Diplomatic Psychiatry: Ghana’s Reconciliation of Chemistry with the Divine
Updated: 38 minutes ago
Written by Sam Tomlinson
*The Names of individuals within this article have been replaced with pseudonyms to protect their privacy
I had not done my homework before going to Ghana, but I soon realised it was a place of extremes and intense contradictions. Like a palimpsest, Ghana’s identity has been written and rewritten time and again. History has pulled it in multiple, sometimes diametrically opposed, directions, shaped by the countries and indigenous groups that have fought over it. These include Europeans such as the Portuguese, Dutch and British, and indigenous groups such as the Ashanti, Denkyira and Gonja. These factions were often hostile to one another, but sometimes they co-operated. Touring Elmina Castle, an epicentre of the transatlantic slave trade, our guide condemned the cruelty of Europeans and indigenous tribes alike. He explained how ascendant tribes sold war captives to European merchants in exchange for firearms, gunpowder and ammunition. These weapons were then used to win further victories and enslave further captives: a vicious cycle of lucrative oppression.
Ghana’s historical DNA contains numerous examples of this kind. Strands of conflicting cultures and ideas have opposed, reinforced and, at times, unified one another. I believe this pattern resembles the double helix structure of DNA itself: two strands that separate and reunite at successive nodes. One such double helix is the relationship between drugs and religion. Both represent different human responses to suffering. One primarily alters biological states; the other transforms meaning and experience. In Ghana, these strands have converged in the domain of psychiatry. This intersection cannot simply be dismissed as a symptom of underdeveloped medical practice. To do so would be to overlook what Ghana reveals about the complexity of suffering. Indeed, Ghana may offer a glimpse of where Western healthcare is heading: a renewed convergence of seemingly disparate approaches to healing.
Drugs
Ghanaians originally used drugs within rituals. Palm wine, pito and potent distilled spirits crept into funerals and chieftaincy ancestor ceremonies, midwifing participants from the material world into the spiritual realm. Later, cannabis was introduced through trans-Saharan networks in the 17th century and spread further with expanding maritime commerce. But the real change came during the late Cold War period. Production of the leading exports, cocoa and gold, declined, and the country faced the political instability of repeated military coups. The result was an economic crash. Then, in 1983, Nigeria forced one million Ghanaian migrants to return home. They came back to find that severe droughts and bushfires had destroyed their farms and food supplies, and millions of Ghanaians moved to the cities looking for work. At the same time, as Cold War tensions eased, international trade barriers loosened. Countries realigned their economic policies around neoliberal principles, which encouraged exports and foreign investment. Ghana became a trade route embedded in global commodity chains. These two factors, rapid urbanisation and greater openness to international trade, provided fertile ground for drug markets.
Today, Ghana is a major drug trafficking hub. It has a convenient location, weak law enforcement and, being anglophone, a useful lingua franca. As a result, Ghana is a heroin middleman between Afghanistan and the US, a methamphetamine fulcrum between Nigeria and South Africa, and a cocaine nexus between Latin America and Europe. But an overloaded artery eventually bursts, and the flow of narcotics has seeped into Ghana’s now densely populated cities. What began as a localised abscess of cocaine and heroin use in the south has since metastasised to the far north.
Drug use in Ghana piles pressure onto an already severely underfunded healthcare system. Unfortunately, it is also partly fuelled by corrupt government officials. While there are no doubt honourable state actors working hard to stop the spread of illicit drugs, institutional corruption is clearly pervasive. Drug traffickers, for example, were alleged to have funded presidential campaigns as recently as 2016. To illustrate the moral ambivalence of some Ghanaian authorities, I will relay an experience I had a week after arriving in the country.
Driving back from an art gallery in Accra, the capital, my colleagues and I were stopped at a checkpoint next to the national police headquarters. A tall officer ordered us out of the vehicle. “Why were there five of you in the car?” he asked, his voice deep like a tuba. “There are five seats in the car,” replied Emmanuel, the head of our organisation. The officer walked up and down the road shaking his head, with Emmanuel following him. Finally the officer asked, “How much are you putting on the table?” Emmanuel was obliged to pay.
