Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis

Attributions and private theories of mental illness among young adults seeking psychiatric... Background: Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extend- ing youth-friendly services. Methods: Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18–25 years about their mental health condition for which they were undergoing treatment. Each interview took 30–45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions. Results: We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents’ separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting interven- tion, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emo- tions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy. Conclusion: Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya. Keywords: Youth in psychiatric facilities, Attributions of mental illness, Locus of control, Private theories interview, Stigma *Correspondence: m.kumar@ucl.ac.uk Department of Psychiatry, College of Health Sciences, University of Nairobi, P.O.Box 19676, Nairobi 00202, Kenya Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 2 of 15 is used to study psychotherapy patients’ subjective beliefs Background about their problems, their causes, and any ideas they may Mental illness affects every segment of the population. have about what would be needed for them to feel bet- Mental health issues among the youth can negatively ter. We used the patient version of the interview (PTI-P). impact the national development of a country. More We superimposed this interview on an attribution model so, the beliefs held by the community about the causes developed by Weiner [16]. We used these two frames to of mental illness are likely to impact individual treat- capture the interviewee’s attempts to give meaning to their ment-seeking behavior [1–4]. Available literature from interpersonal, psychic, and somatic distress, while includ- developing countries show that acceptance of help with ing these experiences in the patient’s private context of mental health issues and engagement with services can be meaning. The PTI-P is a semi-structured, brief qualitative affected by various factors such as belief in evil spirits and interview, which can be used to understand participants’ stigmatization of mental health problems [2, 4–7]. Young personal assumptions of treatment, mental health or ill- people’s attitudes towards peers with mental illnesses has ness qualitatively. We adopted the PTI-P, developed by been studied and the findings suggest that young people [17], as it is with minimal changes. The attribution-focused differentiate between perceptions of how dangerous and questions were superimposed on the PTI-P, by adding fear provoking the individuals might be [8]. However, no extra probes to questions in the PTI-P. See Table 2 for the research has explored young peoples’ beliefs and attribu- newly designed attribution-focused questions. tions associated with their illnesses. Cultural components such as social attitudes, peer group rules, religious beliefs, The attributional framework family morals, and other socio-cultural factors strongly Depression, anxiety, and stress are commonly associated contribute to the behavior and attributions towards men- with negative thinking and attributions. We outlined our tal illness held by the youth [9]. Data on years lived with attribution framework from the original attributional disability (YLD) demonstrate that, in Kenya, the burden of framework done by Bernard Weiner [18]. Attribution mental health is significant and access to specialist care is refers to the assessments of the cause of an action or limited [10, 11]. The gaps in meeting mental health needs behavior [19]. It also refers to the internal (thinking) and and providing services for young adults are worrying, external (talking) process of interpreting and understand- given increasingly high levels of depression and incidents ing what is behind our own and others’ behaviors. Attri- of suicide by young adults in Kenya [12–14]. bution theory explains an occurrence and determines the Young adults’ attributions of mental illness are not cause of the happening or behavior. It starts with the idea well-researched; hence, we know very little about their that individuals are driven to understand the causes of patterns of help-seeking behavior or their commonly the happenings or behavior and that this desire allegedly used description of distress. Our study is an exploratory grows out of individuals’ wish to understand, foresee, and step towards understanding young adults’ expression of control the environment [20–22]. The attributions are distress, their attributions associated with mental illness, known to be of different types. According to Weiner et al. and factors that prevent or contribute to management [23], there are three dimensions of causal attributions of mental disorders. By gathering mental illness-related which include the following. attributions held by the young adults, we made it possible to extrapolate aspects of their psychotherapy care which Locus of control (internal vs. external) need further strengthening. Exploring the beliefs young A person’s belief that the events which occur in life are people hold about their illness and pathways to cure are either a result of personal control and efforts or an out - important steps to facilitating early access to mental side force like luck or fate is referred to as locus of con- health services and improving psychological wellbeing. trol (LoC). Controllable vs. uncontrollable attribution: This includes alerting the practitioners about possible Weiner’s controllability dimension concerns a situation barriers that hinder positive psychotherapy outcome. that is regarded as controllable if the individual is per- Through this research we gained a critical knowledge sonally able to guide, influence, or prevent it. It is the piece that will provide insight into barriers young adults extent to which the individual has control over the cause, encounter in seeking mental health services. To achieve as perceived by observers. Försterling [24] used “drunk- this, we used two theoretical lenses to review subjective enness” as an example to describe the controllability of appraisal from young adults: attributional framework and causes, suggesting that “drunkenness” is perceived as a the private theories interview. controllable cause. Causes that can neither be influenced nor guided such as a physical handicap, for example The private theories interview patient version (PTI‑P) blindness, are regarded as being uncontrollable [24]. The The private theories interview [15] is an interview that was external locus of control are often thought to be relatively developed in the context of psychotherapy research, and Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 3 of 15 uncontrollable and associated with perceived social stress am to 5.00  pm, and roughly ten new patients are regis- that young adults might encounter [25]. tered each week and around fifteen more new patients are added during school holiday periods. It is overseen Stability of causal attribution (stable vs. instability) by resident psychiatrists, psychiatric nurses, and psy- Stability is the time-based nature of causes [16]. Some chotherapists including clinical psychology interns. The causes remain stable over time while others increase or services are free to all youth regardless of type of diag- decrease. Causal attributions, when viewed as stable and nosis, and the clinic also provides outreach services for unchanging as opposed to unstable and fluctuating, are HIV testing and counselling (HTS). This setting was directly related to a person’s expectancy of successful chosen because it serves nationwide referrals and walk- results [24] implying that the stability attribution makes in patients who are predominantly fluent in either Eng - the person less inclined to believe that his/her problems lish or Kiswahili. Most clients are referred from various will improve. As the mental illness deteriorates in an schools, colleges, and universities, and it is also a clinic individual, it perpetuates an irrational outcome and dam- for walk-in cases and emergencies. ages self-governing functions. This could be explained by the knowledge that mental-behavioral or internal stig- Participants mas are normally considered unstable or reversible, while Our participants were between ages 18 and 25  years. physically based stigmas are perceived as stable, or irre- 18 years is the legal age for an adult in Kenya [12], while versible [26]. Stability and instability of attributions refer 25 is the age limit for patients attending the youth clinic to how fixed or how flexible the mental schemas associ - (Table 1). ated with these can be. Unstable attributions may help with the motivation to work in treatment, whereas sta- Sampling ble attributions may lead to hopelessness and not seeking In this exploratory study, we purposely selected young treatment. The more stable an attribution is, the harder it adults who were seeking psychiatric treatment at the is to change it [16]. Inferences on the stability and insta- clinic, were willing to give consent, and had fluency in bility of an attribution depends on how controllable or Kiswahili or English (the two official languages spoken uncontrollable one experiences an event or an individual in Kenya). Assessments from the psychiatrists and clini- attribute to be; it is also contingent on whether one views cal psychologists were used to determine the severity of the event or attribute it from an internal or external locus the patients’ mental illness. Two patients who were eligi- of control. ble for the study were excluded because both had severe psychosis in addition to limited fluency in English and Attribution of stigma (internalized vs. externalized) Kiswahili. None of the participants we approached for Stigma is defined as a social scratch that leads to ques - the study declined to give consent and participate. tioning of associates of a group, such as people with men- tal illness [27]. According to Rüsch et al. [28], the negative Ethical approval and considerations properties of stigma among individuals with mental ill- We received approval from the Kenyatta National Hos- ness lessen self-esteem and health care seeking behavior, pital and University of Nairobi Ethical Review Commit- and increase discrimination. The tendency towards self- tee (no. KNH/UoN P105/02/2015). The participants were stigma has been documented in Sub-Saharan African informed verbally and also provided with a written docu- patients and along this are also religious and supernatu- ment about the purpose of study. In addition, consent ral attributions given to mental health conditions in the to audio-record the interview was sought. Participants form of punishments [29]. Experiences of stigma cata- were informed that participation or refusal to take part in lysed by self-stigma revolve around experiences of deval- the study would not affect their current contact with the uation, exclusion, and disadvantage [30]. Moreso, mental clinic. No rewards were given for participation. illness stigma is one factor that hinders seeking care by distressed people, hence undermining the service system Instruments [31]. The individuals are not only troubled by the external A brief socio-demographic questionnaire was used to mental illness stigma but also by the self-stigma, leading capture key demographic information. These included to low self-esteem and self-efficacy [32]. the age of the participant, Kiswahili and English literacy levels, educational level, and gender of the participants. Methods These were gathered to synthesize the information with Setting their interviews. Data was gathered by use of semi-struc- The study took place at the Kenyatta National Hospital’s tured interviews with open-ended questions encourag- Youth clinic. The clinic runs every weekday from 7.30 ing exploration of experiences within the conceptual Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 4 of 15 Table 1 The Socio-demographic information Participant no. Age Gender Level of education Diagnosis Patient 01 20 Male University Major depressive disorder Patient 02 19 Male High school Substance induced psychosis Patient 03 18 Female College Secondary enuresis Patient 04 22 Female University Schizoaffective disorder Patient 05 19 Female High school Depression Patient 06 24 Female University Depression and epilepsy Patient 07 20 Female High school Conduct disorder Patient 08 22 Male College Somatic disorder Patient 09 19 Male High school Substance induced psychosis Patient 10 20 Female College Post-traumatic stress disorder Table 2 Private theories interview patients’ version and attributions focused questionnaire guide Private theories questions Attributions focussed domains What is it that leads you to seek treatment today? Internal locus of control External locus of control What are your thoughts about the psychological issues you are experiencing? Controllability Uncontrollability Tell me about some or other important experiences or events in your life that you associate with your difficulties Stability and how these problems Instability In relation to the problem (MI) how do you see yourself and others around you? Experiencing stigma Not experiencing stigma What do you desire that would ease your pain/distress? Desired treatment plan or cure framework used. The five questions from the Private suggestions on a few semantic adjustments. The adjust - Theories Interview-Patient version (PTI-P) were the pri - ments were only linguistic in nature. Given that these mary interview questions. We developed an Attributions were semi-structured questionnaires there was no need Focused Question guide that was embedded within the to formally validate the tools. Instead, we tested their cul- PTI questions as probes in such a way as to elicit attribu- tural sensitivity in pilot interviews. We used interpreta- tions. The probes were designed to get the participants tive phenomenological analysis (IPA) [34]—a qualitative to elaborate on the ‘how’, ‘why’, and ‘when’ associated technique to analyze our data. IPA was chosen because with the five private theories questions. The attribution- our goal was to magnify