Background
The transition from war to peace represents not only political and economic shifts. It also reflects a cultural and psychological change in the lives of Liberians. And in light of the recent shootings at the Virginia Tech University, it became critical to write this article considering that in its recovery from war to peace, at least 100, 000 former demobilized fighters are parading the streets amidst a pool of other war-affected people. The government while sympathizing with the victims of this tragedy has done very little or nothing at all to build a systemic response to the mental health needs of Liberians suffering from mental illness, although its own time bombs are clicking daily.

The shift from war to peace is fraught with complex emotional and social adjustments. Among the psychological changes are movements from displacement to reintegration and the trauma associated with gruesome crimes that people witnessed or participated in. The deaths or prolonged loss of loved ones and recovery from the complete breakdown of social relationships are also among changes that have occurred in the Liberian social ecology. Some others are dealing with chronic joblessness as well as the loss of privilege and stature, all of which have taken tremendous toll on people’s existence individually and collectively. Put simply, all Liberians are survivors of trauma. Even Liberians, who are adamant about observing the world from their predatory perches, suffered some form of loss and trauma. But within the triumph over lawlessness, loss, violence, and displacement, that peace, however lukewarm, has produced; we cannot deny that other Liberians are still bogged down by these negative life experiences.

Trauma has an indescribable and elusive personal dimension to it. This personal component of the pain and suffering that we endure cannot be understood, if those undergoing it; fail to share their life story or seek remedy for their condition. The things that many of us take for granted, literally the minutia of life; might just be the most difficult things for others to accomplish. For example, there are those who are plagued by unremitting sleeplessness, fears of different kinds, including phobia of the dark or of groups gathered, while others may find themselves seeking unsuccessfully to overcome feelings of guilt or dissolve their anger or hate. These wide ranging emotional problems are the issues that mental health professionals encounter and seek to help their clients address.

Indeed, the number of Liberians with mental health disorders has increased dramatically during and after the civil war. Nonetheless, published academic studies and government reports examining the needs of Liberians with mental illness are limited in content and scope. I have testified in courts in the Diaspora as an expert witness and provided psychosocial services to many Liberians diagnosed with mental illness, some housed in mental hospitals, residential facilities, and others in prisons, threatened with deportation. I have in this process spoken with some healthcare professionals in Liberia to ascertain the quality of mental health service delivery in the country, especially since some Liberians being forced to return to this country have been diagnosed with mental illness and might go untreated due to short supply of opportunities for care and related reasons.

Assumptions
1. My inquiries have revealed that the dominant paradigm for providing mental health services in Liberia continues to make it subservient to primary health.
2. The government has yet to show robust interest in policy discussions and the development of a continuum of care for people with mental illness. Essentially, the current system of mental health care is grossly inadequate.
3. The families of people with serious and chronic mental illnesses continue to watch the quality of life that their mentally ill relatives lead, erode precipitously.
4. At the same time, no “technological fix” can occur in a political climate where the legislative branch and public attitude about mental health is still evolving or in the primitive stages of development.
5. It is neither socially viable nor politically sensible for the future of the country to not make adequate investments in addressing the needs of Liberians with mental illness.
6. Social issues, including mental health are historically-contingent. Hence, as Liberians transition from war to peace, mental health has to become an integral part of the public policy debate amidst the consequences of the war.
7. Lay Liberians as well as policy makers have to be sensitized to the many underlying factors that shape people’s responses to those with mental illness.
8. A functioning mental health system presupposes infrastructure that includes laws that protect the human rights of people with mental illness, laws by which mental health professionals conduct themselves, a broad continuum of care, including community clinics, low-cost housing, job placement opportunities, life skills development opportunities that integrate people with mental illness fully into communal life, trained Liberian mental health professionals are being recruited to build a sustainable mental health system, and access to care is made available to all Liberians needing mental health care. There could be more.

Introduction
Societal attitude about mental health or people with mental illness cannot be understood apart from culture. Equally so, people’s help-seeking behavior for mental health cannot be understood apart from culture. If society must break the bonds of the pedestrian responses to mental illness, it must understand the enduring influence of culture on societal attitudes about mental illness.

