Culture, Medicine, and Psychiatry

, Volume 40, Issue 3, pp 307–337 | Cite as

“How I Floated on Gentle Webs of Being”: Psychiatrists Stories About the Mental Health Treatment Gap in Africa

  • Sara Cooper
Original Paper


A strong movement has emerged recently which is highlighting the high levels of untreated mental illness in Africa and making proposals for reducing this ‘gap’ in mental health care. This movement has been criticised for insufficiently attending to the epistemologies embedded in its recommendations, and inadequately considering the views of practitioners ‘on the ground’. Employing a narrative-based approach, I accessed the stories about the mental health ‘treatment gap’ of 28 psychiatrists all working clinically in public mental health care settings in South Africa, Uganda, Nigeria or Ethiopia. Rather than focusing on the content of these stories, I was more interested in their underpinning meaning-codes and epistemological politics. Dominant thinking about the ‘treatment gap’ was heavily informed by a biomedical paradigm, and associated epistemological order of European Colonial Modernity. There were, however, cracks in this master narrative, which crystalised in the stories that were told by three particular psychiatrists. Their narratives operated within an alternative paradigm, one which appears to be informed by the tradition of phenomenology, and in particular the ideas associated with French philosopher Merleau-Ponty. This more marginalised thinking may offer important insights into reducing the mental health ‘treatment gap’ in Africa in ways very different from those created by current seats of power.


Mental health treatment gap Africa Psychiatrists Narrative 



This study was funded by the following doctoral research fellowships: Patrick and Margaret Flanagan Award (Rhodes University, South Africa); South African National Research Foundation (Grant no. 74724); Oppenheimer Memorial Trust Award (Reference: 19512/01).

Compliance with Ethical Standards

Conflict of Interest

Sara Cooper has received research grants from the Patrick and Margaret Flanagan Trust (Rhodes University, South Africa); the South African National Research Foundation and the Oppenheimer Memorial Trust (South Africa).

