Mental Health: Global Challenges Journal
ISSN 2612-2138
Mental Health Advocacy in The Gambia, West
Safiya Njai, Stephanie Thorson-Olesen
Antioch University, Seattle, WA, USA
To promote mental health globally, including low-and middle-income
countries, research and advocacy are essential. The Republic of The Gambia is one of the
smallest countries in the world and is the focus of this research.
This study examines social and cultural aspects of access to mental health
treatment in The Gambia, West Africa.
The population of focus consisted of adults over 18 living in The Gambia. The
methodological approach was a qualitative phenomenological study involving semi-
structured interviews conducted via Zoom, by a researcher from The Gambia.
Data were collected from 17 participants living in The Gambia at the time of the
study. A team of analysts with diverse backgrounds evaluated transcripts and identified
five themes highlighting social and cultural conceptualizations of mental health and
mental illness, sociocultural determinants of health, interventions, barriers to care, and
legal frameworks to support mental health change.
The findings from this study are significant for mental health providers who
seek to understand different perceptions of mental health and mental illness and the
associated stigma. Furthermore, this study suggests several opportunities for mental health
advocacy in The Gambia.
mental illness, mental health, The Gambia, Africa, stigma
Address for correspondence:
Dr. Safiya Njai, PhD. Antioch University, Seattle, WA, USA,
This work is licensed under a Creative Commons Attribution-Non-Commercial 4.0
International License (CC BY-NC 4.0).
©Copyright: Njai, 2023
Publisher: Sciendo (De Gruyter)
Submitted for publication: 08
June 2023
Revised: 10 September 2023
Accepted for publication:
16 September 2023
Mental Health: Global Challenges Journal
ISSN 2612-2138
The Republic of The Gambia, commonly
known as The Gambia, is a former British
colony that gained independence in 1965. It
features a democratic system of government
consisting of three branches: the legislature,
the judiciary, and the executive. The president
of the republic is the head of the executive
branch and is assisted by a vice-president and
a cabinet of ministers. The Gambia is one of
the smallest countries in the world, with an
estimated population of 2.2 million people
(World Health Organization [WHO], 2018).
According to The Gambia Bureau of Statistics
(GBOS, 2013), more than half of the
population is female, and over 63% are youth.
Moreover, approximately 50% of the
population lives in rural regions, which
comprise 60% of the country (GBOS, 2013). The
Gambia is also one of the poorest countries in
the world, with an estimated gross domestic
product per capita of $773 in 2020 (World
Bank Group, 2022). The mental health services
comprise one community mental health team
and an in-patient unit called Tanka Tanka
Psychiatric hospital (Kretzschmar et al., 2012).
The exact prevalence of mental illness in
The Gambia is unknown. A situational analysis
of mental health conducted by the Mental
Health Leadership and Advocacy Program
(MHLAP) in 2012 revealed that, of an
estimated population of 1.478 million people,
approximately 120,000 had a mental disorder
(MHLAP, 2012). Since then, the size of the
population has nearly doubled, but no recent
studies have been conducted on the
prevalence of mental illness in the country.
Global Burden of Disease (GBD) statistics from
2017 indicated that more than 34% of
Gambians have a depressive disorder and
35.9% have an anxiety disorder. Mental health
stigma has been identified as a factor
significantly affecting people with mental
health problems in The Gambia.
Stigma is a pervasive condition that often
discredits individuals and leaves them feeling
lesser than others (Abdullah & Brown, 2011;
Goffman, 1963; Monteiro, 2015). The plethora
of emerging research on mental health stigma
in low- and middle-income countries (LMICs)
highlights the role of culture and cultural
differences in conceptualizations and
understandings of mental health (Amuyunzu-
Nyamongo, 2013; WHO, 2012, 2014). In The
Gambia, explanatory beliefs about the
causes and attributions of mental illness and
associated labels are stereotypical, isolating,
discriminating, and stigmatizing toward those
with mental health issues, which may result in
mental health stigma. Empirical studies have
provided a foundational understanding of the
scale, nature, and lack of access to necessary
mental health services (Barrow, 2016; Barrow &
Faerden, 2022; Coleman et al., 2002). These
studies have mentioned the need for better
information on the role, association, and
impact of stigma on care-seeking attitudes
and as a deterrent to service utilization. An
investigation of lived experiences of mental
health stigma would generate significant
findings and serve as a resource for the
Gambian government, which plans and
implements services, and nongovernmental
organizations and institutions that provide
mental health services. Such an investigation
could address the 90% treatment gap
(MHLAP, 2012).
Given the multitude of needs, it is essential
to prioritize those that are most fundamental
to health, including access to treatment and
addressing stigma. Although MHLAP (2012)
indicated that it did not specifically examine
mental health stigma, this factor likely
influences service underutilization. Mental
health in The Gambia is rooted in culturally
nuanced concepts and understandings that
significantly impact the social identity of
people with mental health disorders.