It is hard to suggest that the link between culture and societal response to the mentally ill is “causal, correlative, or autonomous.” But one can say empathically that a relationship of some sort exists and it is hard to decipher, yet significant and worth probing. Culture embodies a variety of components, including superstitions, rituals, beliefs, action, laws, spiritual traditions, speech, attitudes, and many more mystical facets. Culture is also a vehicle through which we express our worldviews. Angel & Williams (2000) have noted that shallow understanding of culture can mask symptoms and further lead to adverse clinical outcomes. This paper is both an advocacy and plead on behalf of the many Liberians with mental illness (undiagnosed and untreated) often characterized as “crazy and insane” and the horror of their invisibility in the public consciousness.

Existing Mental Health Knowledge
Sufficient empirical studies have not been done on the mental health needs of Liberians and the prevalence of mental illness. Limited studies have been done in refugee camps where Liberians have resided. Studies have also been done on Liberians living in the various Diasporas who experienced or participated in the civil war or couples who were displaced by the war now living abroad (see Jarbo, 2001; Dolo & Gilgun, 2002; Dolo, 2003). As a consequence, there exists a need for more robust studies to accumulate grounded knowledge on various aspects of mental health within the Liberian context. Such studies would form the foundation upon which to build mental health service delivery systems. The mental health needs that the war wrought have immense consequences for how Liberia will transition from instability to stability.

Culture Defined and Cultural Factors Considered
Culture is the historically-dependent surround within which societal responses to mental health evolves. Orlando Taylor (2001) defines culture as “the set of perceptions, technologies, and survival systems used by members of a group to ensure the acquisition and perpetuation of what they consider to be high quality of life.” In order for our response to mental illness to be meaningful, clinicians must understand their own culture, cultural assumptions, and more importantly, the cultures of their clients (Taylor, 2001). For Kearney (1984), culture is used interchangeably with worldview, whereby it is construed as the way people perceive their relationship to nature, institutions, other people and objects. Angel & Williams (2000) are keen to observe that culture is not fixed and they are not the aggregates of human behavior. They are therefore not “toolkits” from which clinicians can draw to respond to given mental health disorders. It would also be naive for anyone to read this article as the cultural epidemiology of Liberians relative to mental health practice. Principally, culture is a “catch-all” concept that is applied in a variety of ways by individual users. Culture spurs and also deters individuals and groups from taking specific actions.

Six basic themes or cultural factors considered influential in Liberian attitudes about mental health are discussed briefly. They include: secrecy, shame, and stigma; communal culture; folk and spiritual traditions; empathy; inflexible gender role; and ethnic identity. These cultural factors are known to have some influence how mental health services are prioritized and utilized in our personal and corporate lives. No doubt, more research is needed to examine inter and intra group differences that exist among Liberians along the different dimensions of our diversity: age, geographic location, gender, ethnicity, social economic status, etc.

Secrecy, Shame, and Stigma
Secrecy, stigma, and shame are three related concepts with which one must start when looking at the evolving mental health culture in Liberia. Mental illness in Liberia is still shrouded in secrecy. Most people still feel ashamed given the enormous stigma surrounding mental illness. Indeed, the nexus of secrecy, shame, and stigma definitely shape the attitudes of the larger society toward people with mental illness. As such, the mental health help-seeking behaviors of Liberians, as in many other societies, are influenced greatly by these three interrelated concepts. This is especially true within the indigenous household, although not negating that even in so-called western acculturated households; secrecy, shame, and stigma still prevent people from seeking help for mental health conditions promptly. This is also because mental disorders are perceived as genetic and to have mental illness is to have a “bad gene” which stigmatizes not only the individual, but their family members. The shame and embarrassment that people feel can preclude them from seeking help for mental illness, making them to wait until the condition becomes chronic.

Communal Oriented Culture
Liberians are a communal people, meaning that the rugged individualism that influences mainstream culture in Western societies is less a factor in traditional Liberian culture. Helping each other within the family and family approval and support are critical in a person’s decision making about major life choices. Healthcare decisions are not exceptions. They are approached with the expectation that the family would be involved in making such a weighted decision. Strong and high regard for one’s elders still remains and integral part of Liberian culture, therefore, the role elders play in healthcare decisions are enormous , although they vary from one family to the next. When a person is overwhelmed by emotional issues, they tend to look to the family first for advice and support or to their local mutual aid society or faith community.

