A CAJM article on Psychatric Services.The provision of psychiatric services on a national scale poses many formidable problems for homogenous communities which are traditionally accustomed to adequate and sophisticated medical services. In countries like Rhodesia and Malawi these problems are even greater and more diverse. A simple example which is common to all countries is the impact on these services of variations in population density. In large cities it should be possible to cope with most patients on an outpatient 5 basis or in a day hospital, but in more isolated areas there is a greater demand for inpatient accommodation because of the difficulty in organizing intensive supervision and treatment outside. Furthermore, duration of stay in hospital tends to be more prolonged in rural areas because of delays in obtaining information from relatives and others, and the reluctance to discharge early because of the uncertainty of adequate follow-up. The effectiveness of social workers is also diminished because of the large distances involved

Myre, Sim

Central African Journal of Medicine

English

The provision of psychiatric services on a national scale poses many formidable problems for homogenous communities which are traditionally accustomed to adequate and sophisticated medical services. In countries like Rhodesia and Malawi these problems are even greater and more diverse. A simple example which is common to all countries is the impact on these services of variations in population density. In large cities it should be possible to cope with most patients on an outpatient 5 basis or in a day hospital, but in more isolated areas there is a greater demand for inpatient accommodation because of the difficulty in organizing intensive supervision and treatment outside. Furthermore, duration of stay in hospital tends to be more prolonged in rural areas because of delays in obtaining information from relatives and others, and the reluctance to discharge early because of the uncertainty of adequate follow-up. The effectiveness of social workers is also diminished because of the large distances involved

