Changing times, changing minds: the introduction of psychotherapy in Uganda and Latvia

In this interview both lecturers discuss the similarities and differences between the introduction of psychotherapy in Uganda and Latvia.

What are some common misconceptions about anthropology?

It’s actually hard to explain what anthropology is because you can do so much with it!

Agita Lūse: People in Latvia have had various associations with the word “anthropology”. Up until the late 1990s anthropology was only known as physical anthropology, or biological anthropology. It was practised by, for example, historians who examined the morphological traits of human remains. I remember telling friends or acquaintances that I was going to study anthropology in the ‘90s and getting asked ‘Is it about skeletons? Is it about digging up old bones?’ They were thinking of paleo-anthropology. Social anthropology only became better known here in Latvia when first students got their degrees in social- or cultural anthropology in the late ‘90s. Social anthropology was already quite well known by the 2000s. This was partly thanks to the fact that one of the first Latvian social anthropologists, Roberts Ķīlis, became the Minister for Education and Science.

Julia Vorhölter: It is similar in Germany. People associate anthropology with a kind of physical anthropology, but there are different terms that are used to refer to what we now call social- or cultural anthropology. It used to be called “Ethnologie” or “Völkerkunde” which translates to “the study of peoples”. People, particularly older people, have associations to classic village-based studies in Africa, Asia and South America. People are usually quite surprised at the range of topics that anthropologists study these days. We have these student information days for incoming students, and there one of the questions is always ‘So, what is anthropology?’ It’s actually hard to explain because you can do so much with it! For me, anthropology is about taking a comparative perspective on an issue, like studying how people in different cultural or class contexts think about health.

Could you summarise your field of study?

Vorhölter: My research is based in Uganda, a small east African country. I’ve been working there since 2009, and my current project is to study the emergence of Western-style psychotherapy. Psychiatry has a much longer tradition in the country, as it was already established during colonial times, but the emergence of psychotherapy, is something quite recent. It’s basically emerging in two different ways in Uganda – one centre where it’s emerging is Northern Uganda that was ravaged by a civil war for about 20 years until 2006. After the war ended, there was a big humanitarian relief operation, and increasingly these interventions started to focus on trauma and trauma healing. Psychologists came in to provide more proper therapies all in some way or other based on cognitive behavioural therapies (CBT), so short-term therapies. So in the north it’s all based around trauma.

My work, however, is mainly focused on the second centre which is the capital, Kampala, and the way in which psychotherapy is emerging there. There it is a much more middle, or upper middle class phenomenon. The first private psychotherapy practices were set up there around 2000, and a few years before that the first master’s courses in psychology and psychotherapy were set up at one of the universities. I’m mainly looking at a very small group of Ugandan psychotherapists who are really driving this development.

The kind of issues that the upper middle class people are dealing with are related to lifestyle challenges associated with upward mobility like combining work and family, their relationships with families back home in villages and financial pressure. Forms of stress that I think we find in a lot of places around the world. The increasing interest in psychotherapy is both due to social media and films, for example. This is where they come into contact with what it is, and with terms like “depression”.

Lūse: For my doctoral thesis I researched topics related to medical anthropology, more specifically the anthropology of psychiatry – I was looking at the way in which people’s notions of mental distress changed in the decade following the collapse of the Soviet Union. My focus was basically on the westernisation of psychiatry in Latvia. I conducted interviews with psychiatrists, psychotherapists, patients as well as with some NGOs. At this time various groups appeared as civic initiatives where professional psychotherapists would work with locals so that they would be able to go on and help others in the community. One case study was about an NGO that was funded by American Latvians that was specifically directed at supporting families dealing with mental distress. It was hoped that it would continue after the professionals left, but as soon as the funding ceased the movement stopped. This was in part because the first participants were struggling with their own problems like everybody else at that time.

The ‘90s were an especially trying time as society transitioned to capitalism and was changing in very fundamental ways all around them. People had to find new ways to earn a living, they had to switch professions and acquire new skills, but the main feature of these times was a switch to a more individualistic mode of solving one’s problems. This idea of the autonomous individual was propagated via different channels like mass media and self-help books.

It sounds like there are similarities between how psychotherapy was introduced in Uganda in the 2000s and in Latvia in the 1990s, which coincides with the advent of capitalism and neo-liberalism in both countries. The systems that preceded capitalism were, however, different – do you see similarities, or are the countries too dissimilar to compare?

I think there are a lot of similarities, like the start of a more individualistic lifestyle that particularly people in the middle class experience.

Vorhölter: They are very comparable. In Uganda the neoliberal era started in the mid- to late-‘80s, but it is a very diverse country, so it depends on where you go. Life in the cities can be very fast-paced and middle class and that’s certainly not how people in more rural areas live. So obviously the discourses and practices are different there. 

How do people relate to psychotherapy and concepts of mental health? What do they associate it with?

I would say that the younger generation is much more open to all kinds of ways to improve their mental health.

Lūse: Reactions are definitely generational. The emphasis now, especially among young middle class people, is on enhancing mental potential. Dealing with everyday stresses is important, but a lot of the time they approach therapy thinking about how to adjust to a dynamic lifestyle and to all kinds of professional challenges. People have to make important decisions, and have to take on a lot of responsibility, which, of course, creates stress on a regular basis. So it means that some are even ready to try psychiatry, not just psychotherapy, hoping that psychiatric treatments like anti-depressants can help them. They can perceive this as, what is this term? Cosmetology! Mental cosmetology. People sometimes hope to become better than normal, and enhance their potential. I have to emphasise that these people do not make up the main body of patients, however. 

Regarding the older generation, I think it’s mostly people above 50 who were brought up in the Soviet era whose ideas about psychiatry are very stigmatised.