the subjective experiences, both focused question guide was mapped onto these questions tone and tenor expressed by our participants while inter- to create a subset of categories that explain the attribu- preting their idioms of distress, attributional patterns, tions used by participants in understanding their prob- and highlighting their barriers to mental health care. lems and thinking about how these could be resolved. These questions resulted in the attribution framework Given that mental illness continues to be a highly stigma- as shown in Table 2 below and embody each locus, stabil- tizing condition in Kenya [33], we included stigma as a ity, and stigma probes mapped on PTI-P. The questions category of attributions to see how our participants navi- were the following: gate it. Since the PTI-P was first developed in Sweden, we were 1. What is the problem? concerned how well these questions would fit the needs 2. How did the problems arise? of our Kenyan young participants. In order to enhance 3. How can the problems be remedied? cultural sensitivity and adapt the questions to the Ken- 4. What has changed? yan context, the question-guide was translated into 5. What is your view of others and yourself? Kiswahili. The first author, who is fluent in Kiswahili and English, translated with the help of an English-Kiswahili Each of these questions was paired with a domain from dictionary to ensure that the meaning of each word was the attribution theory. AFQ provided a deepening and retained. Two Kenyan trainee-psychologists also gave Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 5 of 15 expanding of the PTI-P framework and the scope of the approach is committed to detail in-depth analysis as well analyses. The domains adapted from Wieners attribution as to understand how a particular experiential event or theory were locus of control (internal vs. external), con- relationship (phenomenon) has been understood from a trollability (controllable vs. uncontrollable) stability (sta- particular context by different individuals or groups. ble or unstable), and stigma as an independent domain. IPA as a specific method in this study Data collection We used IPA in the following ways: by carrying out ver- Three pilot interviews were conducted at the youth clinic batim transcription of the semantic content of each inter- to test the conceptual framework and gauge participants’ view based on audio recording and followed by reading reaction to the interview questions. The first author was and re-reading of the content, while searching for richer, trained in qualitative interview techniques by her sen- detailed sections and for contradictions and inconsist- ior mentor MK and had regular supervision with all her encies. At the initial noting stage, the first author and mentors on using IPA as well as analyzing the data the- her supervisors identified specific ways the participants matically. The participants in distress were encouraged spoke of an issue, described what mattered to the partici- to continue with psychotherapy, and a referral mecha- pants, and the meaning of these things. This identified nism was built in the study if anyone had self-harming each participant’s emergent themes and the connections/ thoughts or was at a risk of harming themselves or oth- interrelations of the themes for each of the ten partici- ers. Once these procedures were identified, individual pants. Mapping of themes was done to connect and fit interviews took place in the counselling room at the the themes in relation to the research questions. With youth clinic before or after the participants’ counselling each step, every individual participant’s core themes were session. English or Kiswahili language was used as per tallied with other participants’ and we ensured that the the participant’s preference. The first author conducted analysis maintained a strong interpretive focus. The core the audio-recorded interviews with one interviewee themes were later merged with the attribution dimension at a time. The interview duration ranged from thirty to and the PTI-P framework to make sense of the bigger 40  min. Data collected was safely stored without any picture. At this point, our key question was which themes identifiers to ensure confidentiality of the participants. were being articulated by our participants and where did these fit-in vis-à-vis identified attributions. We present Data analytic plan themes emanating out of IPA from the private theories The recorded material was transcribed from the audio interview in the results section and in our discussion sec- recorder to a MS Word document. The first step was to tion we reflect on how these themes map onto attribu - ensure that all experiential material about PTI-P and tions framework as a whole. Attribution Focused questions were adequately answered in the data. The second step was to break the data as per Results the IPA framework. This was done because of the follow - Our results are presented in a twofold process. We high- ing reasons: (i). IPA is consistent with research aims since light the themes that were drawn from the PTI-P: psy- it is committed to the examination of how people make cho-social triggers, biological origins, and preference sense of their major life experiences [35], (ii). It is a phe- for combined treatment as a way of addressing stigma. nomenological approach focusing on exploration of expe- Table  3 lists the core themes arranged from the most riences in its own terms instead of attempting to reduce prominent to the least, as derived from frequency count it to predefined or overly abstract categories. This means among the 10 participants, while Table  2 indicates the that it is interpretative in that the researcher tries to make connections between the attributions and core themes. sense of the participants’ experiences, and (iii). IPA is con- These themes are reviewed here, starting with the psy - cerned with personal experiences and involves interpre- cho-social attributions. tation, with ample consideration of a given context. Psychosocial triggers of distress IPA as a scientific principle Our participants were concerned about various psy- IPA is idiographic in nature. It is concerned with reveal- chosocial triggers that adversely impacted their lives. ing something about the experience of each of the indi- Employing IPA, we identified a number of thoughts and viduals involved and is able to give a detailed conclusion experiences as being the prominent causes of our partici- about the participant group. Our third and next step was pants’ worries and distress. to ensure that we used IPA as a method in the service of teasing out PTI information and how young adults make attributions regarding their own well-being. The Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 6 of 15 Table 3 Building the connections (attributions vs. core themes) (to be placed in page 30, before internal and external locus of control) Interview questions a ttribution dimensions Core themes What is it that leads you to seek treatment Internal locus of control or dispositional attribu- Negative emotions and thoughts misconduct behaviour today? tions: based on behaviour within the client Transitional challenges-from teen to adult life Poor performance in school Self-stigma and shame of disclosure External locus of control or situational attribu- Negative childhood Experiences tions: Based on behaviour (from others) to the Strained relationships with parents and other family individual members Rejection from others and stigma Lack of finances Decline in social life What are your thoughts about the psycho- Controllability: if the individual is personally able Negative emotions and Thoughts logical issues you are experiencing? to guide, influence or prevent the situation Un-controllability: if the individual is personally Negative childhood experiences not able to guide, influence or prevent the Strained relationships with parents and other family situation members Rejection from others and stigma Lack of finances Decline in social life Tell me about some (other) important Stability: unchanging causes Death of loved ones experiences or events in your life that you Un-stable: changing/fluctuating causes Negative emotions and thoughts associate with your difficulties and how the problems began. In relation to the psychological issues, Stigma from others and self Self-stigma what is your view on others and yourself? Stigma from others What do you think is needed for your Treatment preference Need for therapy illness to be cured or might ease your Need for medication pain? Negative thoughts and emotions counterparts. Vignettes such as the following are testa- The participants shared in their interviews that negative ment to these early deprivations and adversities which thoughts and emotions were the core reasons for their they highlighted: illness and distress. Adverse experiences created a spi- “My dad does not care. Since the illness started from ral of negative thoughts and emotions about themselves childhood, he has never sent money for medication. and the world around them. The PTI question 1 was most He went and got another wife. He only sends money reflective of this spiral thinking that our participants for food for me and my sister. But for my medica- struggled to get out. tion, he has never sent … money. My mother who “I had a disagreement with mum. She wants me to lives with me does not work. She is a house wife be like her and I cannot. She separated with my dad and depends on the small amount send my father…” and now she wants me to go live with my uncle who 24-year old female participant diagnosed with epi- is very tough. She is also planning to go for further lepsy. studies abroad.” 20-year old young man. “[…] I used to love my father but when my sister “[…] I had a tough childhood; my brother uses drugs was born, it’s like he forgot about me. He only cared and abuses me. I also lost my dad at a young age…” about her. I started talking to boys and eventually 22-year old female participant. lost my virginity. I still feel bad about it…” 19-year old female participant. These vignettes point to grim interpersonal context that generate self-doubt and apathy in the participants. “My mum died. I still don’t know how to deal with Parental separation, unexpected death of a loved one, that. She was the most important person in my life. and protracted bereavement thereafter worsened the Always cheering me… I was her only child. I have no situation and the participants’ mental health, as expe- dad. I felt lost and never gotten over this. I do not rienced by the young adults interviewed. Female par- understand myself anymore.” 25-year old female ticipants echoed such experiences more than their male Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 7 of 15 participant. “I am not comfortable with my life. I have not achieved the things I have wanted to achieve. Just At a fairly early age, the participants had to deal with the way my life is going…..my career…Everything is situations that left them emotionally scarred. Seven of moving slowly. Am in a stage where I want to do new them had an early childhood experience that they attrib- things and find my own place in life” 24-year old uted to be the cause of their mental illness that brought male participant. them to the hospital in the first place. “Since I went to boarding school in class six my per- Adjustment and behavioral problems in school and college formance dropped and was always punished for This theme captured the participants’ thoughts about it….” 20-year old male participant. the need to be accepted by peers, family, and teachers. It also demonstrated the difficulty one may have in find - As a result of challenges in transitioning to new envi- ing a friend who would guide and influence in a positive ronments (e.g. day schooling to boarding), death of a way. As we learnt in our interviews that the participants loved one, and lack of finances or strained relationships were mostly connected with difficult conduct-related with significant others, four of them described their poor behaviors (externalizing tendencies) for which the youth academic performance as a cause of their psychologi- were seeking support. These vignettes underscore these cal distress. Some maintained this to be the main cause problems: of their mental illness while others thought if they had better upbringing or did not have to face difficulties in “My friend and I had a phone in school. During prep their childhood, they would have performed much better time, the teacher on duty caught us playing games. academically. We have been suspended for 2  weeks and told to go back to our parents…” 19-year old female partici- “I used to think a lot after failing my KCSE . I was pant. wondering what next? This is when I started having too much headache and a lot of fear.” 22-year old “I started taking alcohol after high school. I thought female participant. it was normal for those in university to take alco- hol since now you are a grown-up and other people Strained relationships with parents and other family especially my friends were taking it. So I thought, members why not join them? I hope to stop completely as it is Four participants attributed a conflictual relationship the cause of Bell’s palsy that I have now…” 21-year with their caregiver as a leading cause of their psycholog- old male participant. ical distress. Coming from unsupportive families, abusive parents or siblings, parent child discrimination or pref- Familial challenges and lack of support in transitioning erential treatment, parental divorce or marital conflicts process were shared as being the primary trigger of their current Most of our male participants expressed difficulties in psychological distress. A client reported to have hated overcoming life transitions and alluded to absence of sup- the day her younger sister was born: port in navigating resultant challenges. Six participants “Dad started neglecting me and it is like all the love described the challenges of transiting from one phase of I had for him ended. He still prefers my sister and life to another i.e. from childhood to demands and expec- I feel like she is more special than me. Maybe it is tations of youth, while some struggled with fitting in their because she is named after mum to my dad.” 19-year social milieu due to mental illness. The following vignette female participant. explained these challenges further: A client reported to have had no connection with his “I repeated form IV then joined university where mum due to lack of motherly affection and attention I am studying mass communication. In the first since he was very young: semester, I started having weird feelings and thoughts. I felt like I do not fit into the school culture. “I grew up with my extended family since mum had People were just having fun. Right left and center. travelled out of the country for further studies. When Then I got myself in this group of girls who had she came back, she was a stranger to me. We still do money from their boyfriends and older men. I wish not have a relationship.” 