is continued need to integrate culture-specific theories and interventions into contemporary Western approaches, so as to meet the needs for this context [22]. However, this appears to be being addressed, as the modality gains popularity within the continent. Though to expedite this process, there is need for improvement with regulation and awareness of the modality [35]. One potential manner in which these objectives could be achieved is through the revival of organisations which promote and support the training in, research in and the supervision within this modality. Whilst the value of specific registration category cannot be discounted, however this is perhaps a longer-term goal, to be addressed at a later stage.