The Handbook of Forensic Mental Health in Africa

Adegboyega Ogunwale, Adegboyega Ogunlesi, Stephane M. Shepherd, Katrina I. Serpa, Jay P. Singh, Adegboyega Ogunwale, Adegboyega Ogunlesi, Stephane M. Shepherd, Katrina I. Serpa, Jay P. Singh

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000405057
• Edition: 1
• Topic: Medizin
• Subtopic: Psychiatrische & psychische Pflege

The Handbook of Forensic Mental Health in Africa traces the history of forensic mental health in Africa, discussing the importance of considering cultural differences when implementing Western-validated practices on the continent while establishing state-of-the-art assessment and treatment of justice-involved persons.

Experts in the field of forensic mental health throughout Africa explore the current state of forensic mental health policy and service provision, as well as the unique ethical challenges which have arisen with the recent growth of interest in the field. The African and international research literature on violence risk assessment, competency to stand trial, malingering assessment, Not Guilty by Reason of Insanity (NGRI) evaluations, report writing as an expert witness and mental health legislation in the context of forensic practice are explored throughout. Finally, future directions for forensic mental health in Africa are discussed for juvenile, female and elderly offenders.

This text is ideal for mental health, criminal justice and legal professionals working in clinical, research and policy contexts.

Part I

Introduction

1 The history of forensic mental health in Africa

Adegboyega Ogunlesi and Adegboyega Ogunwale

Introduction

Mental health and by extension, forensic mental health, had been confined to the back burner in many Sub-Saharan African countries for various reasons. Njenga (2006) articulated some of these reasons in the World Psychiatry medical journal. Not much has changed since then. The problems include widespread preternatural beliefs about mental disorder in deeply cultural African societies, stigma, and low budgeting for health generally (subliminally for mental health). Others include the focus on urban or peri-urban non-decentralized, stand-alone, often-neglected mental health facilities (“orphan units”) where the dignity of clients is accorded little respect, as well as absence of modern legislative framework to replace obsolete laws which basically reflected colonial mental health practices in the 18th and 19th centuries respectively. Many African countries were colonized by European powers during those periods (e.g., South Africa by the Dutch and British at various times, Kenya by the British, and Rwanda by Belgium, among others). As such, mental health care approaches in those colonized countries simply mirrored the existent realities within European civilization in those earlier centuries. Equally, the legal framework for mental health services in the colonized countries were modeled after the laws that were in force within the colonial governments themselves. As to be expected, forensic mental health services evolved hand-in-hand with “general” mental health services in most African countries based on this critical interaction between “medical” services related to mental health care and legal aspects of the assessment/treatment as well as custody of the mentally ill. With time, the legal structures or arrangements lagged behind the medical care. Thus, forensic mental health as a structured sub-unit of the overall mental health services suffered a retardation in its evolutionary progress and became shrouded in “mystery and confusion” Njenga (2006) as it became left behind by those fields of psychiatry considered more clinically oriented.

Along this evolutionary trajectory, South Africa provides the most robust history of forensic mental health development in the regional blocks described in this chapter. Gillis (2012) has provided a comprehensive history spanning over five centuries of psychiatry in South Africa since the arrival of the first settlers from Europe in the Cape of Good Hope in 1652. He described three phases viz: the era of restraint, the psychiatric hospital stage, and the modern era when mental health services have become fully developed.

Outpatient clinics as well as legislation providing for community service provision in areas linked with some psychiatric hospitals emerged in the mid-1970s. The first South African academic training leading to the diploma in psychological medicine commenced in 1949. A more comprehensive fellowship program of the Faculty of Psychiatry (later changed to the College of Psychiatry) emerged in 1961. Formal forensic psychiatry practice currently takes place in about seven specially designated hospitals, with about ten psychiatrists having a dedicated commitment to the practice in this field (Ogunlesi, Ogunwale, De Wet, Roos, & Kaliski, 2012). The manpower in this subspecialty should improve in the near future, especially with the emergence of a training program (diploma in forensic psychiatry) by the College of Psychiatrists in South Africa.

In the Eastern Cape, forensic mental health services are provided by the Komani Hospital (Queenstown Mental Hospital) and the Fort England hospital in Grahamstown. Others offering formal forensic facilities in other provinces include Valkenberg Hospital, Lentegeur Hospital and Alexandria Hospital in Cape Town. The Weskoppies Hospital in Pretoria and the Oranje Hospital in Bloemfontein also engage in the delivery of forensic mental health services. Generally speaking, the Eastern Cape is under-resourced with regard to mental health when compared with the Western region (Sukeri et al., 2016).

In the arena of mental health legislation, the first unified legislation was introduced in 1916 (Mental Disorder and Defective Persons Act) and expectedly, emphasized seclusion and restraint in its care approach. Since then, various revisions have occurred to this Act, leading to the most recent Mental Health Care Act 17 of 2002, which replaced the penultimate Mental Health Act of 1973, and is established on the ten basic principles set out by the WHO guiding mental health care law (WHO, 1996). The latest act aligns the country to current global trends, shifting from institutional care to community care, integrating mental health into Primary Health Care and it protects the rights of patients. The history of mental health service development in South Africa would be incomplete without a cursory mention of the influence of the apartheid regime on service provision prior to the dissolution of apartheid in 1994. During this era, service provision for the mentally ill was essentially hospital based and was segregated along racial lines (De Kock & Pillay, 2017), with the inequities in service delivery being predominant in the homelands (Sukeri et al., 2016).