Ethical approval

All research procedures performed were in accordance with the ethical standards of the London School of Hygiene and Tropical Medicine’s, UK and the University of Cape Town’s, South Africa research ethics committees, and with the 1964 Helsinki declaration and its later amendments.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. Armstrong, David 1984 The patients view. Social Science and Medicine 18(9):737–744.CrossRefGoogle Scholar
  2. Bemme, Doerte and D’souza, Nicole 2014 Global mental health and its discontents: An inquiry into the making of global and local scale. Transcultural Psychiatry 51(6):850-74.CrossRefGoogle Scholar
  3. Bracken, Pat, Philip Thomas, Sami Timimi, Eia Asen, Graham Behr, Carl Beuster, Seth Bhunnoo, Ivor Browne, Navjyoat Chhina, Duncan Double, Simon Downer, Chris Evans, Suman Fernando, Malcolm R Garland, William Hopkins, Rhodri Huws, Bob Johnson, Brian Martindale, Hugh Middleton, Daniel Moldavsky, Joanna Moncrieff, Simon Mullins, Julia Nelki, Matteo Pizzo, James Rodger, Marcellino Smyth, Derek Summerfield, Jeremy Wallace, and David Yeomans 2012 Psychiatry beyond the current paradigm. BJP 201: 430–434.CrossRefGoogle Scholar
  4. Campbell, Catherine and Burgess, Rochelle 2012 The role of communities in advancing the goals of the Movement for Global Mental Health. Transcultural Psychiatry 49(3–4):379–395.CrossRefGoogle Scholar
  5. Carroll, Lewis 1872 Through the Looking-Glass. Raleigh, NC: Hayes Barton Press.Google Scholar
  6. Clark, Jocalyn 2014 Medicalization of global health: The medicalization of global mental health, Glob Health Action 7:24000.Google Scholar
  7. Comaroff, Jean 1993 The Diseased Heart of Africa: Medicine, Colonialism and the Black Body. In Knowledge, Power and Practice: The Anthropology of Medicine and Everyday Life. S. Lindenbaum and M. Lock, eds., pp. 305-329. Berkeley, CA: University of California Press.Google Scholar
  8. Cooper, Sara 2014 Prising open the ‘black box’: An epistemological critique of discursive constructions of scaling-up the provision of mental health care in Africa. Health. DOI: 10.1177/1363459314556905.Google Scholar
  9. Deacon, Brett 2013 The biomedical model of mental disorder: A critical analysis of its validity, utility, and effects on psychotherapy research. Clinical Psychology Review 33: 846–861.CrossRefGoogle Scholar
  10. Ethiopian Ministry of Health .2012. National Mental Health Strategy. Ethiopia: Ministry of Health.Google Scholar
  11. Ewick, Patricia and Silbey, Susan 1995 Subversive stories and hegemonic tales: Towards a sociology of narrative. Law and Society Review 29(2):197-226.CrossRefGoogle Scholar
  12. Global Mental Health Group. 2007. Scale-up services for mental disorders: A call for action. The Lancet 370:1241–1252.CrossRefGoogle Scholar
  13. Good, Byron 1994 Medicine, rationality and experience: An anthropological perspective. Cambridge: Cambridge University Press.Google Scholar
  14. Hollway, Wendy and Jefferson, Tony 2000 Doing qualitative research differently: Free association, narrative and the interview method. London: Sage.CrossRefGoogle Scholar
  15. Horton, Richard 2007 Launching a new movement for mental health. The Lancet 370:806.CrossRefGoogle Scholar
  16. Husserl, Edmund 1972 Experience and judgement. Evanston:Northwestern University Press.Google Scholar
  17. Issa, Baba 2005 Dearth of Psychiatrists in Nigeria. Nigerian Medical Practitioner 47(6):127-128.Google Scholar
  18. Jackson, Michael 1996 Things as they are: New directions in phenomenological anthropology. Bloomington: Indiana University Press.Google Scholar
  19. Kigosi, Fred; Ssebunnya, Joshua; Kizza, Dorothy; Cooper, Sara and Ndyanabangi, Sheila 2010 An overview of Uganda’s mental health care system. International Journal of Mental Health Systems 4, 1. doi: 10.1186/1752-4458-4-1.CrossRefGoogle Scholar
  20. Kirmayer, Laurence J. 2012 Cultural competence and evidence-based practice in mental health: Epistemic communities and the politics of pluralism. Social Science and Medicine 75(2):249–56.CrossRefGoogle Scholar
  21. Kleinman, Arthur 2012 The art of medicine: Caregiving as moral experience. Lancet 380(3):1550-1551.CrossRefGoogle Scholar
  22. Kleres, Jochen 2010 Emotions and narrative analysis: a methodological approach. J Theory Soc Behav 41(2):182–202.CrossRefGoogle Scholar
  23. Krieger, Nancy 2000 Passionate epistemology, critical advocacy, and public health: Doing our profession proud. Critical Public Health 10(3):287-294.CrossRefGoogle Scholar
  24. Kuhn, Thomas 1962 The structure of scientific revolutions. Chicago:University of Chicago Press.Google Scholar
  25. Kvale, Steinar 1996 InterViews: An introduction to qualitative research interviewing. California: Sage.Google Scholar
