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to Kleinman, explanatory models consist of the illness and
disease concepts of a single person in a given illness episode
in interaction with his/her cultural context and socio- cultural
environment (e.g. caregivers including experts, family members
etc.).
The research by Williams & Healy, 2001 [41] suggests to
apply the term “explanatory map” as an alternative to “explanatory
model”, because the term “map” refl ects the diversity and
complexity that can be found in conceptions of illness and
disease [41]. That implies that “explanatory models” do not
consist of a coherent set of beliefs, but a multiplicity of illness
and disease explanations constructed in specifi c socio- cultural
settings, which may be infl uenced by time and “historical development
of traditional cultural knowledge” [33,4].
It has been suggested that the way patients feel to be understood
and accepted in the process of treatment has an important
infl uence on the compliance and the experience of therapeutic
relationships [26,5,18,35]. Explanatory models and concepts
also play an important role in terms of beliefs and estimations
of the social consequences of a disease and the social role of a
patient. This can include aspects of social stigmatisation and
ideas about the participation of the patient in social life or the
working environment [9].
In the African context, illness is very often regarded as a family
affair, i.e. a collective experience of different subjects [32]. The
infl uence of cultural knowledge (social rules, rituals, traditions,
symbolisation, communication styles) and (collective) narratives
thus plays an important role in the constructions of “explanatory
models” or “explanatory maps”.
Research on explanatory models of schizophrenia in Afríca
is complicated by the history of psychiatric explanations of
psychosis. For example, Bleuler termed the word “schizophrenia”
when closely cooperating with Freud, and assumed that
schizophrenic thought disorder refl ects a loss of evolutionarily
higher cognitive functions and a return to a “primitive” mode
of wishful (autistic) thinking that characterizes both children
and “the Negro” (in singular! ) [2]. Bleuler suggested that ideas
in the mind are normally connected in a logical way and this
connection is enforced by the experience of ‘reality’. He claimed
that a pathological destruction of the connections can lead into
psychosis. If the logical connections between ideas are lost,
the psyche splits up into incoherent ideas, and the only force
which regulates their manifestation is desire. This split up of
the mental process gave the disease its new name – schizophrenia
[15]. During colonialism, Western psychiatrists claimed
that healthy Africans resemble Europeans after lobotomy (a
destruction of prefrontal cortex function), which was supposed
to explain symptomatic differences in mental disorders between
Europeans and Africans [6]. However, in the 1950ies and 60ies,
the “race” concept was increasingly rejected, because it wrongly
assumes categorical genetic differences between populations
when indeed only gradual differences in allele frequencies are
observed [27]. In psychiatry, Lambo showed that differences in
psychotic symptoms in Nigerian patients are strongly infl uenced
by their individual upbringing, with subjects from traditional
backgrounds displaying mainly polymorphic psychoses and
subjects with Westernized socialisations reporting “classical”
key symptoms of schizophrenia such as certain acustic hallucinations
or passivity phenomena [24,37]. Using such symptoms
F. Napo et al. / European Psychiatry 27 (2012) / supplement n°2 / S44-S49 S45
as diagnostic criteria, the World Health Organization later
observed comparable frequencies of schizophrenia in different
countries around the world, including Nigeria [36]. While these
data falsify hypothesis that suggest fundamental differences in
mental disorders between Africans and Europeans, cultural and
religious differences in e.g. concepts of “the soul”, “the self” or
the existence of supernatural beings and their impact on human
life and experience may cause profound differences in illness
experience.
Therefore, the goal of our study was 1) to assess key
psychotic symptoms and explanatory models/maps of West
African patients and their caregivers, and 2) to investigate how
psychotic patients are treated in a Malian community- orientated
psychiatric context. We tried to focus not only on symptoms
and impairments but to also assess how salutogenetic resources
of the patients are taken into consideration in local treatment
settings [1].
2. The setting
Our investigation was based in the Department of Psychiatry
of the University Hospital, Point G, in Bamako, Mali. The inpatient
service is organized as a communal treatment setting. Since the
1980ies, a reform movement in Mali has focused on changing
the classical view and associated stereotypes of psychiatric treatment
[23]. This movement is interested in minimizing social
stigmatisation and tries to give patients a voice to integrate the
families into the therapeutic process, and to facilitate reintegration
into society. The movement intends to overcome treatment
models in which patients are isolated from their social reality,
placed in the passive role of an “ill patient” and treated nearly
exclusively with medication [23].
In 1984, the Ministry of Health developed treatment guidelines
including the demand for an amelioration of treatment
conditions. Since then, patients who are treated in the so- called
“psychiatric village” at the University Hospital in Bamako are
only admitted when accompanied by a family member [10]. The
family and patients live together in small houses on the compound
and they share the social reality of the patient during the
whole therapeutic process. The patient and his/ her companion
live together, cook together and sleep in the same house, similar
to their home environment.
The centre of the therapeutic village is the “Toguna”, a small
round house where the experts hold clinical consultations with
the patients and their families. The architecture of the small
house has a therapeutic meaning: on the one hand the “Toguna”
is constructed in a round form to include all professionals, relatives
and patients during the consultation, and the “Toguna” has
a very low ceiling. Thus, a person who becomes angry during
the expert consultation is not able to stand up, which, in the
experts’opinion, calms the anger of the person and suppresses
aggression.
A patient’s companion can play an important (salutogenic)
role for the healing process. The family member who accompanies
the patients during the whole therapeutic process acts as
a mediator. The role of the mediator is to clear the way for the
communication between the experiences of the patient and the
socio- culturally constructed realities of the family members.
Proofs
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