Botswana, an upper middle-income country (World Bank, 2015) with a population of about 2 million people (Statistics Botswana, 2011) has 0.29 psychiatrists and 0.37 psychologists per 100,000 people respectively. It has only one psychiatric hospital in Lobatse with 300 beds, located 80 km from its capital, Gabrone. The Sbrana psychiatric hospital is a stand-alone public hospital with teaching and forensic facilities. There are five psychiatric units in general hospitals across the country (Sidandi et al., 2011; Maphisa, 2019). The Mental Disorders Act of 1969 is the primary legislation focusing on mental health in the country and is self-rated to score four out of five on compliance with human rights covenants. The ongoing efforts at updating the Act are expected to address the perceived shortcomings.

In Kenya, the Mathari Hospital in Nairobi which was previously an isolation center for infectious diseases in the 19th century before it became a lunatic Asylum in 1910 is the largest psychiatric hospital in East Africa. It provides 70% of all the psychiatric beds in Kenya (Ibrahim, 2014). A CNN documentary on Mental Health in Kenya titled “Locked up and forgotten” (Mckenzie, 2011) revealed overcrowding, underfunding, and human rights abuse of patients in this major mental health facility. As a result of this publicized palpable neglect of the mentally ill, a Mental Health Amendment Bill 2018 was passed by the senate in July 2019.

Rwanda, a small country in Central Africa, belongs to the East African block. With a population of about 12 million (2017) (Eytan et al., 2018), it had ten psychiatrists in the entire country as at October 2017 (Eytan et al., 2018), superintending over the two main structures providing specialized care in mental health viz, the Ndera Psychiatric Hospital (foremost psychiatric hospital with a bed capacity of 300 and located in the capital city of Kigali) and the psychological counseling center. A dedicated mental health legislation is not available in the country, but in 2019, a proposal to introduce one was put forward. Legal provisions concerning mental health care are covered in some of the other laws (e.g., general health legislation, disability, welfare, etc.). Eytan et al. (2018) in a study aimed at assessing the practices and needs for improvement in the field of forensic psychiatry in Rwanda, conducted a one-week visit in 2017 and interviewed key stakeholders at decision-making levels in the departments of health, justice and security. Three areas of development and improvement in service delivery were identified:

1. A need for a clearer, updated legislative framework.

2. The need to close the gaps created by the absence of a secured unit, thus leading to a compromise of the quality of care for the forensic patients nursed on general psychiatric wards and the security of the other patients and staff.

3. Gaps in supervision and training in forensic mental health needed to be closed through international collaboration.

With these improvements in place, they envisaged that Rwanda could become in the next few years a leading light to illuminate other African countries in the subspecialty of forensic psychiatry.

Eytan et al. (2018) identified four major developmental stages of the Rwandan psychiatric system. The pre-colonial era (emphasized traditional therapies for mental health care) while the colonial stage saw the inputs of Western psychiatry. During the post-independence stage which commenced in 1962, the foremost psychiatric hospital (Ndera) was constructed. The post-genocide period commenced after the 1994 massacre, and saw a rise in the number of mental health professionals (ten psychiatrists as at October 2017).

For Uganda, the situation is similar, as mental health services are generally skewed to the urban areas proximal to the capital, while the majority of those living in the rural areas have little access to mental health care. Mental health service delivery is grossly underfunded, with only about 1% of the health expenditure channeled to mental health. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric in-patient units and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had a specialized training in psychiatry (Kigozi et al., 2010).

The Ugandan mental health legislation (The Mental Treatment Act of 1964), which provided no guarantee for the rights of the stigmatized mentally ill, was replaced with the Mental Health Bill 2014, which provides a more humane template for the mentally ill, in terms of rights protection and provision of treatment facilities at Primary Health Care Centers, among others (World Economic Forum, 2019). The history of forensic psychiatry in West Africa may, arguably, be traced to the colonial societies that emerged from the mid-19th century onwards. Prior to 1951, there were no African psychiatrists on the continent (Forster, 1962). The earliest forensic mental health practice could be said to have been stimulated by the Lunacy Asylum Order, Cap 70 of the Gold Coast (modern-day Ghana), which was passed in 1888 (Asare, 2012; Ogunlesi et al., 2012).

By the governor’s order, the old High Court in Victoriaborg was converted into the first lunatic asylum in the Gold Coast (Forster, 1962). The order essentially made provisions for the custodial care of mentally ill patients, which was basically imprisonment given the absence of effective treatment for mental disorders at the time. Within 16 years, the number of inmates had surpassed 100 and a few years later, a purpose-built asylum was built on the outskirts of Accra. Patients in this new facility were looked after by a visiting doctor who was also in charge of the prisons. In a primitive but quite ingenuous means of achieving some form of forensic psychiatric rehabilitation, the “criminal lunatics” were saddled with the responsibility of preparing the meals of other patients under the nurses’ supervision (Forster, 1962). Currently, there are three mental health hospitals...