Myre,  Sim

National Research Database of Zimbabwe

Psychiatric Services

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Psychiatric Services
(Based on a lecture given to the Malawi Medical 
Association on 21st May, 1970.)
BY
MYRE SIM, m .d.(edin .), f .r .c.p .(ed.), d.p .m . 
Consultant Psychiatrist, United Birmingham Hospitals, 
Lecturer in Psychiatry, University of Birmingham, Visiting 
Lecturer in Psychiatry, University College of Rhodesia.
The provision of psychiatric services on a national 
scale poses many formidable problems for homo­
genous communities which are traditionally 
accustomed to adequate and sophisticated medical 
services. In countries like Rhodesia and Malawi 
these problems are even greater and more diverse. 
A simple example which is common to all coun­
tries is the impact on these services of variations 
in population density. In large cities it should be 
possible to cope with most patients on an out­
patient 5 basis or in a day hospital, but in more 
isolated areas there is a greater demand for in­
patient accommodation because of the difficulty 
in organising intensive supervision and treatment 
outside. Furthermore, duration of stay in hospital 
tends to be more prolonged in rural areas because 
of delays in obtaining information from relatives 
and others, and the reluctance to discharge early 
because of the uncertainty of adequate follow-up. 
The effectiveness of social workers is also dimi­
nished because of the large distances involved.
Even in well-developed countries with a re­
latively homogeneous population differences in 
cultural patterns occur, and these make for uneven 
and excessive demands on psychiatric services. 
The following examples will explain:—
(a) Retirement habits in Britain have led to a 
concentration of the aged in the south 
coast, with consequent over-loading of the 
psychogeratric services in that area.
(b) Social problems like alcoholism and drug 
addiction can saturate a limited service
' both regionally and nationally, while in 
some countries where food is scarce or 
dietary habits are faulty, pellagra can
greatly increase the incidence of mental 
disorder.
(c) Migration to the cities of unemployed, 
unemployable, vagrants and others contri­
bute to the unstable population, and as 
they are generally of no fixed abode and 
with no family support, their rehabilitation 
is formidable.
(d) Mobility of population affects all classes. 
People forsake the villages for the towns 
in their search for work and sacrifice the 
emotional security they derived from their 
village culture. The re-organisation of busi­
ness into larger complexes increases the 
movement of personnel at all levels, and 
enforced changes in housing, schools and 
social contacts can be traumatic for all 
members of the family. A rapid increase 
in the student population with, a simul­
taneous tendency to study away from 
home has contributed to the psychiatric 
hazards of this population and to an in­
crease in suicide. Immigration too contri­
butes, though this is reflected more in' the 
first generation than in the original 
settlers, for the former are not entirely 
accepted by the indigent culture and lack 
the support of the old which they may have 
renounced.
(e) Social mobility, which is closely linked to 
economic factors, is a common cause of 
instability. In affluent and emergent socie­
ties the movement is generally upwards 
and it is the lower ranks who are most 
vulnerable, for they have lost the support 
of the proletariat and have entered the 
wide-ranging and subtle stratification of 
the middle classes. Even when roles have 
been defined, the scene is a rapidly chang­
ing one and newly-formed relationships 
may have to be abandoned with interven­
ing isolation. Re-adjustment can involve 
schools, clubs; housing areas', clothes, cars, 
holidays, hobbies and even churches. Even 
within the family, tensions may be increased 
and children become progressively aliena-
61
M arch, 1972. PSYCHIATRIC SERVICES T h e  Central A frican 
J ournal of Medicine
ted from their parents as they identify 
more and more with their peer groups.
(f) Pathoplastic Effects of Culture.—This may 
not in . itself affect the true incidence of 
mental illness, but it can affect the numbers 
who seek help for cultural by-products 
such as spells and witchcraft or an exces­
sive preoccupation with sexual potency. 
Some cultures have a greater tendency to 
“act out” problems and in doing so disturb 
the environment with increased demands, 
not only on medical and nursing staff, but 
on police and magistrates. Though the 
condition may, in itself, be trivial, by its 
presentation it becomes an emergency and 
brings in its train the legal formalities such 
as certification with a need for escorts and 
transport and special observation in hospi­
tal. In addition, the initial disturbance 
lowers the community tolerance to mental- 
illness and to that patient in particular.
(g) The introduction of contraceptive pills to 
unmarried teenagers launches both sexes 
into behaviour for which they are emotion­
ally unprepared, with resulting heightened 
guilt feelings and a serious handicap in 
forming a mature and permanent relation­
ship.
Cult and Fashion in  Psychiatry
It must not be assumed that all psychiatric 
services, even those of long-standing, are neces­
sarily effective. Cultism is prevalent in all societies, 
but in those which provide comprehensive welfare 
services there are pressures to include all manner 
of healing cults. In organic medicine the appeal 
court of the laboratory has helped to remove these 
pressures, though not entirely. In psychiatry, 
where frequently the definition of successful treat­
ment is that which the patient declares makes him 
feel better, or what a vocal section of the com­
munity regards as appropriate, the situation is 
very different. In the past the latter has led to the 
creation of larger complexes of mental hospitals 
which, even when they were built, were entirely 
unsuitable for the task and are now a monumental 
embarrassment. It has also led to the abandon­
ment of a perfectly good arrangement for one 
which was less effective or harmful. This point 
was made by Greenland (1961) in his comments 
on the rejection in 1889 by the Japanese of an 
enlightened thousand-year-old system of looking 
after the mentally ill in favour of what was then 
considered to be the new asylum system in Europe 
and America.
Even in a democracy, availability or effective­
ness of services is not necessarily equated with
need. An articulate middle class can monopolise 
the mass media and create a “lobby” which will 
syphon off resources for their own problems, re­
gardless of the competing and more established 
claims of others. An example is in the field of 
infantile autism which is probably caused by a 
variety of agencies, mostly undefined, which render 
the child from birth or from an early age severely 
handicapped in acquiring speech and with marked 
perceptual defects. The diagnosis achieved some 
respectability in that it was claimed by Kanner 
(1943), who originally described it, that the 
parents tended to be intelligent and of the pro­
fessional classes. As he was working on the Johns 
Hopkins campus and many of his patients were 
faculty members, his conclusion may have been 
influenced by sampling, but surveys in England 
(Wing et al, 1967) have shown that 60 per cent, 
of the parents belonged to social classes 1 and 2, 
while only 18 per cent, of the parents of mental 
