Abstract
Based on ethnographic fieldwork, this article looks at changing discourses and practices in the field of mental health care in Uganda. In particular, it analyzes two psychotherapeutic institutions designed to treat drug- and alcohol-addiction, and their accessibility and affordability for people from different class backgrounds. The first center is a high-class residential facility near Kampala which offers state-of-the-art addiction therapy, but is affordable only for the rich. The second center, a church-funded organization in Northern Uganda, cares mainly for people from poor, rural families who cannot afford exp/tensive treatment. Comparing the two centers provides important insights not only into the temporalities of mental illness, substance abuse and mental health care, but also into broader socio-economic dynamics and understandings of suffering in contemporary Uganda. The term ‘class-based chronicities’ refers to the way both the urgency with which people seek treatment (when has someone suffered enough?) and the length of treatment they receive (when is someone considered ‘recovered’?) are highly class-dependent. On a theoretical level, the article shows how psychotherapeutic models operate as philosophical systems which not only impact on treatment practices, but also produce different addiction entities and addiction-related subjectivities. As such, it contributes to an emerging anthropology of addiction.
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Notes
In this article I use the terms alcohol/substance abuse, over-consumption, or alcoholism interchangeably to talk about socially problematic, behavioral aspects and negative consequences of alcohol and drug use (cf. Cain 1991:211). I use the term ‘substance/alcohol use disorder’ when specifically referring to the ‘disease model’ of alcoholism as specified in DSM-5 (APA 2013:481ff.). Although both alcohol- and drug-abuse are common in Uganda, and often present comorbidly, I mainly talk about alcoholism as it is more widespread and more widely talked about than drug-abuse.
I commonly encountered the latter view during my fieldwork in Northern Uganda, where—exacerbated by war, displacement and poverty—excessive drinking has become a major communal concern. Generally today, the perception of a ‘drinking crisis’ in Africa is widespread which, according to Willis (2002:2), may be a reflection of (and related to) wider problems of disorder and disease.
The question whether certain mental health conditions are chronic, i.e. life-long and without a cure, and how this affects treatment has always been a central one and goes back to the origins of modern psychiatry. For some, it is primarily a question of ontology—is a particular condition, like alcoholism, chronic or not? For others, it is a more complex, epistemological question which focuses on the effects of living under the description of ‘chronically mentally ill’ on a person’s subjectivity and self-understanding, and how the knowledge and conviction of having a chronic disease can feed back into the recovery process—in both positive and negative ways. This article speaks more to the latter perspective.
I use pseudonyms in this article, although people who are familiar with the subject and situation in Uganda will probably be able to identify the institutions I am referring to.
Centre for Alcohol and Substance Abuse Treatment (pseudonym).
Rose (1999:7) defines psy as the “heterogeneous knowledges, forms of authority and practical techniques that constitute psychological expertise” which are based on the human sciences, especially psychology.
The idea of ‘emerging middle classes’, and the related difficulties of conceptualizing class in the African context, have become a matter of extensive debate in African studies in recent years (e.g. Ncube and Lufumpa 2015; Neubert 2014). In this article, I use the terms ‘poor’ and ‘middle/upper classes’ not in absolute terms (as defined, for instance, by income) but as relative and ‘common sense’ categories in the context of Uganda. Ugandan society is increasingly becoming stratified along class lines and even the most untrained observer will notice a fundamental difference in the lifestyle of ‘the poor’, especially the rural poor, and those who I refer to as ‘middle and upper class’, predominantly urbanites whose lifestyle and attitudes resemble the “(young) urban professionals” described by Spronk (2012).
There is a big corpus of older literature which looks at so-called traditional healing practices and psychiatric practices from a transcultural psychiatry perspective (Corin and Murphy 1979; Corin and Bibeau 1980). There are also more recent studies which study understandings of mental illness in Africa and the way psychiatric care can be improved through new models and interventions (e.g. Akyeampong et al. 2015). Most of these studies, however, have a strong (bio)medical bias.
My thanks to Rebecca Lester for pointing this out.
http://www.health.go.ug/sites/default/files/What_you_need_to_know_about_Mental_Health.pdf, accessed 30 May, 2016.