In Cape Coast, I remember a hovering periphery of cocaine and heroin users around the ports and manual labour sites. This was a far cry from the religious rituals in which substances were historically used. But this more secular form of consumption is not without its own existential telos. The two drugs I saw used most were cannabis, the country’s most popular illicit substance, and tramadol, a pharmaceutical opioid chiefly imported from India and taken at high doses for its euphoric, relaxing and sedative effects. In Ghana, I saw cannabis used in the same way that tramadol is marketed: as a painkiller. This was true in a literal sense, as the lack of standardised medical care meant both were used to self-medicate physical injuries such as burns. But it was also true philosophically. It felt like users were trying to anaesthetise themselves against hopelessness.
My friend Kwame had been working for months without pay, much like a labourer I spoke with at Fetteh Hospital who had been admitted for cannabis addiction. Neither had a ladder to climb or an avenue to explore. Their jobs were boring and passive. I remember seeing Kwame checked out on the balcony, joint in hand. When he was happy, dancing and smiling, he was high. In the morning, he looked sad. Over on the rehabilitation ward, a patient I worked with, Leon, had dwindling educational prospects when a troublemaker took him under his wing. Together, they catfished people in America and Europe and tricked them into sending money. This rise in status, combined with tramadol, kept them sky-high for months. But when he told me the story in rehab, he once again had no money, and his brief taste of abundance had become a distant anecdote.
Religion
Having outlined the history of drugs in Ghana and the existential, albeit secular, reasons for their use today, it is time to turn to the other strand of the double helix: religion. Traditional West African religion holds that there are two worlds, the material and the spiritual. They are porous and complementary, but the spiritual is superordinate. There is a Supreme Being, known by names such as Nyame, Mawu and Ataa Naa Nyɔŋmɔ. Beneath this being sits a pantheon of lesser, more active entities, the most notable of which are ancestor spirits. These beings float around the land of the living, offering guidance and good fortune to their relatives, provided, of course, that they receive the necessary libations and sacrifices. This matters most at death, when ancestors act as psychopomps. If you have just died and want a pleasant journey into the next world, you had better pay your respects. This is why, if you go to Ghana, you will see enormous funerals. Inside the coffins you will find money and heirlooms, and outside you will see drummers and dancers skipping from the morgue to the burial site.
In Ghana I met spiritual people wherever I went, but most were not just spiritual; they were Christian. Christianity was brought to Ghana by European coastal trading powers from the 15th century onwards. The Portuguese came first, introducing Catholicism. Then came Protestantism, brought by British and German missionaries in the 19th century, which proved far more influential. The Protestant emphasis on a direct, personal experience of God resonated with the existing spiritual phenomenology of West African belief systems. This allowed a syncretic form of religion to develop, reaching its apotheosis in the Church of Pentecost. There, Ghanaians kept their belief in a spiritual pantheon, but the Supreme Being was replaced by the Holy Trinity.
Today, Ghana stands out worldwide for its religiosity. Some 99% of Ghanaians report a religious affiliation: 70% are Christian, 20% are Muslim, and the remainder is a mix of traditional religion, Hinduism, Buddhism, the Bahá’í faith and others. Of Ghana’s Christians, 44% are Pentecostal or Charismatic, 24% are Protestant, 14% are Roman Catholic and 17% belong to other denominations. It seemed as if there was a religious building on either side of every street and a religious convention in every town square. The syncretism described above fostered a reverence for spiritual gifts, healing, speaking in tongues, spiritual warfare and, perhaps most significantly, the prophetic ministry. Prophets operate through the Charismatic churches, a more individualistic expression of Pentecostalism that follows the same spiritual logic.
Perhaps the best way to examine Ghana’s religious phenomenology is through a personal anecdote. One Sunday I attended a local Charismatic church. The congregation was dressed in immaculate colours, and on the walls hung posters of two men gazing piously into the distance, one of whom was said to be a prophet. He was leading the service. He preached on the familiar themes of spiritual warfare, his sententious charisma booming through a crackling microphone. Eventually he asked, “Who wants to be saved?” A middle-aged woman volunteered. The prophet called on Jesus for help and rebuked the evil spirit inside her. Then he made a slashing movement with his arm and yelled, “Be gone!” She dropped to the floor, writhing, screaming and wriggling as though a hundred spiders were crawling inside her clothes. Eventually she lay limp on the ground and was lifted into the congregation’s arms.