Furthermore, they define treatment pathways
and modalities for mental health care and
fuel the public stigmatization of mental health
The globalization and decolonization of
mental health in Africa have led researchers
and scholars to call for action to extend the
bio-psycho-social framework of mental health
assessment, diagnosis, and treatment on the
continent (Monteiro, 2015). The bio-psycho-
social model has long been used in contextual
approaches to mental health interventions in
low to middle-income countries (LMICs) in
response to the need to address factors that
determine or improve mental health (Engel,
1977). Research has examined systemic and
structural factors in mental health, such as
lack of funding, limited healthcare
infrastructure, lack of mental health policy
and laws, and mental health stigma and
discrimination (Akinsulure-Smith & Conteh,
2018; Becker & Kleinman, 2013; Monteiro,
2015). Although such a model has increased
overall mental health status in LMICs, mental
health remains a stigmatized and neglected
area of health and well-being in these
countries. Furthermore, due to the widespread
prevalence of mental illness, it has been
described as an epidemic in LMICs (Hohenshil
et al., 2015; Monteiro, 2015). As an LMIC, The
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Gambia shares similar systemic and structural
problems as many other African countries with
regard to the prioritization and delivery of
mental health care (Akinsulure-Smith &
Conteh, 2018).
One way to conceptualize views of mental
health in The Gambia is through the
ecological systems theory of human
development, which can be helpful for
examining mental health care and access
(Bronfenbrenner, 1977). Ecological systems
theory considers the influences of multiple
systems at different levels, which interact to
influence individuals’ lived experiences and
the systems that surround them (Crawford,
2020). According to this theory, human
development results from interactions
between developing human organisms and
environments at five significant levels: the
microsystem, mesosystem, exosystem,
macrosystem, and chronosystem. The
microsystem consists of a person’s immediate
environment and includes their personality,
beliefs, and temperament. The mesosystem
refers to the connection between different
microsystems. For example, elements of the
microsystem affect the individual’s
experiences (e.g., how school and home
interact). Both the microsystem and the
mesosystem must include the individual.
Systems that affect environments at the
meso level but do not include individuals are
the exosystem, which consists of microsystems
interacting with each other. However, at least
one of the microsystems does not include the
individual at the center of the system. For
example, a parent's workplace does not
include the child, but the latter could be
affected by characteristics of the parent’s
workplace (e.g., the parent is required to work
long hours or stressed from work). However,
because the child is not part of the parent’s
work environment, the workplace is not part of
their microsystems or mesosystems. The
macrosystem influences the characteristics of
interactions between different systems; in
other words, it influences the “social design” of
the broader culture or subculture. For
example, family culture develops within a
family in the microsystem, which is influenced
by the mesosystems and exosystems of each
family member. All of these systems are then
affected by broader society and culture.
Bronfenbrenner emphasized the importance
of cultures within groups and the exchange
patterns within and among groups. This theory
emphasizes the reciprocal effects of these
different systems on personality development
and social and psychological outcomes
(Crawford, 2020). Thus, ecological systems
theory provides an essential perspective for
investigating West Africa, access to mental
health care, and associated stigma. This study
begins by examining individual perspectives,
then identifies themes through a
phenomenological interpretive analysis. In the
discussion of the findings, these themes are
viewed through the lens of ecological systems
theory to provide insight on how different
levels of frameworks interact in the context of
one’s life.
The significance of this study cannot be
underscored enough in the context of
opportunities for mental health advocacy in
The Gambia. First, as an LMIC, The Gambia
should make mental health a public health
priority. Mental health is a global pandemic,
and the treatment gap for mental illnesses is
between 76% and 85% in LMICs, compared to
35% to 50% in high-income countries (Barrow,
2016; Evans-Lacko et al., 2012). This wide
treatment gap necessitates an investigation
of factors that impact this disparity.
Second, Patel and Prince (2010)
investigated the intersection of treatment
outcomes and care-seeking behavior to
bridge this treatment gap. They posited that
current interventions utilized in African mental
health care are ineffective without behavioral
change. Furthermore, Summergrad (2016)
underscored the need for early intervention to
avoid secondary effects not only with regard
to general health goals but also socio-
economic development in particular.
Therefore, qualitative and quantitative
research are greatly needed to understand
the nature and scale of the problem (Barrow
& Faerden, 2022). With this in mind, the current
counseling-, advocacy-, and social justice-
focused research can provide a better
understanding of how mental health is
experienced and thus inform interventions.
Third, although the Gambian government
has acknowledged mental health care as a
priority, it has not yet implemented a
framework for developing a viable system.
Although The Gambia has developed a
mental health policy for 20212030 and
validated a mental health bill in 2019 to
legislate mental health laws, this has not yet
been implemented or enacted. Extant mental
health legislation consists of the Lunatic Act
(1964). Therefore, the findings from this study
could inform mental health policy
development and bring The Gambia in line
with its obligations under the Convention on
the Rights of Persons with Disabilities (2008),
which it ratified.
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Fourth, mental health care interventions
must be decolonized in The Gambia. The
current counseling and social justice research
aim to reflect cultural and social
understandings of the research phenomena
and facilitate closer understanding, empathy,
and more interactions with people with
mental illness. This study is well-situated for this
facilitation through its inquiry into the social
and cultural factors that impact mental well-
being. To approach a study with cultural
humility, a term coined by Tervalon and
Murray-García (1998), health practitioners
must exercise restraint in applying previously
acquired cultural knowledge to avoid
perpetuating power imbalances in the
therapeutic setting (Zhu et al., 2021).