19-year old male partici- I did not join them. Somehow I lost my virginity…..” pant. 22-year old female participant. (KCSE) Kenya Certificate of Secondary Education: End of high school level examination. Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 8 of 15 The PTI question “Tell me about some (other) impor - when I feel like everyone knows am not a virgin. I tant experiences or events in your life that you associate don’t want to hang out with boys so that they do not with your difficulties and how the problems began” was nd out a fi bout this.” 19-year old female participant. the most relevant to this theme: “After being caught with bhang, people viewed me “I stay with my mum and brother. We are not close as a peddler making me feel so bad and couldn’t to each other and I am not free to talk to them since face people after that incident. My self-esteem was they do not care about my opinion. I just keep quiet.” affected. Some friends deserted me.” 19-year old 20-year old male participant. male participant. “I am angry at my dad. Really very angry. He listens to his relatives more than he listens to us. Like now I Biological conditions and psychopathologies limiting wanted to go further my education in UK but a sister intervention to my dad said I should not go because I am epilep- Three of our participants shared their struggle with tic. My dad agreed with her. He does not like sup- organic conditions such as Epilepsy, Bell’s palsy, and Psy- porting me. But one day I will prove them wrong. I chosis (under remission). will work hard and show them that epileptic people An Illustration from a participant with Epilepsy: can do great in life.” 24-year old female participant. In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” this is what a participant had to say: Stigma and rejection from significant others and a tendency towards self‑stigma “I was diagnosed with epilepsy when I was a young Five out of ten participants attributed discrimination and child. Growing up as an epileptic person is very chal- stigma emanating from people around them as further lenging. People do not want to be associated with triggering their mental illness and distress. Rejection, you, my father does not care about me. Maybe he being teased, and feeling judged by relatives was common thinks I am a burden, since he doesn’t buy my medi- among the five participants. Peer pressure was mostly cine. Were it not for epilepsy, I would be so happy. I described by the participants with substance abuse. have never been happy in my entire life. But I will The PTI question “In relation to the psychological prove people wrong. I want to show them that I can issues, what is your view on others and yourself?” is illus- achieve my goals despite being epileptic.” 24-year old trated here: female. “When am alone, I feel great. But when am with my This led to experiences of anger and emotional discon - mother [sic] I feel bad because my mum thinks am tent in our participant. She went on to describe her pain unimportant.” 19 years old male participant. as being “too much to bear.” She thought that her unhap- piness was due to the fact that she has always been epi- “My friends used to undermine me because my mum leptic and having to face stigma from close relatives and was old, deaf and dumb. And we were very poor. I friends. had no friends when growing up. They hated me.” An Illustration from a participant with Bell’s palsy: 25-year old female participant In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” The inability of a parent to care, address the partici - “I cannot feel one side of my mouth. It is not there. pants’ needs, or social problems negatively impacted the I have gone for physiotherapy but still… so my dad psychological wellbeing of our participants. Four out of being a psychiatrist thought I counselling would the 10 participants interviewed shared their suffering help solve the issue. But am ne fi . It is only this side from low self-esteem because their families did not sup- of the mouth that is bringing me down and I am not port them or had socioeconomic or psychological prob- myself.” 22-year old male lems themselves. They feared disclosing their illness or others knowing that they were seeking psychiatric help An Illustration from a participant diagnosed with as it would bring stigma. They attributed their distress to Psychosis: rejection or discrimination. In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” “I used to be an active child but am now introverted. I do not want my friends to know that I came for “..…..Then I started getting headaches. Too many counselling. I also did not tell my mum…….. Also, fears and thoughts. When I went to hospital, the doc- Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 9 of 15 tor said I had psychosis. Yes I have tried to Google She believed that working through her past experiences what that means. It is not easy to live with that and would lead to a more productive life and consequently when you tell people they say you are ‘chizzy’ (means enable her to be psychologically healthy. The participant ‘mad’ in Kiswahili).” 22-year old female stated that she needed the support from a professional in order to come to terms with her mum’s death. These par - From the quotes above, it is evident that in the mind of ticipants thought that positive coping mechanisms com- these patients there was a fear about their long term well- ing from interaction with a professional psychotherapist being and a feeling of stigmatization from other relatives were important in reshaping their lives. Another 19-year that led the participants to be withdrawn. old male participant who had been suspended from school said that peer pressure was a cause to his psycho- Preferences and views on cure logical and emotional pain: Nine out of the ten participants interviewed reaffirmed the tremendous value of psychotherapy as the most effec - “If I had listened to my inner voice that was telling tive mode of intervention. One of our participants had me to avoid those guys, I would be so ok. I would be had psychotherapy earlier; this prompted him to initiate in school like other students. I will be attentive to my therapy when the need arose. The following treatment- thoughts when asked to do something next time.” related preferences stood out: A 24-year old young woman participant considered going back to school so that she could be happy: Affirmation of psychotherapy as the most appropriate and helpful intervention “If I get the scholarship to UK, I will be happy. I want Our participants wanted concrete ways to move on from to be a better person and be busy. Being busy has their current situation by guidance and support from a helped me a lot. Now I do not concentrate on dad professional. It shows how several participants wanted not buying medicine. I also do some volunteering to engage in counselling and believed that they could work and get paid. Being busy helps a lot. But when learn and improve their life situations with the skills they idle, I get to think a lot and get angry over small would learn during treatment. issues.” In response to PTI interview question, “What do you Being involved in activities that the participants think is needed for your illness to be cured or might ease enjoyed doing and being in tune with their own feelings your pain?” and thoughts were related to having a positive mental “My dad often takes us for counselling just to make health. In this regard, the treatment offered life skills and sure all is well. Prayers are good but I prefer some- problem-solving strategies. Professional help was empha- thing tangible such as counselling.” 22-year old male sized over other alternative means of coping by our participant. young participants. Involvement in activities that did not yield positive impact brought in the need for counselling. Others wanted to learn coping mechanisms—learn- For those with substance abuse problems, participating ing how to manage their feelings in a constructive way or in support groups that could reverse negative peer influ - focus on important things in their life. ences was a viable solution to psychological challenges. “I believe I need to control myself with regards to my One of the female participants had tried various solu- anger. The only person I cannot control is my dad. tions like going to church and talking to friends but that So I let him be. But I need to know how to stop over did not put an end to her distress or problems. reacting when I get angry.” 24-year old female par- “I used to go to church and share with my girlfriends ticipant. but I was not content. I also think peer counselling Seven participants believed that their negative child- would also be good.” 20-year old female. hood experiences caused their problems and continued “I tried alcohol, cigarettes and generally going out for to affect them, and these needed to be managed in order social events to feel ok but the pain was too deep in to move on with life. In this regard, a 20-year old female me. Especially after losing my dad and the insults I participant, who lost her mum at a young age made the get from my brother. But the drinks did not help….” following remarks: 19-year old female participant. “I still do not know how to deal with her demise. I Other participants who had been in psychotherapy want to understand myself better and be more pro- before shared that it had a life-changing positive impact. ductive in life. I am growing old. I need to know how Another client preferred psychotherapy as opposed to to deal with mum not being around.” Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 10 of 15 talking to friends and relatives. Some participants were at four domains: locus of control (internal vs. external), concerned about the side-effects of medication and pre - controllability of events (controllable vs. uncontrol- ferred psychotherapy as it presented no such risk. lable), stability of life circumstances (stable or unsta- ble). Stigma (self/internal vs. external) was added as an “I do not share my issues with other people. People independent domain given that mental illness can be are superficial and cannot be trusted. I prefer coun - highly stigmatizing in the Kenyan cultural context. The selling. My friend had advised me to ask for anxiety attributions were studied within the PTI-P [23]. In this drugs but I am not ready for medication…” 22-year process, we have tried to demonstrate that the attribu- old male participant tional framework can help expand patients’ private the- We explored different strategies that participants had ories/experiences about their problems and perceived thought of and practiced to ease their pain. Those par - solutions. ticipants who had adjustment problems in school and got suspended on account of misconduct mentioned that Internal and external locus of control they were more mindful of this and chose their friends In the present study, participants with an internal locus carefully. Listening to parental advice, getting involved in of control were relatively more resourceful in control- extracurricular activities like sports, and making use of ling their own behaviors once they were introduced to their talents were the strategies that the participants had psychotherapy. The participants with an external locus put into consideration and practiced. They believed that of control do not have a determined role in shaping their this would not only make them better people, but also response or energies towards a specific experience [36]. help them improve in school performance, time man- This implies that such individuals do not develop a sense agement, and forming bonds with people with whom of responsibility in establishing their own coping mecha- they shared similar goals in life. Our participants alluded nisms and behavioral pathways, and hence their behav- to the family therapy sessions that were organized to iors are shaped more in relation to the perceptions and address interpersonal problems and so their challenges interpretations of other people [37]. Consequently, we were relayed to their caregivers. One of our participant suspect, such individuals take longer to identify how echoes this further: the change could be made. Several studies have pointed to the interrelationship between  increased levels of gen- “If possible, I will ask my mum to come with me in eral self-efficacy, problem-oriented coping strategy, and next session. May be if the counsellor told her that internal locus of control as protective factors in bolster- I cannot be like her she will understand and stop ing mental health [38] and external locus of control is being too harsh on me and having so high expecta- a good predictor of low mental health [39]. In a British tions form me.” 9-year old male participant study, one of the factors which facilitated the UK mili- tary personnel with post-traumatic stress disorder to engage in help-seeking behaviors was the sense of inter- Valuing psychopharmacological support in their overall nal locus of control [40]. A case in point is that feelings treatment of anger, fear, and thoughts of being unwell or the need While we found a lot of validation of the psychothera- to deal with one’s stressors are some of the internal/dis- peutic treatments our participants received, one male positional factors leading to treatment-seeking behavior. participant particularly emphasized his preference for These participants were well in control of their feelings medication as a form of treatment during the interview and thoughts. However, their psychological stressors had saying: roots in some external, uncontrollable traumatic factors “I am not a people person at all. Am hoping to be such as separation from parents, death of a loved one, given some stress medicine and I will be good. Talk- and excessive stigmatization and discrimination from ing to people feels strange especially for a man. Men others. In Julian B. Rotter’s [41] explanation of external do not share their personal information.” 