The whole room queued up to be saved. All around me, people were tumbling over, struck by the prophet’s beam of righteousness. Eventually it was my turn. On hearing that I worked on a psychiatric ward, he announced that he would endow me with prophetic powers so that I might excel in my profession. He spoke in tongues and then gave me the force field push.
I wanted it to work, and I did not want to be a killjoy, so I fell to the floor and shut my eyes. I stayed there for five minutes, at one point squinting them open like a child cheating at Marco Polo. To my relief, the congregation was still there; the prophet was addressing them in Twi. Eventually he switched back to English and whispered, “He is in the spirit world.” Was I? It was news to me. As the crowd lifted me up, I made sure to copy the posture of surrender I had seen in the middle-aged woman. The prophet declared that I was now a prophet. He ran over to a member of the congregation and yelled, “Prophesy!” Torn between a reluctance to deny the congregation’s beliefs and a reluctance to give in to the social pressure of religious zeal, I decided simply to say whatever impressions came to mind. Some seemed to land; others clearly missed the mark. But every time, the prophet shouted in exaltation: “You see what he said? He is seeing into your future!” My success was his success, and every roar of admiration for my clairvoyance protected his reputation. I stopped after the fourth prophecy
I do not wish to belittle the service I took part in. The sense of community among the religious Ghanaians I met was second to none, and the people in those communities often conducted themselves with great integrity. But the risk of charlatanry is obvious, and I will return to it later. First, it is necessary to introduce the node where our two strands, drugs and religion, meet: psychiatry.
Psychiatry
For nine weeks I volunteered at Ankaful Psychiatric Hospital, one of the country’s three psychiatric hospitals. Walking the wards reminded me of an open-air prison. With its enclosing walls, patch of grass in the middle and locked doors, I found myself mistakenly referring to the patients as inmates. First impressions aside, mental health services in Ghana have come a long way. Psychiatry in the country was first shaped by the colonial Lunacy Ordinance. Established under British rule, it rested on the idea that mental illness destabilised social order, so those deemed responsible for the disturbance had to be removed for custodial rather than therapeutic purposes. The British opened the Accra Asylum in 1906. Perhaps it was the remnants of this ethos, which persisted for half a century, that gave Ghana’s psychiatric institutions their prison-like air.
Things changed in 1965 when Ghana’s first president, Kwame Nkrumah, sought to make mental healthcare a rehabilitative state responsibility. He founded psychiatric institutions and embedded mental health services within the national health service. However, living conditions remained poor and patients still had few rights. This was finally addressed by the sweeping reforms of the 2012 Mental Health Act. Mental health services with multidisciplinary teams were integrated into general hospitals, community outreach received funding and the government invested in professional training programmes. The Act also improved hospital living standards and gave mentally ill patients rights: they could no longer be arbitrarily dismissed from work or sectioned simply for looking odd. At the hospital, I was struck by posters reminding patients of their legal protections, a dark homage to a time thankfully past.
A positive vision for psychiatry in Ghana is emerging, but its implementation lags behind. Around 2.3 million Ghanaians experience mental health problems, yet the sector receives a meagre 1.4% of total government health spending. During my time at Ankaful, I do not recall meeting a single psychiatrist. What I saw instead was an institution run by psychiatric nurses. This reflected the national picture: there are only 39 psychiatrists in the country. Psychotropic drugs are also scarce, and nurses have reported using their own salaries to buy medicine for patients.
Ghana’s intensely religious landscape, combined with underfunded psychiatric institutions, means that spiritual frameworks remain prevalent in mental healthcare. Mental distress is approached through psychiatry, spirituality or both. Recently, a Ghanaian friend of mine grew worried about his mother, who was behaving and speaking in ways reminiscent of schizophrenia. To me it seemed obvious that she should see a psychiatrist. Instead, she was taken to a pastor. A few days later, I walked into the kitchen to find my friend beaming: his mother had recovered. Less happily, some Ghanaians are still sent to prayer camps. At best they receive guidance from a caring pastor. At worst, to quote a nurse, “a patient is tied to a pole and remains there whether rain or shine, or they are made to fast for prolonged periods.”