This qualitative phenomenological study
aims to explore and understand experiences
of mental health and the role of mental health
stigma among adults in The Gambia. To this
end, two research questions were developed
for the study. The first research question is,
"What are the lived experiences of mental
health among adults in The Gambia?” The
second research question is, "What is the lived
experience of mental health stigma among
adults in The Gambia?” No hypotheses were
developed due to the qualitative nature of
the study.
Study design
The philosophical ideals that underpin this
study are grounded in phenomenology and
social constructivism, which assume that
absolute realities do not exist. Instead, realities
are constructed through subjective
experiences shaped by the environment and
social interactions (Moustakas, 1994). A
phenomenological approach recognizes the
subjectivity of participants through their
interpretation of the truth, not what is
attributed to or imposed on them by the
researcher (Moustakas, 1994). Therefore,
several steps were followed to gather
qualitative data after the institutional review
board granted approval for the study. No
intervention was undertaken, as this study is
qualitative in nature and focuses on
participants’ lived experiences. For the
purposes of the study, mental health was
defined as a state of optimal well-being that
incorporates physical and mental health
(WHO, 2014). Mental health stigma is a socially
constructed identification that “a social group
creates of a person or group of people based
on some physical, behavioral, or social trait
perceived as being divergent from group
norms” (Goffman, 1963, p. 54).
The population of focus consisted of adults
over the age of 18 in The Gambia. A
convenience sampling strategy and snowball
sampling technique were used, and
participants were recruited through various
means (e.g., email and social media).
Additionally, the informed consent,
demographic questions, and interview
process required an eighth grade-level
understanding of English.
Data sources and collection
To collect data, a recruitment message
was shared with potential respondents,
including a link to SurveyMonkey. On
SurveyMonkey, interested individuals were
asked to review the informed consent form
and demographic questions. The latter
included the following:
Do you live in The Gambia?
Which age range do you fit into?
What is your gender?
What is your marital status?
What is your level of education?
How many people live in your
What best describes your religious or
spiritual beliefs?
Which dates and times would you be
available for a 30-minute Zoom interview
regarding mental health in The Gambia?
Once a suitable date and time for the
Zoom interview was determined, the primary
researcher contacted the participant via
email to confirm these. During the interviews,
the researcher followed a script with a set of
open-ended questions. At the beginning of
the interview, the participant was reminded
that it would be audio recorded. Next, they
were informed of the purpose of the study,
then asked the open-ended questions. The
interview questions included the following:
What do you know about mental
health or mental illness in The Gambia?
How do you think people feel about
mental health/illness in The Gambia?
What is your understanding of how
people see mental health?
What is the meaning of mental health
in your language/cultural group?
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How might people get help for their
mental health issues in The Gambia?
What is your experience with seeking
local and traditional healing for mental
What is your opinion about why mental
health services might be underutilized in The
Upon completion of the interviews,
participants were thanked for their time. The
audio recordings were transcribed, and any
identifying information was removed. The
recordings were then stored on a password-
protected computer for the duration of the
Data analysis
The demographic data were evaluated
with descriptive statistics using JASP, a
statistical analysis program. Then, the
qualitative data were analyzed after the
transcription of the interviews. In
phenomenological studies, researchers are
expected to bracket their feelings,
assumptions, biases, and judgments about the
phenomenon to arrive at the true essence
and a deeper understanding of participants’
lived experience (Moustakas, 1994).
Bracketing allows researchers to process the
identification of the research questions, data
collection, data analysis, and understanding
of the essence of the lived experiences
(Creswell, 1998). Furthermore, as a practice,
bracketing is used to enhance trustworthiness.
All three researchers identified as female and
were aged 33 to 52. Moreover, two
researchers identified as Black and African,
while the third identified as White and of
European descent. During the bracketing
process, it was determined that two
researchers had related lived experiences,
while one had methodological experience.
Potential biases and positionality included the
fact that all three researchers had an interest
in mental health in the population of interest,
were concerned about stigma, and were
aware of the impact of colonization.
Verbatim transcripts of data collected from
the interviews were analyzed. First, a team of
three analysts, including the principal
researcher, developed an understanding of
the data through reading and note-taking.
The data were then coded, and a matrix was
utilized to chart identified commonalities
across analysts. The primary researcher also
collaborated with available participants to
review the data and its interpretation to
achieve triangulation and saturation and
provide some checks and balances.
Throughout the study, the American
Counseling Association Code of Ethics was
referenced (ACA, 2014), and permission was
obtained from the institutional review board to
conduct this research.
Data were collected from a total of 17
participants living in The Gambia at the time
of the study. This section presents
demographic information about the study
sample and reports results from the research,
including direct quotations from participants.
Demographic information
A control question about residence was
asked to ensure that all participants met the
criteria for participation; 100% of participants
indicated that they lived in The Gambia. In
terms of age ranges, one person was 1819
years old, three participants were 20–29 years
old, 10 participants were 3039 years old, one
was 4049 years old, one was 5059 years old,
and one was 6069 years old. Regarding
gender, 70% of participants were male and
30% were female. In addition, 65% of
participants were married and 35% were
single. Regarding level of education, five
participants had a high school degree or
equivalent, seven attended college but did
not obtain a degree, two had an associate
degree, and three had a graduate degree.
When asked how many people lived in their
household, three participants indicated three
to four people, four participants indicated five
to six people, four participants indicated
seven to eight people, four participants
indicated nine to 10 people, and two
participants indicated 11 or more people.