20-year old locus of control, events or outcomes depend on factors male participant diagnosed with major depressive managed by environmental powers such as destiny or disorder. fortune outside of individual’s control [42]. The skills of problem-solving and positive thinking offered in therapy provided one mechanism to cope given these adverse cir- Discussion cumstances in the lives of our participants. For instance, We used a bifocal theoretical approach to guide this participants, who spoke of their childhood experiences or inquiry on attributions and private theories of mental stigma from the public, viewed these challenges as stem- illness amongst young adults. Weiner’s attributional ming from an outward cause (external locus of control) model [16] guided our conceptual model as we looked Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 11 of 15 rather than from within their own thoughts, feelings, or of reaction empowers people to change their roles in the behaviors. Those who attributed psychological problems mental health system, becoming more active participants internally spoke more of their negative thoughts and feel- in their treatment plan and often pushing for improve- ings leading them to experience a psychological problem. ments in the quality of services [44]. It is due to these It is likely that those with an external locus of control will external attributions (stigma from others) that various experience greater challenges with problem-focused cop- participants we interviewed felt the need to seek therapy ing when stressed. and were quite committed to it. Hence, it can be argued that the participants viewed this external attribution Further implications of internal locus of control as an unstable attribution factor that could be changed Bitterness and hatred are internal processes. Each partic- through therapy. Thus this was a controllable attribution ipant had a need for letting go of these emotional strug- as well, since they thought that by being in therapy, they gles [18]. Putting into consideration that these are within were at a higher position of controlling how they felt and a person’s internal locus of control explains our second even reacted towards stigma from others. conjecture that the internal locus of control might be posi- tively associated with early positive engagement with one’s Self‑stigma and its links with attribution of controllability treatment such that it facilitates emotional regulation and An alternative reaction to anger about stigma is to turn re-channeled our participants’ efforts in the face of exter - prejudice inwards as self-discrimination. Research sug- nal stressors. One of the participants, as quoted above, gests self-stigma and fear of rejection by others lead peo- sought help on how to manage her anger. She shared that ple to quit pursuing life opportunities for themselves [47]. anger was the reason why she could not deal with daily Self-esteem suffers, as does confidence in one’s future, as life challenges but instead had outbursts that accelerated indicated by participants interviewed in this study. Some the problem. felt lost and wanted to find their place in society. An indi - vidual with mental illness may experience diminished Stigmatizing contexts and relationships self-esteem/self-efficacy, anger, or relative indifference Stigma can lead to excessive feelings of contempt and depending on the parameters of the situation [48]. anger that triggers hostile behavior and other external- Cognitive theories of depression argue that beliefs izing symptoms [43]. Unlike physical disabilities, persons of low self-worth and the tendency to attribute nega- with mental illness are perceived to be in control of their tive events to causes that are global (widespread rather disabilities and be responsible for causing them. Further- than specific) and stable (will persist rather than change more, people are less likely to pity persons with psychiat- in the future) is associated with the development of ric illness, instead reacting to psychiatric disability with depressed mood (Pearson et al. 2015). In our interviews, anger and believing that help is not deserved [44]. This self-esteem was viewed as proportionally connected to sentiment was also echoed by our research participants. the distress one experienced: the more the distress the For example, one of the participants attributed her psy- poorer the self-esteem. One of our participants shared chological distress to being stigmatized by both family that she sought therapy to regain self-esteem and confi - members and friends because of her epilepsy. Her father dence. Therefore, self-stigma was an internal attribution neglected her by not buying her medication and failing that was viewed as a reason for seeking help since it was to pay her school fees. Another young participant shared within the participants’ ability to be in control. that she had not told any of her friends or relatives about In the present study, prominent bio-psychosocial her decision to visit the clinic. She did not want people explanations of mental illness were identified from our to know that she was seeking psychological help to avoid ten participants. Previous research shows that patients being labelled a mentally ill person. tend to have more than one causal explanation for their Discrimination can also appear in public opinion about mental illness [33]; an observation that echoes in our how to treat people with mental illness. For example, one study too. Our participants attributed their problems to client reported withdrawing from family functions due more than one cause. to stigma and discrimination from his immediate family Studies carried out in high-income countries [49] members and relatives. It is worth noting that the behav- about public views regarding causes of mental illnesses ioral impact (or discrimination) that results from public reported that people predominantly held beliefs on men- stigma may take four forms: withholding help, avoidance, tal illness to be social factors such as stressful life events, coercive treatment, and segregated institutions [45]. traumatic experiences, family problems, and social dis- Research also suggests that, instead of being diminished advantage [49–52]. Research carried out by Muga and by the stigma, many persons become righteously angry Jenkins [3], Ikwuka et al. [53], and Samouilhan and Seabi because of the bias that they experienced [46]. This kind [54] show that in Western contexts people might hold Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 12 of 15 more biological explanations for their mental illness and Meyer and Garcia-Roberts [63] reported that the par- increasingly seek medicines for these biological causes. ticipants in their study preferred ‘sharing and talking However, in our study we noticed that whilst some of our through their distresses as a cathartic and helpful strat- participants had conditions that have biological determi- egy.’ In our study, nine participants had tried other medi- nants, the interface with therapy and work on psycho- ums of support such as prayers, focusing on their unique social stressors remained the articulated needs of our talent, avoiding bad company, and taking note of paren- participants. tal advice. In some ways, there was a development of an Studies by Thwaites et  al. [55] in UK and by Adewuya internal locus of control before they sought help from the and Makanjuola, [56] in South Eastern Nigeria found health services. It could also be that there was a feeling that their participants attributed mental illnesses more that none of this could be sustained without adequate to external than internal causes. Lingman and Lydén motivation and support that a professional could lend. [33] found that causes such as poverty and negative fam- This was a theme echoed by several participants of our ily upbringing were common risk factors amongst young study. adults who sought psychological help. Environmental In a study from Pakistan, nearly half of the respondents and social attributions have been identified as commonly reported psychiatric consultation to be the single most seen stressors and our participants expressed similar important management step [64]. This shows that people concerns. In Ghana, for instance, participants mentioned living in non-western countries endorse modern western issues such as unhealthy living conditions, lack of social medical care for mental health problems in addition to support, relationships problems, society pressures, lone- other more indigenous methods. Our participants tended liness, and failure in life as reasons for becoming men- to be contemplative and open-minded in seeking pro- tally ill [57]. fessional medical and psychosocial help for their mental A large community survey done in Nigeria [58] found illness, for which they were also willing to try various that as many as one-third of the respondents suggested remedies for cure. Their views tended to be dynamic and that possession by evil spirits could be a cause of mental agreeable to change, such as doing away with unwanted illness, which was not the case in this present study. We behavior that was a result of peer pressure in school. This suspect that as our work involved young adults’ under- is similar to other findings from non-western countries 30  years of age, the belief in spirit possession and tradi- [65]. However, in our study it was evident that the private tional healing might not be as common as it might be in theories of several participants were influenced by West - older people. More recent studies from Ethiopia showed ern views of pathogenesis and cure for mental illness. The inclusion of biological and psychosocial factors as expla- apparent existence of Western conceptions could be the nations of mental disturbances in addition to the age-old result of the participants being, what Sunday and Ibadan spiritual and magical views [59]. Similarly a survey from [66] describes as ‘transitional Africans’. Transitional Afri- a small town in Western Ethiopia reported psychoso- cans have received a Western education and, therefore, cial problems such as poverty, stress, and drug abuse as often incorporate both the African and Western values. common explanations for mental illness in addition to We found this flexibility in thinking very heartening and explanations from religious/magical views such as God’s felt that our participants understood their problems and will or an attack by the evil spirit [60]. Another finding appraised solutions in fairly multidimensional ways. from North-western Ethiopia was that psychosocial and supernatural retribution were predominant explanations Conclusions of mental illness, but less common for physical illnesses Most research about etiological beliefs have investigated [61]. Mamah et  al. [62] carried out a study on Kenyan peoples’ beliefs about mental illness in general but there youths’ perceptions about mental illness where they is virtually no scholarship on young peoples’ private found that spiritual explanations were highly prevalent. theories of their own mental illness in Kenya. We have However, in contrast to our study, the attribution to a provided subjective explanations of Kenyan youths’ per- spiritual cause was not alluded to, which is also similar to ceptions of their mental illness. Three key themes, psy - the findings by Ikwuka et al. [53]. This study was carried chosocial triggers of distress, biological conditions, and out at a public hospital based in the country capital and psychopathologies limiting interventions and subjective the participants interviewed had acquired a high school views on cure were private theories that we unpacked. education with free access to the services offered at the When these private theories were mapped onto the hospital’s youth clinic; these factors may have influenced attributional framework we imposed on the PTI-P we findings. In addition, we did not specifically explore spir - found that those who attributed their distress to an itual attribution further in our interviewing. internal locus of control had a positive outlook towards therapy and behavior change. External factors were Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 13 of 15 Authors’ contributions mainly ascribed to be the cause of negative emotions JWM carried out the research as a fulfillment of the Masters of Science in and thoughts leading to psychological illness. Stigma and clinical psychology at the University of Nairobi, department of psychiatry. MK self-stigma particularly were challenging attributions that was her primary mentor who helped with conceptualizing and analyzing the study, CO was the second mentor to JWM and helped with translation of the needed socio-cultural awareness and youth empower- tool and proofreading the manuscript, FF was the third mentor who helped in ment work. Our limited data suggests that certain aspects conceptualizing and proofreading the manuscript, MWK helped in proof read- of our participants’ lives emanated from uncontrollable ing the manuscript. All authors read and approved the final manuscript. events that shaped their locus of control to be external- Author details ized. Mental health care of young adults could benefit Department of Psychiatry, College of Health Sciences, University of Nai- from exploration of their personal beliefs and attribu- robi, P.O.Box 19676, Nairobi 00202, Kenya. Research Department of Clinical Health and Educational Psychology, University College London, Gower Street, tions about their illness and cure in order to provide the London WC1E 6BT, UK. Department of Behavioural Sciences and Learning, best-adapted treatment for them and consequently make Linköping University, Linköping, Sweden. the mental health care more attuned to their concerns Acknowledgements