The Opening of the MAP
Teaching on the Kintampo Project’s Medical Assistant Psychiatry degree course
The Need for MAPs
For a population of 22 million people, Ghana has just 13 psychiatrists (Asare 2010). Thus within the country’s three psychiatric hospitals, Medical Assistants (MAs) regularly perform a much-needed doctor-like role, though their psychiatric education has not previously been formalised. Furthermore, there is recognition that mental health services need to shift from being focused at the three, south coast based hospitals to the wider community.
The Kintampo Project has thus been developed by the Kintampo Rural Health Training School (KHRTS) in conjunction with Hampshire Partnership NHS Foundation Trust (HPFT) and the University of Winchester to deliver Ghana’s first dedicated psychiatric training for middle level health workers. This consists of two courses to train two new types of mental health worker known as Medical Assistant Psychiatry (MAP) and Community Mental Health Officer (CMHO). Consequently it is hoped that as this psychiatric workforce develops, mental health care can be spread more equitably across Ghana’s 170 districts.
The MAP opens
In May 2010, the Project’s inaugural 18 month MAP degree course welcomed its first intake of students. Each of the nine students were experienced MAs who had previously attended KHRTS in central Ghana for their initial MA training. While they were supported by their employers to attend, it was still a significant commitment to make towards an unprecedented course and most had left young families during the week to share dormitories with classes starting at 7:00 a.m.
For the MAP course’s first two weeks, I joined a UK-led teaching programme which included HPFT employees clinical psychologist, Dr Tess Maguire, and community psychiatric nurse, Patrice Fugah. I had only arrived in Ghana two weeks earlier as part of a three-month volunteer placement based at Pantang Psychiatric Hospital on the outskirts of the capital, Accra and a nine-hour drive south from Kintampo. While I was the fifth UK trainee to volunteer for this Royal College of Psychiatrists’ approved training opportunity (Neate 2011), the Kintampo Project was a new experience for everyone.
Although my initial time at Pantang had been brief, it provided an invaluable introduction to Ghana’s culture and its health service. Thus during my presentations on psychosis, mood disorders and performing mental state examinations, I was able to include descriptions of actual patients that I had seen. These presentations were also then linked with the corresponding chapter in the Oxford Handbook of Psychiatry, which each student had received a copy of.
In keeping with the approach of my fellow teachers, student interaction was encouraged, particularly during the reflective session that ended each day. While the students had expected a more traditional, didactic style of teaching, after some hesitancy they became more personally involved, which we hoped would encourage their future learning.
Meanwhile outside of class, Dr Mark Roberts, the Project’s UK lead, collaborated with the tutors at KHRTS on the curriculum for both courses and supervised the tutor’s personal development plans. With such measures being undertaken to ‘educate the educators’, it is intended that the Project will become sustainable and the development of an excellent mental health workforce can be maintained.
Further Collective Learning
In addition to our teaching presentations, two field trips were arranged to observe the local context in which mental illness is perceived and managed. While these were valuable learning experiences for the students, they were as much of an education for us, their UK-based teachers.
Our first trip involved visiting two spiritually based, informal healing centres that provide treatment for people with mental illness. Both functioned as communities in themselves and who welcomed us warmly, offering us seats in a circle that faced their leader’s designated, elevated chair. In the Ghanaian custom, our hosts then shook hands with us in turn, following in an anti-clockwise direction to ensure that none were approached with the backs of their hands. After prayers were said to their inspirational source, all eyes remained on the group’s charismatic healer who led through his aura and authority. Understandable really as both the traditional healer and Evangelical pastor said they could remove illness by communicating with a supernatural force!
In Ghana many traditional healers are known as fetish priests who serve a shrine, which a ‘Spirit’ inhabits. The priest at the remote, rural community that we visited said that he had been called by the Spirit of his community’s shrine to succeed his deceased uncle. Subsequently, when he underwent twice-weekly possession, this Spirit communicated through him ‘in tongues’. While the priest said he lacked for any memory whilst possessed, with the assistance of his ‘linguist’ who transcribed his unintelligible speech, he could identify what ails and which herbal preparation would treat those who sought his help.
We then met the pastor of an Evangelical church and prayer camp who provides a similar link between this world and a spiritual one through the word of God. Citing the Bible’s account of how Jesus healed a man with ‘evil spirits’ through prayer, the pastor told us that as all illnesses are caused by ‘evil spirits’, then prayer is the only effective treatment.
At one location we were shaken to see shackles used to detain and treat people with disturbed behaviour, though it has been reported that their removal may have a symbolic value as a “dramatic demonstration of the efficacy of healing” (Read et al, 2009). Other ‘healing’ treatments reported include enforced fasting and even beatings, though we did not see evidence of the latter. Back in the classroom we discussed and reflected on the role these spiritual healers play in providing culturally acceptable explanations for mental illness.
Our second field trip also revealed some unexpected approaches at the nurse-led psychiatric outpatient clinic at the nearby hospital. Here our students met with a young woman complaining of headaches and depressed mood. Although the consultation was unevenly matched, we were interested to observe the student’s assessment skills, particularly after my session on mental state examinations. What we didn’t expect was for the besieged woman to face questions in a free-for-all style that matched the busy waiting area outside.
Clearly more work was required to reinforce what appeared understood in the classroom but abandoned in the field. Therefore we arranged interview practice for the students with us, their teachers, simulating the presentations of patients. Then using their peer’s observations, we encouraged each student’s strengths and made suggestions that linked with our earlier teaching. We particularly recommended this approach to the MAP tutors and later heard that KHRTS plan to establish teaching clinics where students are supervised while assessing local patients.
Return to Kintampo
Six weeks later I returned to Kintampo to provide three more days of teaching. The students remained committed and had been taught psychology, ethics, research and management as outlined in the curriculum by the tutors at KHRTS but had lacked further actual psychiatry.
Thus, I expanded upon my earlier teaching and delivered a presentation on perinatal psychiatry. In addition, with my visiting girlfriend, Wendy, we developed a simulation of postnatal depression with and without psychotic features, which allowed for comparison and provided more interview practice. The students also presented projects that they had completed in pairs between my visits and I suggested further topics for them to prepare.
While my experience at Kintampo was personally positive, more importantly it appeared to have been a good start for the Project. The students were appreciative too but asked what would happen between UK visits? At times I wondered myself, were we just psychiatry colonialists visiting temporarily with our own values?
Here though our purpose was clear; to contribute as guests of KHRTS to a course that would receive ongoing support and further support from the UK to supplement their own resources. Thus while it was the responsibility of the tutors at KHRTS to ensure that the teaching programme was delivered, I hoped that my ongoing interest would encourage the student’s own development and that of Ghana’s future mental health service.
Neate, G. Out of Programme Experience in Ghana. Royal College of Psychiatrists. Retrieved July 9 2011 from http://www.rcpsych.ac.uk/members/internationalaffairsunit/volunteersprogramm/ghana-maytoaugust2010.aspx
Asare, J. Mental health profile of Ghana. International Psychiatry 2010; 7, 67-8.
Read U, Adiibokah E, Nyame S. Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana. Globalization and Health 5:13. 2009
Declaration of Interest
The Royal College of Psychiatrists provided my airfare to Ghana as a registered volunteer with the College. The Kintampo Project provided my transport and accommodation while teaching in Kintampo.
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Tags: CMHO, Community Mental Health Officer, Dr Mark Roberts, Dr Tess Maguire, Ghana, Kintampo Rural Health Training School, MAP, May 2010, Medical Assistant Psychiatry, Patrice Fugah, psychiatry, Royal College of Psychiatrists, teaching, the Kintampo Project