Finally, with regard to religious or spiritual
beliefs, 88% of participants responded that
they were Muslim and 12% responded that
they were Protestant Christian.
Five themes were identified during the data
analysis: social and cultural
conceptualizations of mental health and
mental illness, sociocultural determinants of
mental health/mental illness, mental health
care interventions and bio-psycho-social
interventions, barriers to mental health care,
and legal frameworks to support mental
health change.
Theme 1: Social and cultural
conceptualizations of mental health/mental
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Constructions of mental health and mental
illness differ across cultures and communities.
One participant said, “I want to clarify
something, and I can see that the question
has made a distinction between mental
health and mental illness. Here in The Gambia,
there is not a distinction between the two.”
Regarding etiology, one participant stated,
"Others tend to say that they steal from
people; that is why they are taken to the
marabout and the marabout put a charm on
them. Another participant said,Some
people feel like they are possessed by
demon[s] or things like that, you know. The
public will run away from them because it’s
believed that these people are cursed, an evil
spell from the Devil or wicked spirit.” Another
participant shared that mental health was
also seen as something that could be inflicted:
To some people, it’s just a problem that is
prompted by a jinn. It’s more common here
that people see it as something that is being
inflicted from the spiritual world.” While many
participants believe that the spiritual world
inflicts mental illness, a participant stated, “My
understanding of the whole thing from
people’s perspective is mental illness is not
God’s doing. It’s not God’s doing.” Another
participant said, “Those ones are the ones that
are mentally imbalanced. Like one of their
senses is lacking.” Another participant added,
They lack self-esteem. That’s what they lack.
Self-esteem and common sense.” One
participant explained that “mental health or
illnesses have some interesting classifications,
ranging from drug abuse related, absent-
mindedness either by drug addiction or
affliction by black magic.” Participants also
believed that disease is a cause of mental
health/mental illness. For instance, one
participant said, Epilepsy is also believed to
be part of the problem. Yeah, a gradual
process that can send somebody crazy.”
Another participant stated, “Some believe, for
example, that cerebral malaria causes
[mental illness].”
Many participants questioned whether
there is a cure for mental illness. For example,
one participant explained that, “in The
Gambia, mental health is something that is not
easily curable. It’s not easy for people that
have mental health to recover from the
mental illness in [the] Gambia.” Another
participant also discussed suffering related to
mental illness: “Since I was a child to now over
40 years old, people that I know that had
mental illness are still suffering from it.” Another
participant said, “Traditionally, you cannot be
healed when you have mental health [issues].
You cannot be healed by traditional means.
Something is lacking in your brain, or your
system is lacking something, so a marabout
cannot heal you.”
The participants also expressed concerns
about helping those with mental health issues.
One participant explained, “People fear them
thinking that they might attack them.”
Another participant noted, “Some people
even go to the extent of chasing them away
because they think when people are near the
mentally affected, that they themselves might
also contract the mental illness.” One
participant said, “So, because they don’t
understand it, they have a concept, a
prevalent belief system in the society, a belief
that when you touch them the thing that is
affecting him or her will fight you.” The
participant further shared, “I've seen that. It’s
like when you start helping the person, for
example, even by simply escorting the person
to a healer, like, for example, the hospital or
even the traditional healer, you will start
seeing strange things happening to you.”
Theme 2: Sociocultural determinants of
mental health/mental illness
The second theme focuses on sociocultural
determinants of mental health/mental illness.
Regarding this topic, one participant said,
Personally, from my own point of view, I think
mental illness, if it’s not caused by society,
then society will exacerbate it.” Another
participant stated, “In fact, to be possessed
doesn’t always mean you have to be mad.
However, even with the lack of access to
opportunity here, many would believe the
person is possessed.”
Respondents also suggested that poverty
plays a role in mental illness. One participant
said, “Society now believes that you have to
have money in order to be a human being.
Once you don’t have money, which means
you have mental problem.” Another
participant stated, “The majority of members
of the society feels that once you are poor,
then there’s something happening to you.
Some may call it bewitching, like the guy in
Bewitched; that is why he is poor. The person
cannot have opportunity.” Another
participant said,
In fact, 79 of the patients at Tanka
Tanka, when I asked them, they said
their condition is directly related to
poverty. They traveled to look for money
in Europe or America. And, when
deported, it’s like they have no purpose
living any longer. They said that their
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parents sold all compound or cattle;
they had to send them through back
way to Europe. If they don’t reach or
they are deported, they have nothing
A prominent subtheme was migration or
failed migration. Participants discussed various
issues related to this topic. One person stated,
They see their friends are finally sending
money back home, taking care of their
families. And here they sit, unable to do the
same. Some people actually do go insane just
because of this.” One participant shared, “We
have a saying over here. We say, ‘Nerves.’ We
say, ‘This boy is nerves.’ What that means is
that this person wants to go abroad so bad
that they’re starting to go crazy.” Another
participant associated deportation with
mental health/mental illness: “What
aggravates the problem of these people is
mostly when they are deported back to their
native land. There is this stigma that goes with
it when they come back.” One participant
also stated, “People see them as failures. They
went to search for money and opportunity but
ended up being sent back with nothing.”
Another subtheme related to the labels
and names that are used to describe and
refer to people with mental illness. Participants
shared meanings associated with mental
health/illness in some of their languages and
cultural groups. For example, one participant
said, "Yes, we call them Nymatou in Mandinka.