and needs. We thank all the participants who took part in the research interviews making this study possible and to the clinicians and staff members at the Youth Clinic Limitations and next steps run by the Department of Mental Health, Kenyatta National Hospital who facilitated data collection. Acknowledgements are also due to the direct and We interviewed participants after they had a psycho- indirect support of the three grants mentioned above. therapy session with their therapist and diagnoses were already established by then. This might have influenced Competing interests The authors declare that they have no competing interests. the clients’ thoughts and perceptions on mental illness and cure. However, the designed interview guide was Availability of data and materials structured in such a way that the client’s personal percep- Coded qualitative data is available in form of word Tables and excel sheets. tions on these issues were explored, independent from Consent for publication therapist’s thoughts. The study was carried out in an All participants consented for the findings of the work to be published. urban setting with young adults, hence cannot be entirely Ethics approval and consent to participate generalized to youth living in rural or remote setting who The study was reviewed by the Kenyatta National Hospital and University of may experience unique challenges in addition to their ill- Nairobi Ethical Review Committee No. KNH/UoN P105/02/2015. Patients who ness or those living in more marginal conditions, how- agreed to participate were issued an explanation of the research protocol. Refusal to participate in the study did not affect the way in which the partici- ever the clinic serves as a referral for clients from all over pants were subsequently treated. The consent from was signed by both the the country. The experiences of our participants would participants and a witness. most likely generalize to some other participants in the Funding population. JWM received seed funding from NIMH funded Partnership for Mental Health We strongly feel that focusing on addressing expe- Development in Sub-Saharan Africa (PaMD), CJO is a Co-I on the PaMD project riences of young people in phenomenological ways and MK was awarded PRIME-K seed award as part of NIH funded MEPI/PRIME- K AWARD NUMBER 1R24TW008889. offer insights into their psychosocial and intrapsychic processes. Future research efforts should be directed Publisher’s Note towards using this approach to understand attributions Springer Nature remains neutral with regard to jurisdictional claims in pub- of mental illness in young people in diverse contexts, lished maps and institutional affiliations. and more research is needed from resource-scarce con- Received: 2 January 2018 Accepted: 17 April 2018 text to understand mental health service implementa- tion challenges. We believe that mental health needs of young people is an area requiring further phenomeno- logical grounded theory based research. Such exercises References would build an edifice of theoretical constructs useful for 1. Boldero J, Fallon B. Adolescent help-seeking: what do they get help for understanding what mental health, mental illness, and and from whom? J Adolesc. 1995;18:193–209. https ://doi.org/10.1006/ jado.1995.1013. psychotherapies mean for young people in Kenya. And 2. 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Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis

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Medicine & Public Health; Psychiatry; Pediatrics; Clinical Psychology; Child and Adolescent Psychiatry; Forensic Psychiatry
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Abstract

Background: Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extend- ing youth-friendly services. Methods: Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18–25 years about their mental health condition for which they were undergoing treatment. Each interview took 30–45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions. Results: We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents’ separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting interven- tion, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emo- tions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy. Conclusion: Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya. Keywords: Youth in psychiatric facilities, Attributions of mental illness, Locus of control, Private theories interview, Stigma *Correspondence: m.kumar@ucl.ac.uk Department of Psychiatry, College of Health Sciences, University of Nairobi, P.O.Box 19676, Nairobi 00202, Kenya Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 2 of 15 is used to study psychotherapy patients’ subjective beliefs Background about their problems, their causes, and any ideas they may Mental illness affects every segment of the population. have about what would be needed for them to feel bet- Mental health issues among the youth can negatively ter. We used the patient version of the interview (PTI-P). impact the national development of a country. More We superimposed this interview on an attribution model so, the beliefs held by the community about the causes developed by Weiner [16]. We used these two frames to of mental illness are likely to impact individual treat- capture the interviewee’s attempts to give meaning to their ment-seeking behavior [1–4]. Available literature from interpersonal, psychic, and somatic distress, while includ- developing countries show that acceptance of help with ing these experiences in the patient’s private context of mental health issues and engagement with services can be meaning. The PTI-P is a semi-structured, brief qualitative affected by various factors such as belief in evil spirits and interview, which can be used to understand participants’ stigmatization of mental health problems [2, 4–7]. Young personal assumptions of treatment, mental health or ill- people’s attitudes towards peers with mental illnesses has ness qualitatively. We adopted the PTI-P, developed by been studied and the findings suggest that young people [17], as it is with minimal changes. The attribution-focused differentiate between perceptions of how dangerous and questions were superimposed on the PTI-P, by adding fear provoking the individuals might be [8]. However, no extra probes to questions in the PTI-P. See Table 2 for the research has explored young peoples’ beliefs and attribu- newly designed attribution-focused questions. tions associated with their illnesses. Cultural components such as social attitudes, peer group rules, religious beliefs, The attributional framework family morals, and other socio-cultural factors strongly Depression, anxiety, and stress are commonly associated contribute to the behavior and attributions towards men- with negative thinking and attributions. We outlined our tal illness held by the youth [9]. Data on years lived with attribution framework from the original attributional disability (YLD) demonstrate that, in Kenya, the burden of framework done by Bernard Weiner [18]. Attribution mental health is significant and access to specialist care is refers to the assessments of the cause of an action or limited [10, 11]. The gaps in meeting mental health needs behavior [19]. It also refers to the internal (thinking) and and providing services for young adults are worrying, external (talking) process of interpreting and understand- given increasingly high levels of depression and incidents ing what is behind our own and others’ behaviors. Attri- of suicide by young adults in Kenya [12–14]. bution theory explains an occurrence and determines the Young adults’ attributions of mental illness are not cause of the happening or behavior. It starts with the idea well-researched; hence, we know very little about their that individuals are driven to understand the causes of patterns of help-seeking behavior or their commonly the happenings or behavior and that this desire allegedly used description of distress. Our study is an exploratory grows out of individuals’ wish to understand, foresee, and step towards understanding young adults’ expression of control the environment [20–22]. The attributions are distress, their attributions associated with mental illness, known to be of different types. According to Weiner et al. and factors that prevent or contribute to management [23], there are three dimensions of causal attributions of mental disorders. By gathering mental illness-related which include the following. attributions held by the young adults, we made it possible to extrapolate aspects of their psychotherapy care which Locus of control (internal vs. external) need further strengthening. Exploring the beliefs young A person’s belief that the events which occur in life are people hold about their illness and pathways to cure are either a result of personal control and efforts or an out - important steps to facilitating early access to mental side force like luck or fate is referred to as locus of con- health services and improving psychological wellbeing. trol (LoC). Controllable vs. uncontrollable attribution: This includes alerting the practitioners about possible Weiner’s controllability dimension concerns a situation barriers that hinder positive psychotherapy outcome. that is regarded as controllable if the individual is per- Through this research we gained a critical knowledge sonally able to guide, influence, or prevent it. It is the piece that will provide insight into barriers young adults extent to which the individual has control over the cause, encounter in seeking mental health services. To achieve as perceived by observers. Försterling [24] used “drunk- this, we used two theoretical lenses to review subjective enness” as an example to describe the controllability of appraisal from young adults: attributional framework and causes, suggesting that “drunkenness” is perceived as a the private theories interview. controllable cause. Causes that can neither be influenced nor guided such as a physical handicap, for example The private theories interview patient version (PTI‑P) blindness, are regarded as being uncontrollable [24]. The The private theories interview [15] is an interview that was external locus of control are often thought to be relatively developed in the context of psychotherapy research, and Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 3 of 15 uncontrollable and associated with perceived social stress am to 5.00  pm, and roughly ten new patients are regis- that young adults might encounter [25]. tered each week and around fifteen more new patients are added during school holiday periods. It is overseen Stability of causal attribution (stable vs. instability) by resident psychiatrists, psychiatric nurses, and psy- Stability is the time-based nature of causes [16]. Some chotherapists including clinical psychology interns. The causes remain stable over time while others increase or services are free to all youth regardless of type of diag- decrease. Causal attributions, when viewed as stable and nosis, and the clinic also provides outreach services for unchanging as opposed to unstable and fluctuating, are HIV testing and counselling (HTS). This setting was directly related to a person’s expectancy of successful chosen because it serves nationwide referrals and walk- results [24] implying that the stability attribution makes in patients who are predominantly fluent in either Eng - the person less inclined to believe that his/her problems lish or Kiswahili. Most clients are referred from various will improve. As the mental illness deteriorates in an schools, colleges, and universities, and it is also a clinic individual, it perpetuates an irrational outcome and dam- for walk-in cases and emergencies. ages self-governing functions. This could be explained by the knowledge that mental-behavioral or internal stig- Participants mas are normally considered unstable or reversible, while Our participants were between ages 18 and 25  years. physically based stigmas are perceived as stable, or irre- 18 years is the legal age for an adult in Kenya [12], while versible [26]. Stability and instability of attributions refer 25 is the age limit for patients attending the youth clinic to how fixed or how flexible the mental schemas associ - (Table 1). ated with these can be. Unstable attributions may help with the motivation to work in treatment, whereas sta- Sampling ble attributions may lead to hopelessness and not seeking In this exploratory study, we purposely selected young treatment. The more stable an attribution is, the harder it adults who were seeking psychiatric treatment at the is to change it [16]. Inferences on the stability and insta- clinic, were willing to give consent, and had fluency in bility of an attribution depends on how controllable or Kiswahili or English (the two official languages spoken uncontrollable one experiences an event or an individual in Kenya). Assessments from the psychiatrists and clini- attribute to be; it is also contingent on whether one views cal psychologists were used to determine the severity of the event or attribute it from an internal or external locus the patients’ mental illness. Two patients who were eligi- of control. ble for the study were excluded because both had severe psychosis in addition to limited fluency in English and Attribution of stigma (internalized vs. externalized) Kiswahili. None of the participants we approached for Stigma is defined as a social scratch that leads to ques - the study declined to give consent and participate. tioning of associates of a group, such as people with men- tal illness [27]. According to Rüsch et al. [28], the negative Ethical approval and considerations properties of stigma among individuals with mental ill- We received approval from the Kenyatta National Hos- ness lessen self-esteem and health care seeking behavior, pital and University of Nairobi Ethical Review Commit- and increase discrimination. The tendency towards self- tee (no. KNH/UoN P105/02/2015). The participants were stigma has been documented in Sub-Saharan African informed verbally and also provided with a written docu- patients and along this are also religious and supernatu- ment about the purpose of study. In addition, consent ral attributions given to mental