  26. Lamarque, Peter 1990 Narrative and invention: The limits of fictionality. In Narrative in Culture: The Uses of Storytelling in the Sciences, Philosophy and Literature. C Nash, ed., pp.131-53. London: Routledge.Google Scholar
  27. Latour, Bruno 1999 Pandora’s hope: Essays on the reality of Science Studies. Cambridge, MA:Harvard University Press.Google Scholar
  28. Law, John 1999 After ANT: Complexity, naming and typology. In Actor network theory and after. J Law and J Hassard, eds., pp. 1–14. Oxford: Blackwell Publishers.Google Scholar
  29. Lucas, Rodney and Barret, Robert 1995 Interpreting culture and psychopathology: Primitivist themes in cross-cultural debate. Culture, Medicine and Psychiatry 19: 287–326.CrossRefGoogle Scholar
  30. Lund, Crick; Kleintjes, Sharon; Kakuma, Ritz and Flisher, Alan 2009 Public sector mental health systems in South Africa: Inter-provincial comparisons and policy implications. Social Psychiatry and Psychiatric Epidemiology 45(3):393-404.CrossRefGoogle Scholar
  31. Matthews, Eric 2002 The philosophy of Merleau-Ponty. Chesham:Acumen.Google Scholar
  32. Merleau-Ponty, Maurice 2004 The world of perception. London:Routledge.Google Scholar
  33. Merleau-Ponty, Maurice 1962 The phenomenology of perception. London:Routledge.Google Scholar
  34. Mills, China and Fernando, Suman 2014 Globalising Mental Health or Pathologising the Global South? Disability and the Global South 1(2):188-202.Google Scholar
  35. Mol, Annemarie 2008 The logic of care: Health and the problem of patient choice. New York:Routledge.Google Scholar
  36. Montgomery, Katherine 2006 How doctors Think: Clinical judgment and the practice of medicine. Oxford: Oxford University Press.Google Scholar
  37. Morant, Nicola 2006 Social representations and professional knowledge: The representation of mental illness among mental health practitioners. British Journal of Social Psychology 45:817–838.CrossRefGoogle Scholar
  38. Parker, Ian 1992 Discourse dynamics: Critical analysis for social and individual psychology. London:Routledge.Google Scholar
  39. Patel, Vikram; Boyce, Niall; Collins, Pamela; Saxena, Shekhar and Horton, Richard. 2011 A renewed agenda for global mental health. The Lancet 378:1441–1442.CrossRefGoogle Scholar
  40. Petersen, Inge, Lund, Crick and Stein Dan 2011 Optimizing mental health services in low-income-and middle-income countries. Current Opinion in Psychiatry 24(4): 318–323.CrossRefGoogle Scholar
  41. Pluciennik, Mark 1990 Archaeological narratives and other ways of telling. Current Anthropology, 40(5): 653-94.CrossRefGoogle Scholar
  42. Riessman, Catherine K. 2008 Narrative methods for the Human Sciences. London:Sage.Google Scholar
  43. Riessman, Catherine K. 1993 Narrative Analysis. London:Sage.Google Scholar
  44. Summerfield, Dereck 2012 Afterword: Against ‘global mental health’. Transcultural Psychiatry 49(3–4):519–530.CrossRefGoogle Scholar
  45. Swartz, Leslie 2007 The virtues of feeling culturally incompetent. Monash Bioeth Rev, 26(4):36-46.CrossRefGoogle Scholar
  46. Swartz, Leslie 2012 An unruly coming of age: The benefits of discomfort for global mental health. Transcultural Psychiatry 49(3–4):531–538.CrossRefGoogle Scholar
  47. Timimi, Sami 2011 A Reply to ‘Grand Challenges in Mental Health. Science, Medicine, and Anthropology:
  48. Turnbull, David 2004 Narrative traditions of Space, Time and Trust in Court. In Expertise in Regulation and Law. G Edmond, ed., pp.116-183. Ashgate: Aldershot.Google Scholar
  49. Turnbull, David 2000 Masons, tricksters and cartographers: Comparative studies in the sociology of scientific and indigenous knowledge. The Netherlands:Harwood Academic Publishers.CrossRefGoogle Scholar
  50. Vaughan, Megan 1991 Curing their ills: Colonial power and African illness. Cambridge: Polity Press.Google Scholar
  51. Velpry, Livia 2008 The patient’s view: Issues of theory and practice. Culture, Medicine and Psychiatry 32:238–258.CrossRefGoogle Scholar
  52. Weed, Douglas 1995 Epidemiology, the humanities, and public health. American Journal of Public Health 85(7):914-918.CrossRefGoogle Scholar
  53. Willig, Carla 2001. Introducing qualitative research: Adventures in theory and method. Berkshire: Open University Press.Google Scholar
  54. World Health Organization 2008 Mental Health Gap Action Programme: Scaling-up care for mental, neurological, and substance use disorders. Geneva:WHO.Google Scholar
  55. World Health Organization 2001 Mental Health: New Understanding, New hope. Geneva:WHO.Google Scholar
  56. Yen, Jeffery and Wilbraham, Lindy 2003. Discourses of culture and illness in South African mental health care and indigenous healing. Part I: Western psychiatric power. Transcultural Psychiatry 40(4): 542–561.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Social and Environmental HealthLondon School of Hygiene and Tropical MedicineLondonUK

Personalised recommendations