In Wolof, they call them Duff; in Jola, also, they
call them Ahnymatou. These mean crazy or
mad person.” Another participant said, “If you
call somebody who is not mad, you call them
kangardo, they will not like that. You are
abusing them.”
A third subtheme was stigma,
discrimination, social isolation, and labeling.
One participant explained that “the stigma
around mental health is very high. This is one of
the reasons why even with the awareness
creation that we are doing at the moment,
many people are still reluctant to come out to
local services.” This participant also said,
There’s this common statement that we say,
a crazy person can never be well again (Duff
due musa wayrl)” and “if you have any
mental problem, you will never recover from
it.” This statement alone is very powerful in
stigmatizing an individual. One participant
also shared, “Whenever there is talk of
somebody being mentally disturbed, the first
thing people do is try to stigmatize the person.
Yeah, that’s stigma, that will start even from
the immediate family members, most of the
time.” Another participant also stated,
Instead of taking you for services, they might
even lock you in the house because of stigma
that can follow the family.” One participant
stated, “It’s like when people feel that one is
mad, they will not eat with the person. They will
not sit with the person in one place. So, total
isolation and discrimination.”
Theme 3: Mental health care and bio-
psycho-social interventions
A significant theme addressed is mental
health care pathways in The Gambia. A
subtheme of mental health care and bio-
psycho-social interventions was local and
traditional healing. For example, one
participant stated, “In most cases, many
people tend to go to [a] traditional healer or a
marabout rather than medical.” Another
participant stated, “Traditional healers, but
mostly religious, like they normally cure with
the Quran, such as Ruqya. Yeah, I’ve
personally seen that, using methods from the
Quran and some, you know, Arabic textbooks,
Islamic textbooks to cure them.” One
participant clarified, I’ve experienced the
Muslim way of treating the problem aside from
[the] medical way of treating. There is this
religious formula that they use called Ruqya.
Ruqya, I think is exorcism in English.” Another
participant shared, “People believe when you
successfully cure a mentally ill person, that
disease or that mental problem will transfer to
you. If it cannot do anything to you as the
healer or as the traditional doctor, it will
transfer to the family.”
When discussing additional treatment
options, the participants emphasized a lack of
support. One person said, “Normally, lots of
family people here cannot afford to take their
mental illness people to the medical sector for
them to be treated, so they lack support.”
Another participant shared, “As you can see,
there is only one center in The Gambia where
they normally take these mad people. They
shove them in one place, that is Tanka Tanka.”
One participant said, “The medical side, they
only give them medication to tame them, if
the person is violent, but not actually to treat
the person.” One participant described this
treatment pathway as follows: “Mental health
in The Gambia is more chemotropic. When I
say chemotropic, I mean the use of drugs
(medication). They look at every mental illness
or issue as being treated only with the use of
In terms of counseling services, one
participant shared, “Just recently, people are
becoming aware of counseling and
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psychosocial support. And I think that one is
more related to people who are mentally
distressed.” Another person said, “Many of the
deportees may know about Western
treatment because they are coming from
detention camps. I understand that they give
them counseling when they are at those
camps.” Another participant stated, “As for
counseling and psychotherapy, they are new
innovative treatment[s] but are not known.
Some Europeans are starting it here. They
need to sensitize the public.”
Theme 4: Barriers to mental health care
The participants mentioned several
subthemes under the theme of barriers to
accessing mental health care: mental health
literacy, awareness, and affordability. They
discussed increasing access to mental health
services and shared relevant experiences.
One participant recounted, “We have
succeeded in decentralizing the outpatient
services in every region … there is one in Basse,
one in Bansang, Soma, Farafeni, and Esau. But
for the in-service mental health facility, we
have not succeeded in the same capacity
yet.” This participant continued,
For the community mental health
team, previously, they used to go
around the country quarterly, every
three months, they will take around all
their equipment, and then they will
announce their outreach dates. But
recently, also due to gross lack of
finance or lack of a sponsor in [the]
mental health sector, such services
[have] been truncated in such a way
that it is only available within [the]
greater Banjul area. And even the
greater Banjul area, it’s only few
communities that are benefiting from
that community mental health services.
Mobility is a problem … they used to visit
prison, every month. But that also has
not been possible as we are speaking.
Another person stated, “They should build
more health places to have those that are
mentally ill.” In addition, one participant
expressed the need to “sensitize people on
the use of the drugs and order stuff and taking
care of our children in our own place.”
On the issue of counseling awareness, one
participant stated, “And, to me, the idea of
going for counseling is still not widely spread.
There needs to be awareness, and people
need to accept it. It’s new, and people don’t
trust it yet.” Another participant emphasized,
People may not realize the kind of behavior
that the person is indicating, or the kind of
signs that will warn them that this person is
developing certain things.” Another
participant added, We need to create more
health awareness, educate people about
health, make them know about mental health
issues, especially people that don’t know
about mental health, the illiterates will be
taught [about] mental health and what to do
with a person with mental health.”
