Most of the way through a doctorate in medical anthropology, Dr. Brandon Kohrt felt a void: "I was doing research on cross-cultural mental health, and I realized that just doing research – especially in areas where there are no services – wasn’t enough." That’s when he decided to get some more hands-on clinical training. Now in his second year of residency in general psychiatry at Emory University in Atlanta, Dr. Kohrt also is working with the Carter Center, a not-for-profit organization founded by former President Jimmy Carter and Rosalynn Carter that works in collaboration with the government of Liberia to improve mental health care.
He spent a month in Liberia last fall and recently returned in March from his second trip.
What were your goals during your first visit?
The Carter Center’s goal is to develop mental health services throughout the entire country, in coordination with the government, with the aim that the government would own the system. I was brought on to help figure out the best way to make this a culturally competent mental health program.
I focused on what the local beliefs were regarding mental health and mental illness, what types of mental illnesses were present, what the ideas were about causation of mental illness, what services were or were not available to treat them, and ways to shore up existing capacity to address mental health needs.
How would you describe the mental health challenges in Liberia?
There are at least three major issues. One is a lack of trained mental health workers. In the current curricula for nurses and doctors, there is almost no exposure to mental health care. One of our goals is to help educate doctors, nurses, and other health professionals about what mental illness is and how to treat it.
The second is the need to improve psychotherapeutic services and access to medication. Many local health centers have no psychiatric medications available, nothing to treat psychosis, depression, or epilepsy. We saw information provided by the Clinton Foundation that assessed approximately 500 health care facilities in Liberia, and fewer than 5% of them had appropriate mental health medication.
The third problem is a lack of understanding among family members and the general public about what mental illness is, how to best support their loved ones, and what treatments are available. A goal of the Carter Center’s project, in addition to training clinicians and improving mental health care infrastructure, is to raise awareness in the community about mental illness and improve opportunities for families to seek support.
Here’s a case that illustrates these challenges: We interviewed a woman in the countryside who was worried about her daughter. As she described her daughter’s condition, I realized that the daughter was suffering from postpartum psychosis. She was acutely psychotic and unable to care for her baby. She finally brought her baby to a local hospital, but the infant was already in a state of severe malnutrition. The woman’s family did not know what was wrong with her. They had been unable to help her. They did not realize that she has a mental illness. Even if they realized their daughter had a psychiatric condition, there was not a mental health service provider within a day’s drive. They had spent a great deal of money taking her to traditional healers in Guinea who were unable to treat her condition.
This dire situation could have been prevented. Had there been more training of local health care professionals and medications available, this new mother could have been treated in an affordable fashion that could have improved her mental health and also the well-being of her baby.
Have people in Liberia been receptive to mental health care?
In my experience, I think that people would be very open to obtaining more mental health care. In the capital city of Monrovia, there is one psychiatric hospital, and people do go there for treatment and medications.
I think that culturally, people are able to understand the biological and medical aspects of mental illness. With the right education and public awareness, people could incorporate biomedical understandings of mental illness into their existing ideas of what constitutes a healthy person. If appropriate treatment were available, families would take their loved ones for mental health care.
The problem arises when there aren’t mental health professionals and appropriate medications available. As long as there are no alternatives, people will continue to rely solely on traditional and religious healers. These healers can be useful in many cases, but the best care will require access to psychiatric services as well other traditional psychosocial practices. The woman with postpartum psychosis needed psychiatric care; traditional healers, alone, were not enough. Ultimately, it is not the belief system but rather a services gap that keeps people from getting appropriate care.