defectives belonged to these classes. It is possible 
that in indistinguishable clinical problems the 
upper-class parent would secure a diagnosis of 
infantile autism, while the lower-class parent 
would not object to the child being labelled men­
tally defective. There is now tremendous pressure 
on government to provide more facilities for this 
small and select group, though this can only be 
done by depriving mental defectives of their 
already meagre allocation, even though most of 
the evidence indicates that infantile autism is 
generally not amenable to intensive and prolonged 
treatment.
Another example is in the field of drug-taking. 
Here, too, pressure from the mothers of drug 
takers who are generally middle class has per­
suaded the government in Britain to- set up 
“treatment centres” . They are not expected to 
treat, but are really off-licence premises where 
drugs are distributed but not consumed at the 
time. As drug-taking frequently results from 
oral pacifying in infancy or childhood, one can 
see the propaganda for “treatment centres” as 
another attempt to ensure that “Johnny gets his 
sweets”!
The mushrooming of the so-called therapeutic 
communities in psychiatric units and the vogue 
for group therapy are developments whose 
efficacy in the treatment of the mentally ill has 
still to be validated. The large field of child guid­
ance with its concentration of professional skills 
is yet another example which even after 40 years 
has provided no satisfactory evidence that.-the 
results have justified the investment. Similarly, 
the proliferation of clinical psychologists, psychia­
tric social workers and psychiatrists, too, has still 
to pass the scrutiny of an Auditor General. Even
[
March , 1971 PSYCHIATRIC SERVICES
if it be shown that all or most of what they do 
is of value, their geographical distribution is so 
disparate that some areas are virtually deprived 
of psychotherapists and psychiatric social workers, 
while the London area which accounts for only 
; 20 per cent, of the population is relatively 
saturated.
The Problems of an U nderdeveloped 
Country
At the outset it can be said that manifestations 
of psychiatric illness are not racial but cultural, 
and as such are liable to change. There will be 
considerable differences in the needs of those who 
! are organised in primitive tribal associations, those 
who are beginning to acquire the outlook of West­
ern civilisation and those whose training and 
employment have committed them to the now 
international standards of the modern world. It 
is not profitable at this stage to compare these 
cultures and express value judgments.-It is prob­
ably true that the more primitive are happier and 
the more advanced are more anxious, but anxiety 
is the stimulus of modern society and it is through 
its mastery that man progresses, certainly 
materially.
Psychiatric illness is heavily dependant on 
cultural influences apart from the pathoplastic 
effects described above. It varies in nature from 
culture to culture, and even within the same 
culture where it is possible to study the differing 
social classes and levels of responsibility, the 
range can be striking (Sim, 1946). In more primi­
tive societies the incidence of anxiety states and 
depressive psychoses is very low, while hysterical 
and what one might label schizophrenic states are 
proportionately high. As cultures approximate to 
those of the modern world there is a greater 
number of anxiety states and depressive psychoses. 
Even in a relatively homogeneous community like 
Britain in the 1940s the nature of mental illness 
in British Army personnel varied as widely be­
tween officers and non-commissioned officers and 
other ranks as between British personnel as a 
whole and East Africans.
All societies, even the most primitive, have their 
own brand of medical practice, and though in 
organic medicine the less developed countries do 
not match the more developed, in the treatment 
of the functional disorders of their members they 
would appear to be at least as successful. A 
developing country has therefore need for its 
traditional psychiatric services in the form of the 
witch doctor, an intermediate service for those 
who are beginning to meet with anxiety and de­
pression and a more modern service for those of 
all races who have reacted similarly to the more
T h e  Central African 
J ournal of Medicine
advanced cultural conserve. The African, whether 
of the professional or business class, is beginning 
to reflect the problems of his adopted culture and 
is presenting the same psychiatric problems as the 
European. Nobody can predict how long it will 
be before the vast majority of the African popula­
tion will be in a similar position, though if history 
is a guide it will be sooner than later. Pathoplastic 
influences will probably persist for many years, 
but these will be like medallions on a black cloth 
and will not unduly influence the true nature of 
the reaction in its essential clinical features or in 
its response to treatment.
The scene, though rapidly changing, will in the 
initial phase rely heavily on what one must call 
African psychiatry, and it will require a major 
re-adjustment of traditional medical attitudes in 
recognising that in this respect Western medicine 
has less to offer. The mistakes of previous genera­
tions of Western psychiatry must not be repeated 
and the asylum system should, if possible, be 
eliminated by more effective psychiatric “first-aid” 
at the site of origin and the provision of the 
essential agents to control the acute episodes of 
the alcoholic, the pellagric or the “acting-out” of 
the unstable. In-patient accommodation and out­
patient services should be reserved for those who 
can be helped by modern psychiatric treatment, 
and as these problems are generally readily re­
coverable there would be every advantage in 
siting these units within the general hospital. 
Furthermore, a progressive unit with a high dis­
charge rate would overcome the resistance of 
those who need its help but have not yet accepted 
the fact that their problems are within the com­
petence of modern psychiatry.
Personnel and T heir Training
At the medical level this involves post-graduate 
training and there is considerable advantage in 
locating these in or near the country to. be served. 
In psychiatry, training is a matter of suitable 
patients, of which there is an abundance, and 
experienced teachers. The traditional method of 
sending young doctors overseas has disadvantages 
in that their community is deprived of their ser­
vices while they are away, some never to return. 
The training overseas cannot entirely suit the local 
scene and they are likely to import inappropriate 
schemes or express dissatisfaction with the short­
ages which are inevitable in a developing situation. 
This does not preclude foreign travel at a later 
date.
Similarly, nursing personnel should be locally 
trained and at the village level somebody should 
be competent to administer psychiatric first-aid,
63
Vol. 17. No. 3. M arch, 1971.
even if it be the local policeman. It is not often 
that the opportunity presents to initiate psychiatric 
services, almost from scratch. These opportunities 
must not be wasted.
T h e  Central African 
J ournal of Medicine
REFERENCES
Greenland, C. (1961). Lancet, II, 605i 
Kanner, L. (1943). Nerv. Child., 2, 217.
Sim , M. (1946). J. Ment. Set., 92, 118.
W ing , J. K., O’Connor, N. & L otter, V. (1967). Brit. 
Med. J., 3, 389.
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