Theme 5: Legal frameworks to support
mental health change
A subtheme concerned human rights. One
participant described human rights violations
against people with mental illness who seek
traditional healing:
When they reach that place, if the
craziness has deeply entered inside the
person’s system, they might chain the
person. They might put a chain on the
legs to avoid misbehaving, and the
marabout there will have a lot of men,
big men, strong men that would help
him when he is reciting and doing the
healing. There are some healers that will
chain some of the patient[s] that then
are quite aggressive to make sure that
they are in one place. And some will
even include beating them. So, yes. In
providing these services, they are also
abusing the people, which is also
against their human rights. Human right
violations. That’s [the] downside of the
traditional healing.
Participants further discussed the need for
comprehensive mental health policies and
legal frameworks for mental health. One
participant noted, “We have a mental health
bill that has been validated in 2019. But
unfortunately, it has not yet been enacted.
We are pushing very hard, but yeah, it has not
been enacted yet.” They clarified, “The law
that we are going by is the Lunatic Act. It’s the
law of the land, which does not provide any
rights to a person with [a] mental disorder. And
it’s very vague.” One participant also
expressed interest in attempting to “train non-
mental health specialists to be able to assess,
diagnose, and make simple interventions for
common mental health problems. … to train
the general health care personnel, to make
sure that mental health services can be
accessed at every facility, irrespective of
where you are.” One participant also
expressed, “So, of recent, what we have
started developing is to incorporate mental
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health services into the primary health service,
that is the existing health services.”
The current phenomenological
investigation aims to understand the
phenomena of mental health and mental
health stigma among adults living in The
Gambia. The findings from the study
demonstrate the role of culture in people’s
understanding of mental health. These
perceptions significantly impact the social
identity of people with mental health issues,
the limited access to treatment pathways and
modalities for mental health care, and the
public stigmatization of mental health/illness.
The first theme identified in the data
analysis was social and cultural
conceptualizations of mental health/mental
illness. Given that 90% of Gambians identify as
Muslim, it was surprising that cultural norms
featured more prominently than religious
beliefs in the participants’ conceptualizations
of mental health. The causes of mental
health/illness were seen as spiritual and
beyond the human realm and attributed to
many explanatory forms, such as mysticism,
possession by jinns or demons, and even
revenge on healers or family members from
responsible agents for healing or helping a
person with mental illness. The transgression of
norms by a person or their family member
were also identified as a cause of mental
health/illness. Mental illness was seen as
retaliation, either from spiritually unseen forces
or a wronged individual who took revenge by
inflicting the condition through spiritual means.
These beliefs are so long-standing that they
have contextualized how people experience
mental illness and are labeled, stereotyped,
and discriminated against (Galvin, 2021). To
foster improvements in mental health, the
population must be educated on the etiology
of mental health, treatments, and possibilities
for care that have been identified elsewhere.
Unless this education is provided, the
treatment gap and mental health stigma will
Firdos et al. (2021) conducted a
community-based study on beliefs about
mental illness in different populations in Al-
Ahsa. The sample consisted of Muslim
participants with similar beliefs about the
causes of mental illness as the participants in
this study. This study is crucial for
understanding how similar Muslim countries
conceptualize and experience the research
phenomenon. Cultural beliefs are key to
addressing mental illness in The Gambia. To
contend with the gap in treatment,
psychoeducation for both the awareness and
treatment of mental health concerns must
consider the context of beliefs that impede
treatment at both the individual and systemic
levels. For mental health providers, developing
cultural humility necessitates continual
learning and openness toward their clients’
diverse cultural experiences and beliefs (Zhu
et al., 2021).
The second theme identified in this study
was sociocultural determinants of mental
health/mental illness. The Gambia is a LMIC; as
in many similar countries, there is inherent
economic inequality. This affects people's self-
concept in terms of lifestyle choices. In
addition, social issues such as poverty impact
the majority of the Gambian population. The
participants in this study discussed substance
abuse and poverty as causes of mental illness
and factors that deter people from accessing
treatment. They also noted family support in
the form of providing financial assistance to
obtain treatment and purchase medication.
The findings from this study align with those of
a recent foundational study on mental health
in The Gambia (Barrow & Faerden, 2022),
which significantly discussed poverty as a
factor that impedes positive mental health
outcomes and cited the high costs of
treatment, prescription injections, and
medications as a frequent barrier to accessing
care. Barrow and Faerden (2022) also found
that the cost of consulting traditional healers
was approximately $187 and that the cost of
biomedical interventions for injections and
medications ranged from $912. These high
costs and disparities are significant barriers to
accessing services (Barrow & Faerden, 2022).
Barrow and Faerden (2022) also noted that
reducing the factors that contribute to mental
illness would significantly reduce the
prevalence of mental health issues and help
close the treatment gap, which is consistent
with the findings from this dissertation.
In addition, participants in this study
referenced failed migration as a social issue
that leads to the displacement of Gambian
youth. They noted that globalization has led
many Gambians to seek better lives and
improve their family’s living conditions. Since
opportunities are not available in their own
country, they look to distant shores. One way
of seeking opportunity is through the “back
way” by illegally migrating through the Sahara
Desert and the Atlantic Ocean and entering
Europe. Although this approach has proven
fruitful for some, participants noted that
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widespread illegal migration has led to more
control and repatriation agreements, which
have made it somewhat easier for migrants to
be held in detention centers and eventually
deported. Participants also shared that, when
people plan to leave The Gambia, their
families often incur debt or sell land and
resources to ensure that their children will
succeed and be able to support them and
augment the family's status. Conversely, entire
families may suffer when people do not
successfully migrate, are detained for many
years, and eventually deported or returned,
as stigma is also attached to these
deportations. As described by participants,
returnees are viewed as having lost an
opportunity and mitigated to a life of poverty.