The network of support extends beyond blood relatives and includes extended relatives and friends. Hence, Liberians are linked in an interdependent network that in most cases serve as a source of resilience, especially during the traumatic events. For Liberians who felt isolated and alienated during the civil war and associated destabilization of the society, it is indicated that extended families and friends served as sources of strength when they least expected (Dolo, 2003). True, many Liberians were the target of vengeance and violence from townsmen, neighbors, and kinsmen, but acts of goodwill and/or valor also kept many Liberians alive and sustained them throughout the instability, destruction and carnage (Dolo, Forthcoming).

Folk and Spiritual Traditions
Folk and spiritual rituals, traditions, and practices play a central role in the daily lives of many Liberians. Within the arena of health, folk medicine and incantations by spiritual healers including herbal medicines are some of the interventions that Liberians turn to in order to relieve mental illness. This is true in contexts where mental illness is looked upon as a person’s disconnect with the folk or natural world. It should be noted that the folk and spiritual traditions in Liberia are not monolithic, and thus vary from one group to another. Yet it is possible to generalize based on their mutual intersections.

Even when individuals demonstrate serious psychopathology (disorder), their family members may fail to seek help publicly. They might turn to a folk or spiritual healer for herbal intervention first. This is due in part to the fact that mental illness and even other physical ailment are likely to be attributed to witchcraft or a person being “poisoned” by an enemy or someone who is jealous of the other’s success. These claims have etiologies or origins that are mystical, but not bio-medically and organically based. Attributing mental illness to supernatural origins as it is done in traditional Liberian society or even the blending of the mystical and biomedical explanations, which happens in some quarters, is the pathway to the folk healer or other holistic medicinal approaches as the first line of defense. Still, the treatment approaches that Liberians pursue need to be exposed to rigorous epidemiological research to learn more about the pervasiveness of mental illness and treatment utilization patterns.

If the experiences of Liberians living in the Diaspora are any warning sign, mental health disorders are beginning to emerge within the Liberian community. Some of the Liberian couples that this author studied for a dissertation research talked about low levels of depression and other disorders and a risk for Post-Traumatic Stress Syndrome (PTSD) due to gender role imbalances that they experienced as a result of their forced displacement and acculturation stress (Dolo, 2003). In the homeland, social stressors such as poverty, participation in combat, witnessing or participating in gruesome acts of violence, and torture during their internal displacement; point to the presence of high rates of psychopathology.

One can also speculate that the fundamentalism of the Liberian Christian church may have contributed to a reticence to embrace mental health issues. Although psychology and mental health practice have had longer traditions in the West than Liberia, missionaries who administered higher education institutions and hospitals may have been slow to make this a part of the menu of services because psychology seemed anathema to a Bible-believing ethos. Psychology would seem to have some anti-religious underpinnings, and thus reconciling it with matters of faith might create tensions, which could be avoided.

Empathy
On one extreme, Liberians tend to stigmatize people who suffer from mental illness. But on the other hand, Liberians accord relatives, friends, and others with other illnesses that are not brain-based, particularly mental illness with great empathy. I acknowledge that these are untested generalizations. Yet, one must intellectually wonder about these paradoxical responses. Two factors may be playing out here. The first is the communal tradition, and the second, is the spiritual tradition also mentioned. Both evoke empathy as the way of dealing with tragedy in support of others. Incorporated in Liberian belief and value systems is the need to embrace, support, and respect others in their times of vulnerability. Insensitivity in people’s times of tragedy is detested. How come then are Liberians insensitive to people with mental illness? The answer may reside simply in lack of knowledge or the absence of systems for increasing public consciousness around mental health issues.