health conditions in the to audio-record the interview was sought. Participants form of punishments [29]. Experiences of stigma cata- were informed that participation or refusal to take part in lysed by self-stigma revolve around experiences of deval- the study would not affect their current contact with the uation, exclusion, and disadvantage [30]. Moreso, mental clinic. No rewards were given for participation. illness stigma is one factor that hinders seeking care by distressed people, hence undermining the service system Instruments [31]. The individuals are not only troubled by the external A brief socio-demographic questionnaire was used to mental illness stigma but also by the self-stigma, leading capture key demographic information. These included to low self-esteem and self-efficacy [32]. the age of the participant, Kiswahili and English literacy levels, educational level, and gender of the participants. Methods These were gathered to synthesize the information with Setting their interviews. Data was gathered by use of semi-struc- The study took place at the Kenyatta National Hospital’s tured interviews with open-ended questions encourag- Youth clinic. The clinic runs every weekday from 7.30 ing exploration of experiences within the conceptual Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 4 of 15 Table 1 The Socio-demographic information Participant no. Age Gender Level of education Diagnosis Patient 01 20 Male University Major depressive disorder Patient 02 19 Male High school Substance induced psychosis Patient 03 18 Female College Secondary enuresis Patient 04 22 Female University Schizoaffective disorder Patient 05 19 Female High school Depression Patient 06 24 Female University Depression and epilepsy Patient 07 20 Female High school Conduct disorder Patient 08 22 Male College Somatic disorder Patient 09 19 Male High school Substance induced psychosis Patient 10 20 Female College Post-traumatic stress disorder Table 2 Private theories interview patients’ version and attributions focused questionnaire guide Private theories questions Attributions focussed domains What is it that leads you to seek treatment today? Internal locus of control External locus of control What are your thoughts about the psychological issues you are experiencing? Controllability Uncontrollability Tell me about some or other important experiences or events in your life that you associate with your difficulties Stability and how these problems Instability In relation to the problem (MI) how do you see yourself and others around you? Experiencing stigma Not experiencing stigma What do you desire that would ease your pain/distress? Desired treatment plan or cure framework used. The five questions from the Private suggestions on a few semantic adjustments. The adjust - Theories Interview-Patient version (PTI-P) were the pri - ments were only linguistic in nature. Given that these mary interview questions. We developed an Attributions were semi-structured questionnaires there was no need Focused Question guide that was embedded within the to formally validate the tools. Instead, we tested their cul- PTI questions as probes in such a way as to elicit attribu- tural sensitivity in pilot interviews. We used interpreta- tions. The probes were designed to get the participants tive phenomenological analysis (IPA) [34]—a qualitative to elaborate on the ‘how’, ‘why’, and ‘when’ associated technique to analyze our data. IPA was chosen because with the five private theories questions. The attribution- our goal was to magnify the subjective experiences, both focused question guide was mapped onto these questions tone and tenor expressed by our participants while inter- to create a subset of categories that explain the attribu- preting their idioms of distress, attributional patterns, tions used by participants in understanding their prob- and highlighting their barriers to mental health care. lems and thinking about how these could be resolved. These questions resulted in the attribution framework Given that mental illness continues to be a highly stigma- as shown in Table 2 below and embody each locus, stabil- tizing condition in Kenya [33], we included stigma as a ity, and stigma probes mapped on PTI-P. The questions category of attributions to see how our participants navi- were the following: gate it. Since the PTI-P was first developed in Sweden, we were 1. What is the problem? concerned how well these questions would fit the needs 2. How did the problems arise? of our Kenyan young participants. In order to enhance 3. How can the problems be remedied? cultural sensitivity and adapt the questions to the Ken- 4. What has changed? yan context, the question-guide was translated into 5. What is your view of others and yourself? Kiswahili. The first author, who is fluent in Kiswahili and English, translated with the help of an English-Kiswahili Each of these questions was paired with a domain from dictionary to ensure that the meaning of each word was the attribution theory. AFQ provided a deepening and retained. Two Kenyan trainee-psychologists also gave Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 5 of 15 expanding of the PTI-P framework and the scope of the approach is committed to detail in-depth analysis as well analyses. The domains adapted from Wieners attribution as to understand how a particular experiential event or theory were locus of control (internal vs. external), con- relationship (phenomenon) has been understood from a trollability (controllable vs. uncontrollable) stability (sta- particular context by different individuals or groups. ble or unstable), and stigma as an independent domain. IPA as a specific method in this study Data collection We used IPA in the following ways: by carrying out ver- Three pilot interviews were conducted at the youth clinic batim transcription of the semantic content of each inter- to test the conceptual framework and gauge participants’ view based on audio recording and followed by reading reaction to the interview questions. The first author was and re-reading of the content, while searching for richer, trained in qualitative interview techniques by her sen- detailed sections and for contradictions and inconsist- ior mentor MK and had regular supervision with all her encies. At the initial noting stage, the first author and mentors on using IPA as well as analyzing the data the- her supervisors identified specific ways the participants matically. The participants in distress were encouraged spoke of an issue, described what mattered to the partici- to continue with psychotherapy, and a referral mecha- pants, and the meaning of these things. This identified nism was built in the study if anyone had self-harming each participant’s emergent themes and the connections/ thoughts or was at a risk of harming themselves or oth- interrelations of the themes for each of the ten partici- ers. Once these procedures were identified, individual pants. Mapping of themes was done to connect and fit interviews took place in the counselling room at the the themes in relation to the research questions. With youth clinic before or after the participants’ counselling each step, every individual participant’s core themes were session. English or Kiswahili language was used as per tallied with other participants’ and we ensured that the the participant’s preference. The first author conducted analysis maintained a strong interpretive focus. The core the audio-recorded interviews with one interviewee themes were later merged with the attribution dimension at a time. The interview duration ranged from thirty to and the PTI-P framework to make sense of the bigger 40  min. Data collected was safely stored without any picture. At this point, our key question was which themes identifiers to ensure confidentiality of the participants. were being articulated by our participants and where did these fit-in vis-à-vis identified attributions. We present Data analytic plan themes emanating out of IPA from the private theories The recorded material was transcribed from the audio interview in the results section and in our discussion sec- recorder to a MS Word document. The first step was to tion we reflect on how these themes map onto attribu - ensure that all experiential material about PTI-P and tions framework as a whole. Attribution Focused questions were adequately answered in the data. The second step was to break the data as per Results the IPA framework. This was done because of the follow - Our results are presented in a twofold process. We high- ing reasons: (i). IPA is consistent with research aims since light the themes that were drawn from the PTI-P: psy- it is committed to the examination of how people make cho-social triggers, biological origins, and preference sense of their major life experiences [35], (ii). It is a phe- for combined treatment as a way of addressing stigma. nomenological approach focusing on exploration of expe- Table  3 lists the core themes arranged from the most riences in its own terms instead of attempting to reduce prominent to the least, as derived from frequency count it to predefined or overly abstract categories. This means among the 10 participants, while Table  2 indicates the that it is interpretative in that the researcher tries to make connections between the attributions and core themes. sense of the participants’ experiences, and (iii). IPA is con- These themes are reviewed here, starting with the psy - cerned with personal experiences and involves interpre- cho-social attributions. tation, with ample consideration of a given context. Psychosocial triggers of distress IPA as a scientific principle Our participants were concerned about various psy- IPA is idiographic in nature. It is concerned with reveal- chosocial triggers that adversely impacted their lives. ing something about the experience of each of the indi- Employing IPA, we identified a number of thoughts and viduals involved and is able to give a detailed conclusion experiences as being the prominent causes of our partici- about the participant group. Our third and next step was pants’ worries and distress. to ensure that we used IPA as a method in the service of teasing out PTI information and how young adults make attributions regarding their own well-being. The Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 6 of 15 Table 3 Building the connections (attributions vs. core themes) (to be placed in page 30, before internal and external locus of control) Interview questions a ttribution dimensions Core themes What is it that leads you to seek treatment Internal locus of control or dispositional attribu- Negative emotions and thoughts misconduct behaviour today? tions: based on behaviour within the client Transitional challenges-from teen to adult life Poor performance in school Self-stigma and shame of disclosure External locus of control or situational attribu- Negative childhood Experiences tions: Based on behaviour (from others) to the Strained relationships with parents and other family individual members Rejection from others and stigma Lack of finances Decline in social life What are your thoughts about the psycho- Controllability: if the individual is personally able Negative emotions and Thoughts logical issues you are experiencing? to guide, influence or prevent the situation Un-controllability: if the individual is personally Negative childhood experiences not able to guide, influence or prevent the Strained relationships with parents and other family situation members Rejection from others and stigma Lack of finances Decline in social life Tell me about some (other) important Stability: unchanging causes Death of loved ones experiences or events in your life that you Un-stable: changing/fluctuating causes Negative emotions and thoughts associate with your difficulties and how the problems began. In relation to the psychological issues, Stigma from others and self Self-stigma what is your view on others and yourself? Stigma from others What do you think is needed for your Treatment preference Need for therapy illness to be cured or might ease your Need for medication pain? Negative thoughts and emotions counterparts. Vignettes such as the following are testa- The participants shared in their interviews that negative ment to these early deprivations and adversities which thoughts and emotions were the core reasons for their they highlighted: illness and distress. Adverse experiences created a spi- “My dad does not care. Since the illness started from ral of negative thoughts and emotions about themselves childhood, he has never sent money for medication. and the world around them. The PTI question 1 was most He went and got another wife. He only sends money reflective of this spiral thinking that our participants for food for me and my sister. But for my medica- struggled to get out. tion, he has never sent … money. My mother who “I had a disagreement with mum. She wants me to lives with me does not work. She is a house wife be like her and I cannot. She separated with my dad and depends on the small amount send my father…” and now she wants me to go live with my uncle who 24-year old female participant diagnosed with epi- is very tough. She is also planning to go for further lepsy. studies abroad.” 20-year old young man. “[…] I used to love my father but when my sister “[…] I had a tough childhood; my brother uses drugs was born, it’s like he forgot about me. He only cared and abuses me. I also lost my dad at a young age…” about her. I started talking to boys and eventually 22-year old female participant. lost my virginity. I still feel bad about it…” 19-year old female participant. These vignettes point to grim interpersonal context that generate self-doubt and apathy in the participants. “My mum died. I still don’t know how to deal with Parental separation, unexpected death of a loved one, that. She was the most important person in my life. and protracted bereavement thereafter worsened the Always cheering me… I was her only child. I have no situation and the participants’ mental health, as expe- dad. I felt lost and never gotten over this. I do not rienced by the young adults interviewed. Female par- understand myself anymore.” 