This can result in stress, depression, and
traumatic conditions, which may be
compounded by stigma and limited access to
professional counseling services.
The understandings, descriptions, and
labels attached to mental illness reflect the
highest level of public stigma. Stigma is socially
constructed and permeates all aspects of
Gambian society. Research on mental health
stigma has posited that language shapes
perceptions and can significantly influence
psychological or cognitive processes
(Granello & Gibbs, 2016). The terms that
participants used to describe mental health
did not reflect linguistic relativity (Wolf &
Holmes, 2011) or align with “people-first”
language (Granello & Gibbs, 2016). Instead,
they used stereotyping and portrayed mental
illness as a permanent, incurable condition
that affects the self-esteem and social identity
of affected people. A prevailing sentiment
among participants was that people do not
associate with those who suffer from mental
illness. Globally, there is evidence that public
stigma is a deterrent to seeking treatment for
mental illness, which aligns with the findings
from the present study. Participants shared
that many people would lock up a family
member with a mental illness rather than face
public stigmatization. Women from families
with mental illness are particularly affected,
and their marriage prospects are limited due
to the negative connotations attached to
their family history of mental health
(Amuyunzu-Nyamongo, 2013).
The third theme identified in the data
analysis was mental health care and
biopsychosocial interventions. The prevailing
belief among participants was that local,
traditional, or faith-based healing is the most
popular and accessible type of intervention.
In a seminal study on mental illness in The
Gambia, Coleman et al. (2002) found that
approximately 80% of the population resorts to
local and traditional pathways. These are
more aligned with people’s understandings of
mental health, as they are rooted in local and
cultural beliefs. Biomedical services in The
Gambia are the mainstream conventional
system of treating mental health in terms of
legal services. There is limited access to
outpatient services; currently, there is only one
inpatient facility in the country. The
participants shared that, as a result, people
must find the finances to travel to the region or
not go at all. The findings from this study also
suggest that there was previously a
community mental health team that traveled
around the country every three months to
provide greater access. However, this
program has been challenging to maintain.
Thus, a lack of funds significantly impacts
community services that could enhance
access to medical and mental health care.
From a multicultural standpoint (Ratts et al.,
2016; Bharti et al., 2021; Sue, 1994), it is
essential to recognize that counseling is an
emerging field in The Gambia. Although some
nongovernmental organizations are working
to increase services, a lack of awareness of
mental health issues in communities is a risk
factor for their sustainability. Given the
importance of the globalization and
internationalization of mental health
counseling in African countries, there have
been significant intersectional challenges
related to contextual factors such as stigma,
lack of awareness, and lack of infrastructure
(Amuyunzu-Nyamongo, 2013). Multicultural
counseling may also involve certain ideals,
such as decolonizing concepts. Due to
people’s beliefs about mental health, it is
difficult to demonstrate the potential healing
capacity of Western counseling.
Acknowledging current beliefs while showing
the possibilities of mental health care requires
balance, which a multicultural counseling
approach might be able to help with.
The traditional healing system of treatment
includes local, traditional, spiritual, and faith-
based pathways. Participants shared that
these are the most available and accessible
forms of treatment; they are grounded in local
belief systems and accepted by many people
as their first choice of treatment. Other
regional studies have also highlighted this
alignment with local cultural beliefs and the
accessibility of treatment. Furthermore, the
Work Health Organization Alma-Ata
Declaration (1978) recognized the role of
traditional medicine in the primary healthcare
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sector. The participants in this study
empathized with this treatment modality.
Findings from the subregion also showed that
80% of people who seek mental health
treatment in Ghana rely on the
abovementioned system of care (Krah et al.,
2018). Findings show that, although The
Gambian health sector is relatively small-
scale, it is moving toward full integration of
mental health care. This provides an
opportunity to foster the integration of
traditional healing into delivery and
multicultural counseling into mainstream
biomedical services or collaboration with local
and traditional healers. The Gambian
government could also help with the
integration of multicultural counseling and
The fourth theme identified in this study was
barriers to mental health care. All participants
suggested poverty was a social factor that
immensely impacts mental well-being. They
described poverty as a barrier to mental
health treatment and a cause of mental
illness. Therefore, reducing the circumstances
that cause economic inequality could be a
prime policy matter for the government. Since
around 60% of the population consists of
youth, the government could support training
and skills development of projects to alleviate
poverty among young people. Furthermore, a
lack of funds to pay for medication or daily
meals can impact mental health and well-
being. The current research did not examine
mental health among youth and women,
which are two groups significantly affected by
poverty; however, this area needs attention.
In addition, there is a need for mental
health literacy in The Gambia while also
respecting long-held traditions and values.
Local people could be trained to know about
mental health practices that promote
wellness. Some efforts are already underway
in this area, which could promote access to
services. As participants shared, community
mental health services could also improve
access. Although such programs have been
implemented in the past, they were cut due to
a need for more funding. This sentiment was
highlighted in a study by Kutcher et al. (2016),
which aligns with the findings from the present
study. For communities to benefit from
counseling, adequate training from qualified
professionals is required. These professionals
could work within the guidelines of
multicultural counseling practice and ethical
standards. So far, no known counselor training
programs or institutions exist in The Gambia.