Inflexible Gender Role
Another critical feature of Liberian culture is a rigid adherence to gender role. Males and females have well-defined social roles. Traditionally, the father is the breadwinner (earns the money and feeds the family). The mother, on the other hand, is traditionally the one who raises the children and does the housework. However, following the war, conditions are changing and these roles are being reversed with much greater frequency than ever before (Dolo, 2001; 2003). For their part, children are the vessels through which parents fulfill their dreams, and thus are expected to seek high achievement and surpass their parents’ achievement. Furthermore, children are to adhere to their parent’s rules and regulations, meaning they occupy a subordinate role in the authority chain which is some cases based also on age hierarchy. Family disagreements are not supposed to be disclosed to non-relatives and as such, to safe face, only harmonious social relationships should be displayed in the public, even if conflict is occurring.

Boys and girls are socialized differently and each enjoys a different level of protection from the family around mental health issues. A girl diagnosed as having mental illness, would be protected from public notice because that would prevent her from finding a spouse, and also diminish the chances of other single females (young and old) women in the family from getting married. On the other hand, boys enjoy a sort of latitude with respect to being called crazy. Boys or men designated as crazy might possibly get away with such a designation as opposed to their female counterpart simply because a family’s honor has matriarchal pathway. It should be noted that the traditional culture wanes and waxes as the generation connects with and is exposed to western civilization. Later generations of Liberians might not be holding on to some of the familial values noted here, especially in the absence of intergenerational dialogue and planned social activities and networks.

Ethnic Identity
With ethnic identity as important cultural marker demarcating social practices, it is possible that the definition of mental health, disorder, and health help-seeking behavior are all affected by this phenomenon. Liberians of indigenous descent and those of non-indigenous descent would have some clear distinctions in their approaches to mental health. As mentioned previously, indigenous Liberians, for the most part seek folk and spiritual interventions for mental health problems. Those Liberians with western orientation would usually, although not exclusively seek western psychological interventions. Some Liberians mix the supernatural practices with western psychological interventions viewing both as having specific efficacy. Those who hail from ethnic groups that enroll males and females in the Pora and Sande societies, may have a different approaches to mental illness, although there may also be variations based on the ethnic group from which a person hails. Again, one has to be careful, not to construe all Liberians as a homogeneous group because different Liberian ethnicities exist, thus avoiding the quick shift from generalization to stereotyping.

Facing the Future
To face the future continuing to have a grossly inadequate mental health system is a dismal prospect. Among the changes that we need to be prepared for are former child soldiers growing up as adults having been traumatized by the war. Liberians returning in droves from their various places of refuge either being forced to return or returning on their own from nations where they have been marginalized or acquired habits that have eaten at the core of their brains: dope smoking, alcoholism, the use of other illegal substances, etc. Add this to the growing number of Liberians in the homeland already combating these same problems. The effects of chronic poverty and political unrest have resulted in manifold psychological tolls, including children that are maladjusted intellectually and socially. More healthcare professionals in the homeland have begun to notice that those Liberians who seek help for mental health disorders are those individuals physically manifesting signs of acute disturbance or have threatened their own safety and that of others. Care is episodic and the acuity of disorders is worsening.

We also have a growing population of aged Liberians who will face health and social problems naturally related to their aging. These older adults will face cognitive and emotional problems and thus resolving their psychological health will be a matter of necessity. This is especially true in a case where we lack a trained workforce with competence in gero-psychology to address the deteriorating quality of life that older adults face. For example, although cultural norms have tended to constrain Liberians from placing their older relatives in out-of-home placements, as the work and social lives of Liberians change, one wonders if these seeming taboos would also change? Would there exist, a need to establish an old-age pension system for older adults unrelated to employment history?

One would also think that in a climate where intimate partner violence, rape, and pedophilia (sexual relations with a child/minor) are deeply embedded within the culture, their negative mental health consequences would need attention. Evidence exists that intimate partner violence leaves emotional scars on children that are exposed to this societal ill. In a cultural context where many in society turn a blind eye to intimate partner violence (gender-based violence); the fear which it generates in victims, might just lock the country into a spiral of violence.