Vorhölter: I’ve found an interesting similarity in my research, where some companies increasingly want to send their employees for psychological check-ups with the rationale that if they have issues on their mind that they can’t concentrate on their work.

Self-help literature is becoming much more prevalent, and people go online and learn about terms like “depression”. So thoughts about what happiness is, or what is normal are changing. It’s not necessarily about becoming better than normal, but attitudes around mental health are definitely changing.

New discourses on psychotherapy include a much broader range of people, because they conceptualise the problem in terms of mental health rather than mental illness.

Psychiatry, on the other hand, has been around since the colonial times. Here the focus has, however, been on people who are severely mentally ill. I think everyone has a problem with their mental health in one way or another, but people who have less formal education and do not live in the urban centres still associate "psychiatry" with a narrower category of “crazy” people, so there’s a lot of stigma associated with it.

What is the relationship between individual and community, personal improvement and community healing in both Uganda and Latvia?

Vorhölter: I think it’s quite an interesting thing, because I think that middle class people in urban areas in Uganda live a kind of very western lifestyle. They’re experiencing exactly that conflict – for them upward mobility means they have fewer children, they live in fenced-off houses, and their children don’t grow up in communal spaces anymore. They spend hours every day in traffic jams, they have stress trying to earn money, and schools are massively expensive, so in order to be able to maintain this kind of lifestyle they have huge amounts of stress. This is in part where a lot of their mental health issues come from. The therapists I talk to see that some of these issues wouldn’t come up in more communal contexts, while at the same time asking where therapy can intervene. 
There’s been interesting work done by anthropologist Leith Mullings who worked in Ghana in the 1980s. She describes how any type of therapy is always about aligning the individual with the broader social context. The more traditional healing approaches are like socio-therapy, and they’re about re-integrating the individual into the social and cosmological order. Whereas psychotherapy, on the other hand, is by definition very much about the individual and trying to enable the individual to live in a neoliberal context.

There’s a lot of focus on “self-responsibilisation”, which I think can both be a positive and a negative thing. Saying to someone ‘It’s down to your agency, you can change this. It’s not society, or spirits, or ancestors, or elders, or the church, but you yourself have it in your hand to shape your life like you want it to be,’ can be liberating, but at the same time it’s obviously also a big burden, because you’re basically saying ‘If you can’t manage it, it’s your own fault.’ I think people find it very compelling, because they’ve grown up in a much more hierarchical context where there are always particular authorities that tell them how to live their lives. Now all of a sudden they are in these much freer spaces, but it comes at the cost of not having that kind of social structure.

Lūse: There are a lot of similarities to Latvia, it seems! Adapting to life in a society where everybody else minds their business, where there is less hierarchy, and more responsibility hasn’t come very easily to people here. It has demanded us to change our mind-set and to re-organise family, work and neighbourly relationships. Listening to Julia I was considering the fact that I actually very rarely see children play in the yard, although I live in a multi-storey building with quite a nice green yard, I actually only see people walking their dogs there. Smaller children do go across the road to the park, but then always accompanied by adults. Communal life really has been reduced to special occasions or festivities when people meet up. Overall the contact between relatives is also no as regular as it was in the ‘80s and ‘90s.

It seems there is this demand in society to look at a wider perspective, rather than only solving one’s own problems or adjusting ones thinking and feeling to social expectations. There is an interest in inheritance and generational patterns. This can be seen in approaches like family therapy, which is less common, or in people examining their roots. This very often means that people broaden their knowledge of what has happened in previous generations. Equally, it is about how certain historical and political events have affected their family, like a world war, repressions or deportations. This helps people understand what our surroundings have given us, and where certain models and patterns of thinking and feeling come from.

If these environmental and social factors affect our well-being, is there a movement to join the more invidualistic therapy approach with broader activism or activities to improve the surroundings that might be contributing to people’s mental health?

Vorhölter: I think in Uganda, most of the therapists I talked to certainly saw themselves as agents of positive change. They weren’t necessarily thinking that they could totally change these lives, because there are huge issues like the rapid changes in urban cities, the work stress, and the impact of the war in northern Uganda. I don’t think any one of them was under the illusion that they could really change these larger structures in society.

But what I did encounter a lot was people, particularly in northern Uganda, saying that for most people trauma is not necessarily the appropriate approach, because the problems they face in their day to day lives, like gender based violence, or family issues, cause bigger problems to their mental health, rather than something that happened in the past. For example, a woman from a rural setting who experiences gender based violence at home due to her role in the marriage, family and clan is not seen as an individual. For her, therapy can offer a space where she is really seen as an individual and even though you can’t change her family structure, and you can’t even tell her to involve the police, because of the way the larger structures work, you can give her one hour or so where she is seen as an individual. For some people that’s hugely empowering in its own right. This is activism in a different way.

Lūse: From my point of view I would like to add that art, like the performing arts and literature, have a lot to contribute to promoting new understandings about this matter – how individual well-being comes into contact with society, and how a society accepts people changing. Maybe this self-reliant, autonomous approach is not always the most desirable for a society. Our social environment very often expects us to be ready to contribute and cooperate in order to feel solidarity and empathy, to always try and to find this balance. I have observed that young artists are trying to advance these questions. How we react to diversity of expression, how we relate to individual pursuits of happiness, and what consequences there are for families, children, colleagues and friends. It’s really a matter that needs to be constantly discussed among people in different environments, and art can very much promote this discussion because it addresses us as moral ethical beings who are constantly faced with challenges. How to react to changes, to new values, new norms, also norms of well-being and what wellbeing means for mental health, like is it really a personal matter, or is it really more like community matter?