The training of paraprofessionals could be
helpful, but they would only partially replace
professionals. Professional associations could
also provide counseling in underdeveloped
nations. Furthermore, the field of mental
health counseling must be regulated to
ensure that professionals who treat people
have an appropriate clinical background.
The fifth theme identified in the study was
legal frameworks to support mental health
change. The Gambia has stated its stance on
mental health: to promote it. To this end,
greater attention should be paid to mental
health policy, laws, facilities, and access to
services. In addition, there has been a call to
meet United Nations conventions. For
instance, it addresses the rights of people with
disabilities. The Gambia has an opportunity to
identify well-trained, experienced mental
health professionals and collaborate with
them to improve services and policies. It is
important to have a mental health policy in
place to guide mental health regulations and
access. Other studies have mentioned the
need for protection for people with mental
illness. For example, Lund et al. (2011) argued
that legislation and policies are required to
optimize mental health services in LMICs. The
Gambia alludes to this in its mental health
policy for 20212030.
With regard to policies, the ministry could
begin by revising practices in the existing
facility and increasing standards of care. For
instance, only one facility offers substance
abuse treatment and conventional mental
health care. A lack of halfway houses was also
noted in this study. Furthermore, it is essential
to address the financial burden of family
caregivers, if possible. Currently, a risk factor is
that the government does not regulate
traditional healing practices, which sometimes
entail physical beatings and other human
rights violations that can further exacerbate
mental illness. There has also been a call to
ensure access to food, housing, employment,
safe living and working conditions, gender
equity, and mental health (Cosgrove et al.,
2021). Collaboration between traditional
healers and counseling professionals could
result in the identification of common ground
to uphold human rights.
Limitations of the Study
While a qualitative data analysis yields
descriptive data, it needs to be more
generalizable and show the exact prevalence
of issues and needs in The Gambia.
Additionally, this study was conducted in
English, which only sometimes
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ISSN 2612-2138
accommodates local dialects. It also
excluded many people who needed to speak
English. Furthermore, the data were collected
via Zoom, which required an internet
connection. Another limitation was that this
study did not focus on women and children,
who are the most widely affected.
Future Directions
Many opportunities exist for further research
on implementing mental health services in The
Gambia while considering the challenges of
an LMIC. Future research could utilize a
quantitative approach to identify the
prevalence of mental illness and the need for
mental health services more accurately.
Additionally, a quantitative approach might
identify the specific needs of people with
statistical data. Future research could also
investigate opportunities for multicultural
counseling professionals to collaborate with
traditional healers and biomedical services.
Furthermore, researchers could collaborate
with the government to identify legislation and
policies that promote mental health and well-
being in the country. This also sets a framework
for other LMICs to promote mental health
There are many opportunities for mental
health care and advocacy in The Gambia
and beyond. Yet, it is also essential to
recognize traditional healing practices and
beliefs about mental health, as these can
impact mental health stigma. While working
with populations that are only beginning to
explore mental health services, it is vital to
recognize community-based resilience in The
Gambia. For instance, people must become
accustomed to independently seeking care.
Instead, family members are typically tasked
with caring for them. Furthermore, recognizing
people’s inherent worth, and acknowledging
and accentuating their personal strengths
can help provide a buffer against the impact
of mental illness. This also challenges the idea
that people are solely defined by their deficits,
illnesses, or life circumstances; they are
capable and resilient when connected to
caring communities and systems (Ward &
Reuter, 2011). This reiterates the importance of
ecological systems theory and how different
systems interact and have great importance.
Utilizing Bronfenbrenner's ecological
systems theory, many people with mental
health issues rely on the family system for care
and access to mental health care.
Participants noted that families utilize
pathways that align with their worldviews and
cultural nuances since they are the decision
makers for individuals who need mental
health care. This reflects the family’s vital role
in a collectivist system. The mesosystem
concerns the connections between peers
and family. Sometimes, families fear sharing
that a family member is struggling with mental
illness because of prevailing beliefs about
being possessed or cursed. This can cause
isolation and stress for the family system. In
addition, it is essential to recognize that, with
some psychoeducation, communities might
be able to unite for early intervention. The
exosystem involves links between social
systems that do not directly involve an
individual (e.g., a family member’s job requires
travel). The macrosystem describes the
overarching culture, such as the challenges of
socioeconomic status and poverty in The
Gambia. Finally, the chronosystem involves
beliefs embedded in the Gambian culture
that can be passed down from generation to
generation, such as the assumption that all
people with mental illness are dangerous,
cursed, and often incurable. As evidenced by
the results from this study, there is also a widely
held belief that little can be done to support
the health of people with mental illness
beyond attempts to use traditional methods
of healing or institutionalization. However,
some participants with a higher level of
education recognized that there are
opportunities to revise policies, systems, and
care. In LMICs, mental health care cannot be
one-dimensional, and financial needs must be
addressed. In addition, cultural humility is vital
to advocate for people in The Gambia. It is
essential to help clients identify issues as they
see them and focus on the specific needs of
populations worldwide to promote mental
health and well-being.
Conflict of interest
The authors declare that they have no
conflicts of interest.
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