Knowing also that rape does not only have psychological effects, but medical ones as well, including HIV/AIDS and other sexually transmitted diseases, the disease burden of these social conditions leave one wondering about the current political climate that has left observers wanting for a robust healthcare policy from the Sirleaf administration. Having being raped, how many Liberian girls and boys are living with the self-inflicted guilt of being “damaged goods?” If the country continues to lack a systematic approach to addressing this critical healthcare need, plus the tacit approval of sexual harassment, could the nation be aiming for years of destructive consequences?

Recommendations
1. Although as our leaders are faced with the monumental task of developing systems of care that are modern in scope, they should be careful for the systems that they develop not to be colonized by western views of mental illness and interventions. Much is there to learn from our western counterparts, but we must be careful about the cultural myopia of some western interventions.

2. The fields of psychiatry, psychology, social work, and counseling are still not incorporated in the higher education curriculum in Liberia as have the traditional social sciences or liberal arts. These sciences have intellectual and practical ramifications for preparing people with the skills to alleviate mental illness in our society. Private and public higher education institutions should include these areas of specialty within their curriculum.

3. Public awareness of mental health is still in its infancy. The Liberian government should engage in a very aggressive public education campaign to change perceptions and increase their knowledge about mental health and mental illness.

4. People with mental health disorders are likely to have poor physical health because they rarely access care for their conditions. Worse, in the absence of a functioning mental health care infrastructure and national surveys to measure how widespread mental disorders have affected the population, a wholesale reform in the healthcare policy arena is needed. No longer should mental health policy be an afterthought of policy makers and the national populace.

5. Lack of functioning locally accessible in-patient community-based facilities is a major concern, and the Ministry of Health has to make this a priority. For people with psychiatric disability, community mental health resources should include access to stable low cost housing, job training and placement opportunities, emergency and respite care, and psychosocial activities.

6. Family care giving is the bloodline for recovery from mental health disorders. But the paucity of knowledge on mental health only dampens the prospect that families will perceive mental illness as any other health condition, thus reducing the secrecy, stigma, shame surrounding having mental illness.

7. It is still difficult to ascertain how much of the nation’s healthcare budget is spent on mental health. But one would guess that it is low compared to other civilized nations. The government must allocate adequate portions of its healthcare expenditure on mental health services and decentralize service delivery within the counties and local communities, utilizing a community mental health paradigm.

8. Workforce shortage in general within the post-war economy is acknowledged. However, it is even clearer that gaps will continue to exist in the present and future healthcare workforce, if sufficient numbers of trained personnel are not recruited with skills as mental health practitioners and trainer of trainers. Current workforce, including physicians and nurses may need retraining to meet the demands of a modern mental health practice.

9. Essentially, the Sirleaf administration in collaboration with the National Legislature should demonstrate national leadership through the development and implementation of a well thought out, well funded, and strategic national mental health plan for the remainder of its term, if not the next decade. This plan should invest heavily in mitigating some of the issues raised, accelerate the pace of reform, set national benchmarks, and ensure that all local jurisdictions are incorporated in the making of this plan. An evaluation plan should also accompany this strategic document that would allow for monitoring, if the targets set are accomplished within the timeline established.

10. Noteworthy, a national plan for reform of the mental health sector should not be atomized into silos, excluding it from the other social development goals of the nation. Instead, the mutual intersection with economic and planning, education, primary health and social welfare, youth and sports, internal affairs, and other related ministries of the government should be explored and incorporated in the plan.

11. Develop a strong system for addressing the mental health needs of the aged, including old-age pension schemes and training institutions in gero-psychology and other career paths that address abnormal changes in the cognition and physical structures of older adults.

Conclusions
More than a year after the election of the Sirleaf administration, the problem of Liberians with mental illness languishing in the streets without reasonable care or plan of care continues. It is possible to establish safe, permanent, and timely interventions to address the needs of the many Liberians with mental health disorders, especially those who are severely and chronically ill. Investments in psychology, social work, counseling, and other related areas of knowledge building cannot be overstated. Constructing community based care as opposed to large scale hospitals like the Catherine Millis Memorial Hospital can improve the functioning of people with mental illness, and even their prognoses, as well as provide support to their families and caregivers. These measures have an important role to play in integrating some mentally ill people into mainstream society and also preventing them from being recruited to be parts of movements to destabilize the society.

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