Sometimes psychiatry and spirituality are applied in parallel to the same patient. At Kasoa Hospital, a girl was being treated for social anxiety. The clinical psychologist was using cognitive behavioural therapy, yet her case notes included a spiritual diagnosis from a priest: she had been shot in the spirit realm. Another patient, this time at Ankaful, had been admitted with schizophrenic psychosis. Nurses had prescribed antipsychotic medication and she was receiving cognitive “insight therapy” for her delusions. Yet the notion that her model of reality was mistaken was complicated by the fact that the psychologists had to wait for the pastor. The patient was a soothsayer, and only a spiritual professional could identify the right exorcism ritual to expel the demonic spirit with which she had become entangled.
However, the most interesting cases I encountered were those in which psychiatry and religion were synthesised. Many clinical psychologists in Ghana are also pastors. This may look like an epistemological conflict of interest, but that is not how it played out. One patient with schizophrenia refused her antipsychotic medication because she believed the voice she was hearing was God’s. I watched the clinical psychologist go toe to toe with her on scripture. “Is God all-powerful?” he asked. “Yes,” she replied. “If that is the case,” he said, “then how could taking this pill subvert the will of God? If you take this pill and the voices go away, then clearly the voices you were hearing were not God’s.” This seemed to convince her.
Another example is Osei, a teacher who had quit his job to preach the Word. He was convinced he had received the call from God and now had to reject the material world in His service. He had grabbed the roots of his life and pulled as hard as he could. Soon he had no job, no relationships and no money, but he was still not preaching. It was clearly a sub-optimal state of affairs, yet the psychologist treating him did not ridicule the idea that God could intervene in a man’s life. Instead, he explained how to tell an impulsive, quixotic fantasy apart from a practical reorientation of one’s life towards religion. St Francis of Assisi heard the voice of God but, unlike Osei, combined his ascetic lifestyle with productive missionary work. By teaching both Osei and the woman with schizophrenia to separate the wheat from the chaff, this reverend-psychologist offered a therapeutic framework that made psychiatric medication more palatable, helped patients without alienating them from their worldview, and did not undermine the power of spirits.
Why would a judicious, knowledgeable psychologist tolerate ideas of the supernatural? This is where the threads of this essay come together. Each of the domains explored, drugs, religion and psychiatry, represents a response to suffering, whether productive or counterproductive. Which is most closely aligned with reality? Frontier neuroscience suggests the answer is less clear than we once thought.
The West
Does the persistence of religious frameworks within psychiatry simply show that Ghanaian healthcare lags behind the West? A cynic would say yes, and there is some truth in that. Yet this view risks overlooking the complex reality of suffering and where the ultimate answers to it may lie. In the West, we generally believe that phenomena are the product of cause and effect: if something can be observed, science will eventually explain it. Yet when we consider the most reliable and significant mental health interventions, can their effects truly be reduced to scientific explanation alone?
Despite the continued secularisation of Western culture, the spiritual realm appears to be making a comeback. This is most evident in the growing field of psychedelic research. The work pioneered by Roland Griffiths at Johns Hopkins School of Medicine is a prime example. His studies showed that a single high dose of psilocybin, the classic hallucinogen found in magic mushrooms, could turn some lifelong smokers away from cigarettes, ease the existential dread of terminal cancer patients and significantly reduce symptoms of anxiety and depression in chronic sufferers. Psilocybin can also increase participants’ Openness, a personality trait associated with creativity and curiosity. Participants have even rated the psychedelic experience among the five most meaningful and spiritually significant moments of their lives.