Mulago National Referral Hospital, situated in Kampala, is the largest hospital in Uganda.
Makerere, located in Kampala, is the oldest, biggest and most prestigious Ugandan public university.
I discuss the gradual expansion of psychology-based psychotherapy in Uganda at length elsewhere (Vorhölter 2016) and cannot go into detail here.
According to UN-data, the GDP per capita for Uganda in 2014 was 726.90 $US (http://data.un.org/CountryProfile.aspx?crName=uganda, accessed 12 December, 2016).
For a more extensive analysis see Vorhölter 2016.
A psychiatrist who runs a private clinic at one of the best private hospitals in Kampala told me: “It is voluntary, they come by themselves or are brought by relatives (…) We don’t turn anyone away, as long as they can afford the fee we admit them, irrespectable of how severe the illness is. (…) It has become so popular, it is always full, I invite you to come and see it one day” (Interview 01.09.2015).
In a very different context, i.e. Ukraine medical politics after Chernobyl, Petryna (2003) shows to what extent systems of knowledge or non-knowledge as well as medico-political apparatuses shape people’s experiences and perceptions of illness and suffering, and their actions towards it.
In asking this, I do not wish to imply that (chronic) alcohol disorder is not ‘real’ or merely a label. For a more complex perspective on this matter, i.e. the question whether mental illness is ‘real’, see Hacking (1995:8ff).
The Minnesota-Model is the leading model for dealing with substance abuse in the US and was developed in the 1940s and 50s as a “counseling approach” which “combines psycho-education, whose goal is to build self-awareness, with group counseling, which is designed to confront denial” (Summerson-Carr 2011:12). It rests on the idea that addiction is an incurable, if treatable disease.
I do not have any figures.
This goal of the program is clearly stated in the information leaflet: “To empower communities and addicted individuals affected by substance abuse with knowledge, skills and opportunities to attain [and] (sic) sustain sobriety.” The leaflet further states that the philosophy of Sobriety Support is “a non-Permissive (sic) approach to the treatment of alcoholism and addiction”.
The same logic also applies to the NACARE program mentioned above. A newsfeed on the program’s success rate states: “since the inception of NACARE in 2005, only 170 clients (out of 235) stayed for the period of 2 to 6 months. It is this group that has mainly produced the 102 clients (60%) who are sober. The 23 clients who are in relapse were never properly counseled, because they either refused to stay or escaped” (NACARE 2014).
In her ethnography of outpatient drug treatment program in the US Summerson-Carr (2011) criticizes the disease model of addiction on which the treatment is based as a particular belief system rather than a natural given. She speaks of addiction as a “semiotic malady” (ibid.:4) and, similar to Cain (1991), focuses on the production or person-making of addicts rather than taking their existence as a (naturally-given) starting point.
For some general information on the MAST, see https://www.verywell.com/the-michigan-alcohol-screening-test-69497 and http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/42_MAST.pdf, both accessed 16.06.2016.
This is also explicitly stated in the Program Report which defines the overall goal of CASAT as follows: “Improved health status of Ugandans, especially those in the Acholi sub-region, through reduced substance abuse and HIV infection among youth and other members of the community” (my emphasis).
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Acknowledegments
I thank Rebecca Lester for her very thoughtful comments on an earlier version of this paper. I am also grateful to the participants of the ‘Ethnographic Theory Workshop’ at Washington University in St. Louis, the participants of the ‘African Diversities Colloquium’ at the Max Planck Institute for the Study of Religious and Ethnic Diversity in Göttingen, Jovan Maud, and two anonymous reviewers for their comments and suggestions on earlier versions.
Funding
Parts of the research for this article were funded by the Fritz-Thyssen-Foundation and the Volkswagen Foundation.
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Vorhölter, J. Class-Based Chronicities of Suffering and Seeking Help: Comparing Addiction Treatment Programs in Uganda. Cult Med Psychiatry 41, 564–589 (2017). https://doi.org/10.1007/s11013-017-9541-z
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DOI: https://doi.org/10.1007/s11013-017-9541-z