Neuroscientists have tried to measure the neurobiological basis of these striking results. But while science may identify the neural correlates of the experience, it is unlikely ever to penetrate its essence. Consider this: in the psilocybin studies, the size of the effects described above tracked the extent to which participants described their experience as mystical. The higher they scored on the Mystical Experience Questionnaire, the greater the benefit. Crucially, when participants are given high doses of psilocybin but have their 5-HT2A receptors blocked (the mechanism behind its psychedelic effects), the subjective intensity of the experience diminishes. Research has yet to establish whether psilocybin without its psychedelic effects is therapeutically effective. However, given the relationship between therapeutic outcomes and psychedelic intensity, I would venture that the experience itself, rather than the compound alone, may be the key mediator of psilocybin’s psychological benefits. In light of this, Western approaches to mental healthcare must, at least in part, cede territory to the mystical.
A leap of faith into what we can never fully understand is a common thread in highly effective mental health interventions. In psychedelic studies, participants are told to “trust, let go and be open”. In the Twelve Step programme of Alcoholics Anonymous, one of the most effective frameworks for long-term sobriety, the first three steps are admitting powerlessness over alcohol, coming to believe that a higher power can restore one to sanity, and turning one’s will and life over to that power. Like psychedelic therapy, this treatment centres on spiritual transformation. The pinnacle of the psychedelic mystical experience is a phenomenon called ego dissolution; a favourite mantra among recovering alcoholics is “I went from being the centre of the world to being part of the world.”
One of AA’s two founders, Bill Wilson, was in fact inspired by a drug-induced experience. In December 1934, Wilson was hospitalised for alcoholism and given belladonna, a hallucinogenic deliriant. He had a spiritual awakening accompanied by a profound “white light”, and afterwards lost his desire to drink. This first intimation of the divine was consolidated and systematised for Wilson by the Oxford Group, a Christian revival movement that espoused surrender to God, confession, personal inventory, restitution and helping others. The combination of Wilson’s experience on belladonna and his time with the Oxford Group inspired the Twelve Step programme, which is still widely used today. It seems that, as in Ghana, combining drugs and religion to relieve suffering is not such a contradiction after all.
Both science and religion carry benefits and costs. Psychiatric medication is often essential. If a patient with schizophrenia has no access to antipsychotics, the chance of them being freed from dangerous delusions and frightening hallucinations approaches zero. But relying solely on, say, antidepressants brings two problems: unwanted side effects, such as reduced libido, and treating the symptom rather than the cause of a person’s suffering. Is a patient depressed because of a hormonal imbalance, or because he has neither a job nor a family? Psychedelics carry their own risks too. They have the potential to revolutionise mental healthcare, yet the rise of “guru ego”, a term for people (often psychedelic practitioners) who consider themselves spiritually awakened and therefore entitled to use their supposedly superior wisdom to manipulate others, poses a growing threat. Even a brief look at the history of psychedelics shows the perennial risk of their use being co-opted by cultish influences; Timothy Leary and the Manson Family are ominous warnings. Even seemingly harmless spiritual practices such as meditation are not free of risk, with some studies finding that experienced meditators score above average on certain dimensions of narcissism.
Indiscriminate religious deference can also be harmful, as the risk of charlatanry mentioned earlier makes clear. Charismatic individuals can bend the fervent piety of a congregation towards their own self-serving pursuit of status and wealth. Yet I must stress that the most welcoming and generous communities I encountered were invariably religious. Moreover, even seemingly extraordinary propositions, such as the therapeutic value of exorcism, have found support from prominent psychiatrists such as Dr M. Scott Peck and Dr Iain McGilchrist. This is not to say that every supernatural claim deserves credence. Rather, it shows that rejecting spiritual approaches to healing out of hand deserves the same scrutiny as accepting them blindly.
My account of Ghana is not, then, a call to place religion above the scientific method, nor to abandon spirituality in favour of psychiatric medication. Rather, it is a rebuttal, grounded in the lived experience of the Ghanaians I met, of the way these two domains have become divorced in our collective imagination. Suffering is often accompanied by a desire to change one’s consciousness. As I have shown, this can take the form of the euphoria of opioids, the spiritual catharsis of an exorcism, the numbing effect of antidepressants or the reassurance of religious dogma. Amid these many responses to suffering, one truth has emerged: the seemingly separate strands of drugs and religion are more connected than we realise. They have reunited at the node of Ghanaian psychiatry, and in the West, the same double helix is beginning to re-form.