25-year old female ticipants echoed such experiences more than their male Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 7 of 15 participant. “I am not comfortable with my life. I have not achieved the things I have wanted to achieve. Just At a fairly early age, the participants had to deal with the way my life is going…..my career…Everything is situations that left them emotionally scarred. Seven of moving slowly. Am in a stage where I want to do new them had an early childhood experience that they attrib- things and find my own place in life” 24-year old uted to be the cause of their mental illness that brought male participant. them to the hospital in the first place. “Since I went to boarding school in class six my per- Adjustment and behavioral problems in school and college formance dropped and was always punished for This theme captured the participants’ thoughts about it….” 20-year old male participant. the need to be accepted by peers, family, and teachers. It also demonstrated the difficulty one may have in find - As a result of challenges in transitioning to new envi- ing a friend who would guide and influence in a positive ronments (e.g. day schooling to boarding), death of a way. As we learnt in our interviews that the participants loved one, and lack of finances or strained relationships were mostly connected with difficult conduct-related with significant others, four of them described their poor behaviors (externalizing tendencies) for which the youth academic performance as a cause of their psychologi- were seeking support. These vignettes underscore these cal distress. Some maintained this to be the main cause problems: of their mental illness while others thought if they had better upbringing or did not have to face difficulties in “My friend and I had a phone in school. During prep their childhood, they would have performed much better time, the teacher on duty caught us playing games. academically. We have been suspended for 2  weeks and told to go back to our parents…” 19-year old female partici- “I used to think a lot after failing my KCSE . I was pant. wondering what next? This is when I started having too much headache and a lot of fear.” 22-year old “I started taking alcohol after high school. I thought female participant. it was normal for those in university to take alco- hol since now you are a grown-up and other people Strained relationships with parents and other family especially my friends were taking it. So I thought, members why not join them? I hope to stop completely as it is Four participants attributed a conflictual relationship the cause of Bell’s palsy that I have now…” 21-year with their caregiver as a leading cause of their psycholog- old male participant. ical distress. Coming from unsupportive families, abusive parents or siblings, parent child discrimination or pref- Familial challenges and lack of support in transitioning erential treatment, parental divorce or marital conflicts process were shared as being the primary trigger of their current Most of our male participants expressed difficulties in psychological distress. A client reported to have hated overcoming life transitions and alluded to absence of sup- the day her younger sister was born: port in navigating resultant challenges. Six participants “Dad started neglecting me and it is like all the love described the challenges of transiting from one phase of I had for him ended. He still prefers my sister and life to another i.e. from childhood to demands and expec- I feel like she is more special than me. Maybe it is tations of youth, while some struggled with fitting in their because she is named after mum to my dad.” 19-year social milieu due to mental illness. The following vignette female participant. explained these challenges further: A client reported to have had no connection with his “I repeated form IV then joined university where mum due to lack of motherly affection and attention I am studying mass communication. In the first since he was very young: semester, I started having weird feelings and thoughts. I felt like I do not fit into the school culture. “I grew up with my extended family since mum had People were just having fun. Right left and center. travelled out of the country for further studies. When Then I got myself in this group of girls who had she came back, she was a stranger to me. We still do money from their boyfriends and older men. I wish not have a relationship.” 19-year old male partici- I did not join them. Somehow I lost my virginity…..” pant. 22-year old female participant. (KCSE) Kenya Certificate of Secondary Education: End of high school level examination. Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 8 of 15 The PTI question “Tell me about some (other) impor - when I feel like everyone knows am not a virgin. I tant experiences or events in your life that you associate don’t want to hang out with boys so that they do not with your difficulties and how the problems began” was nd out a fi bout this.” 19-year old female participant. the most relevant to this theme: “After being caught with bhang, people viewed me “I stay with my mum and brother. We are not close as a peddler making me feel so bad and couldn’t to each other and I am not free to talk to them since face people after that incident. My self-esteem was they do not care about my opinion. I just keep quiet.” affected. Some friends deserted me.” 19-year old 20-year old male participant. male participant. “I am angry at my dad. Really very angry. He listens to his relatives more than he listens to us. Like now I Biological conditions and psychopathologies limiting wanted to go further my education in UK but a sister intervention to my dad said I should not go because I am epilep- Three of our participants shared their struggle with tic. My dad agreed with her. He does not like sup- organic conditions such as Epilepsy, Bell’s palsy, and Psy- porting me. But one day I will prove them wrong. I chosis (under remission). will work hard and show them that epileptic people An Illustration from a participant with Epilepsy: can do great in life.” 24-year old female participant. In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” this is what a participant had to say: Stigma and rejection from significant others and a tendency towards self‑stigma “I was diagnosed with epilepsy when I was a young Five out of ten participants attributed discrimination and child. Growing up as an epileptic person is very chal- stigma emanating from people around them as further lenging. People do not want to be associated with triggering their mental illness and distress. Rejection, you, my father does not care about me. Maybe he being teased, and feeling judged by relatives was common thinks I am a burden, since he doesn’t buy my medi- among the five participants. Peer pressure was mostly cine. Were it not for epilepsy, I would be so happy. I described by the participants with substance abuse. have never been happy in my entire life. But I will The PTI question “In relation to the psychological prove people wrong. I want to show them that I can issues, what is your view on others and yourself?” is illus- achieve my goals despite being epileptic.” 24-year old trated here: female. “When am alone, I feel great. But when am with my This led to experiences of anger and emotional discon - mother [sic] I feel bad because my mum thinks am tent in our participant. She went on to describe her pain unimportant.” 19 years old male participant. as being “too much to bear.” She thought that her unhap- piness was due to the fact that she has always been epi- “My friends used to undermine me because my mum leptic and having to face stigma from close relatives and was old, deaf and dumb. And we were very poor. I friends. had no friends when growing up. They hated me.” An Illustration from a participant with Bell’s palsy: 25-year old female participant In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” The inability of a parent to care, address the partici - “I cannot feel one side of my mouth. It is not there. pants’ needs, or social problems negatively impacted the I have gone for physiotherapy but still… so my dad psychological wellbeing of our participants. Four out of being a psychiatrist thought I counselling would the 10 participants interviewed shared their suffering help solve the issue. But am ne fi . It is only this side from low self-esteem because their families did not sup- of the mouth that is bringing me down and I am not port them or had socioeconomic or psychological prob- myself.” 22-year old male lems themselves. They feared disclosing their illness or others knowing that they were seeking psychiatric help An Illustration from a participant diagnosed with as it would bring stigma. They attributed their distress to Psychosis: rejection or discrimination. In response to PTI question “What are your thoughts about the psychological issues you are experiencing?” “I used to be an active child but am now introverted. I do not want my friends to know that I came for “..…..Then I started getting headaches. Too many counselling. I also did not tell my mum…….. Also, fears and thoughts. When I went to hospital, the doc- Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 9 of 15 tor said I had psychosis. Yes I have tried to Google She believed that working through her past experiences what that means. It is not easy to live with that and would lead to a more productive life and consequently when you tell people they say you are ‘chizzy’ (means enable her to be psychologically healthy. The participant ‘mad’ in Kiswahili).” 22-year old female stated that she needed the support from a professional in order to come to terms with her mum’s death. These par - From the quotes above, it is evident that in the mind of ticipants thought that positive coping mechanisms com- these patients there was a fear about their long term well- ing from interaction with a professional psychotherapist being and a feeling of stigmatization from other relatives were important in reshaping their lives. Another 19-year that led the participants to be withdrawn. old male participant who had been suspended from school said that peer pressure was a cause to his psycho- Preferences and views on cure logical and emotional pain: Nine out of the ten participants interviewed reaffirmed the tremendous value of psychotherapy as the most effec - “If I had listened to my inner voice that was telling tive mode of intervention. One of our participants had me to avoid those guys, I would be so ok. I would be had psychotherapy earlier; this prompted him to initiate in school like other students. I will be attentive to my therapy when the need arose. The following treatment- thoughts when asked to do something next time.” related preferences stood out: A 24-year old young woman participant considered going back to school so that she could be happy: Affirmation of psychotherapy as the most appropriate and helpful intervention “If I get the scholarship to UK, I will be happy. I want Our participants wanted concrete ways to move on from to be a better person and be busy. Being busy has their current situation by guidance and support from a helped me a lot. Now I do not concentrate on dad professional. It shows how several participants wanted not buying medicine. I also do some volunteering to engage in counselling and believed that they could work and get paid. Being busy helps a lot. But when learn and improve their life situations with the skills they idle, I get to think a lot and get angry over small would learn during treatment. issues.” In response to PTI interview question, “What do you Being involved in activities that the participants think is needed for your illness to be cured or might ease enjoyed doing and being in tune with their own feelings your pain?” and thoughts were related to having a positive mental “My dad often takes us for counselling just to make health. In this regard, the treatment offered life skills and sure all is well. Prayers are good but I prefer some- problem-solving strategies. Professional help was empha- thing tangible such as counselling.” 22-year old male sized over other alternative means of coping by our participant. young participants. Involvement in activities that did not yield positive impact brought in the need for counselling. Others wanted to learn coping mechanisms—learn- For those with substance abuse problems, participating ing how to manage their feelings in a constructive way or in support groups that could reverse negative peer influ - focus on important things in their life. ences was a viable solution to psychological challenges. “I believe I need to control myself with regards to my One of the female participants had tried various solu- anger. The only person I cannot control is my dad. tions like going to church and talking to friends but that So I let him be. But I need to know how to stop over did not put an end to her distress or problems. reacting when I get angry.” 24-year old female par- “I used to go to church and share with my girlfriends ticipant. but I was not content. I also think peer counselling Seven participants believed that their negative child- would also be good.” 20-year old female. hood experiences caused their problems and continued “I tried alcohol, cigarettes and generally going out for to affect them, and these needed to be managed in order social events to feel ok but the pain was too deep in to move on with life. In this regard, a 20-year old female me. Especially after losing my dad and the insults I participant, who lost her mum at a young age made the get from my brother. But the drinks did not help….” following remarks: 19-year old female participant. “I still do not know how to deal with her demise. I Other participants who had been in psychotherapy want to understand myself better and be more pro- before shared that it had a life-changing positive impact. ductive in life. I am growing old. I need to know how Another client preferred psychotherapy as opposed to to deal with mum not being around.” Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 10 of 15 talking to friends and relatives. Some participants were at four domains: locus of control (internal vs. external), concerned about the side-effects of medication and pre - controllability of events (controllable vs. uncontrol- ferred psychotherapy as it presented no such risk. lable), stability of life circumstances (stable or unsta- ble). Stigma (self/internal vs. external) was added as an “I do not share my issues with other people. People independent domain given that mental illness can be are superficial and cannot be trusted. I prefer coun - highly stigmatizing in the Kenyan cultural context. The selling. My friend had advised me to ask for anxiety attributions were studied within the PTI-P [23]. In this drugs but I am not ready for medication…” 22-year process, we have tried to demonstrate that the attribu- old male participant tional framework can help expand patients’ private the- We explored different strategies that participants had ories/experiences about their problems and perceived thought of and practiced to ease their pain. Those par - solutions. ticipants who had adjustment problems in school and got suspended on account of misconduct mentioned that Internal and external locus of control they were more mindful of this and chose their friends In the present study, participants with an internal locus carefully. Listening to parental advice, getting involved in of control were relatively more resourceful in control- extracurricular activities like sports, and making use of ling their own behaviors once they were introduced to their talents were the strategies that the participants had psychotherapy. The participants with an external locus put into consideration and practiced. They believed that of control do not have a determined role in shaping their this would not only make them better people, but also response or energies towards a specific experience [36]. help them improve in school performance, time man- This implies that such individuals do not develop a sense agement, and forming bonds with people with whom of responsibility in establishing their own coping mecha- they shared similar goals in life. Our participants alluded nisms and behavioral pathways, and hence their behav- to the family therapy sessions that were organized to iors are shaped more in relation to the perceptions and address interpersonal problems and so their challenges interpretations of other people [37]. Consequently, we were relayed to their caregivers. One of our participant suspect, such individuals take longer to identify how echoes this further: the change could be made. Several studies have pointed to the interrelationship between  increased levels of gen- “If possible, I will ask my mum to come with me in eral self-efficacy, problem-oriented coping strategy, and next session. May be if the counsellor told her that internal locus of control as protective factors in bolster- I cannot be like her she will understand and stop ing mental health [38] and external locus of control is being too harsh on me and having so high expecta- a good predictor of low mental health [39]. In a British tions form me.” 9-year old male participant study, one of the factors which facilitated the UK mili- tary personnel with post-traumatic stress disorder to engage in help-seeking behaviors was the sense of inter- Valuing psychopharmacological support in their overall nal locus of control [40]. A case in point is that feelings treatment of anger, fear, and thoughts of being unwell or the need While we found a lot of validation of the psychothera- to deal with one’s stressors are some of the internal/dis- peutic treatments our participants received, one male positional factors leading to treatment-seeking behavior. participant particularly emphasized his preference for These participants were well in control of their feelings medication as a form of treatment during the interview and thoughts. However, their psychological stressors had saying: roots in some external, uncontrollable traumatic factors “I am not a people person at all. Am hoping to be such as separation from parents, death of a loved one, given some stress medicine and I will be good. Talk- and excessive stigmatization and discrimination from ing to people feels strange especially for a man. Men others. In Julian B. Rotter’s [41] explanation of external do not share their personal information.” 20-year old locus of control, events or outcomes depend on factors male participant diagnosed with major depressive managed by environmental powers such as destiny or disorder. fortune outside of individual’s control [42]. The skills of problem-solving and positive thinking offered in therapy provided one mechanism to cope given these adverse cir- Discussion cumstances in the lives of our participants. For instance, We used a bifocal theoretical approach to guide this participants, who spoke of their childhood experiences or inquiry on attributions and private theories of mental stigma from the public, viewed these challenges as stem- illness amongst young adults. Weiner’s attributional ming from an outward cause (external locus of control) model [16] guided our conceptual model as we looked Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 11 of 15 rather than from within their own thoughts, feelings, or of reaction empowers people to change their roles in the behaviors. Those who attributed psychological problems mental health system, becoming more active participants internally spoke more of their negative thoughts and feel- in their treatment plan and often pushing for improve- ings leading them to experience a psychological problem. ments in the quality of services [44]. It is due to these It is likely that those with an external locus of control will external attributions (stigma from others) that various experience greater challenges with problem-focused cop- participants we interviewed felt the need to seek therapy ing when stressed. and were quite committed to it. Hence, it can be argued that the participants viewed this external attribution Further implications of internal locus of control as an unstable attribution factor that could be changed Bitterness and hatred are internal processes. Each partic- through therapy. Thus this was a controllable attribution ipant had a need for letting go of these emotional strug- as well, since they thought that by being in therapy, they gles [18]. Putting into consideration that these are within were at a higher position of controlling how they felt and a person’s internal locus of control explains our second even reacted towards stigma from others. conjecture that the internal locus of control might be posi- tively associated with early positive engagement with one’s Self‑stigma and its links with attribution of controllability treatment such that it facilitates emotional regulation and An alternative reaction to anger about stigma is to turn re-channeled our participants’ efforts in the face of exter - prejudice inwards as self-discrimination. Research sug- nal stressors. One of the participants, as quoted above, gests self-stigma and fear of rejection by others lead peo- sought help on how to manage her anger. She shared that ple to quit pursuing life opportunities for themselves [47]. anger was the reason why she could not deal with daily Self-esteem suffers, as does confidence in one’s future, as life challenges but instead had outbursts that accelerated indicated by participants interviewed in this study. Some the problem. felt lost and wanted to find their place in society. An indi - vidual with mental illness may experience diminished Stigmatizing contexts and relationships self-esteem/self-efficacy, anger, or relative indifference Stigma can lead to excessive feelings of contempt and depending on the parameters of the situation [48]. anger that triggers hostile behavior and other external- Cognitive theories of depression argue that beliefs izing symptoms [43]. Unlike physical disabilities, persons of low self-worth and the tendency to attribute nega- with mental illness are perceived to be in control of their tive events to causes that are global (widespread rather disabilities and be responsible for causing them. Further- than specific) and stable (will persist rather than change more, people are less likely to pity persons with psychiat- in the future) is associated with the development of ric illness, instead reacting to psychiatric disability with depressed mood (Pearson et al. 2015). In our interviews, anger and believing that help is not deserved [44]. This self-esteem was viewed as proportionally connected to sentiment was also echoed by our research participants. the distress one experienced: the more the distress the For example, one of the participants attributed her psy- poorer the self-esteem. One of our participants shared chological distress to being stigmatized by both family that she sought therapy to regain self-esteem and confi - members and friends because of her epilepsy. Her father dence. Therefore, self-stigma was an internal attribution neglected her by not buying her medication and failing that was viewed as a reason for seeking help since it was to pay her school fees. Another young participant shared within the participants’ ability to be in control. that she had not told any of her friends or relatives about In the present study, prominent bio-psychosocial her decision to visit the clinic. She did not want people explanations of mental illness were identified from our to know that she was seeking psychological help to avoid ten participants. Previous research shows that patients being labelled a mentally ill person. tend to have more than one causal explanation for their Discrimination can also appear in public opinion about mental illness [33]; an observation that echoes in our how to treat people with mental illness. For example, one study too. Our participants attributed their problems to client reported withdrawing from family functions due more than one cause. to stigma and discrimination from his immediate family Studies carried out in high-income countries [49] members and relatives. It is worth noting that the behav- about public views regarding causes of mental illnesses ioral impact (or discrimination) that results from public reported that people predominantly held beliefs on men- stigma may take four forms: withholding help, avoidance, tal illness to be social factors such as stressful life events, coercive treatment, and segregated institutions [45]. traumatic experiences, family problems, and social dis- Research also suggests that, instead of being diminished advantage [49–52]. Research carried out by Muga and by the stigma, many persons become righteously angry Jenkins [3], Ikwuka et al. [53], and Samouilhan and Seabi because of the bias that they experienced [46]. This kind [54] show that in Western contexts people might hold Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 12 of 15 more biological explanations for their mental illness and Meyer and Garcia-Roberts [63] reported that the par- increasingly seek medicines for these biological causes. ticipants in their study preferred ‘sharing and talking However, in our study we noticed that whilst some of our through their distresses as a cathartic and helpful strat- participants had conditions that have biological determi- egy.’ In our study, nine participants had tried other medi- nants, the interface with therapy and work on psycho- ums of support such as prayers, focusing on their unique social stressors remained the articulated needs of our talent, avoiding bad company, and taking note of paren- participants. tal advice. In some ways, there was a development of an Studies by Thwaites et  al. [55] in UK and by Adewuya internal locus of control before they sought help from the and Makanjuola, [56] in South Eastern Nigeria found health services. It could also be that there was a feeling that their participants attributed mental illnesses more that none of this could be sustained without adequate to external than internal causes. Lingman and Lydén motivation and support that a professional could lend. [33] found that causes such as poverty and negative fam- This was a theme echoed by several participants of our ily upbringing were common risk factors amongst young study. adults who sought psychological help. Environmental In a study from Pakistan, nearly half of the respondents and social attributions have been identified as commonly reported psychiatric consultation to be the single most seen stressors and our participants expressed similar important management step [64]. This shows that people concerns. In Ghana, for instance, participants mentioned living in non-western countries endorse modern western issues such as unhealthy living conditions, lack of social medical care for mental health problems in addition to support, relationships problems, society pressures, lone- other more indigenous methods. Our participants tended liness, and failure in life as reasons for becoming men- to be contemplative and open-minded in seeking pro- tally ill [57]. fessional medical and psychosocial help for their mental A large community survey done in Nigeria [58] found illness, for which they were also willing to try various that as many as one-third of the respondents suggested remedies for cure. Their views tended to be dynamic and that possession by evil spirits could be a cause of mental agreeable to change, such as doing away with unwanted illness, which was not the case in this present study. We behavior that was a result of peer pressure in school. This suspect that as our work involved young adults’ under- is similar to other findings from non-western countries 30  years of age, the belief in spirit possession and tradi- [65]. However, in our study it was evident that the private tional healing might not be as common as it might be in theories of several participants were influenced by West - older people. More recent studies from Ethiopia showed ern views of pathogenesis and cure for mental illness. The inclusion of biological and psychosocial factors as expla- apparent existence of Western conceptions could be the nations of mental disturbances in addition to the age-old result of the participants being, what Sunday and Ibadan spiritual and magical views [59]. Similarly a survey from [66] describes as ‘transitional Africans’. Transitional Afri- a small town in Western Ethiopia reported psychoso- cans have received a Western education and, therefore, cial problems such as poverty, stress, and drug abuse as often incorporate both the African and Western values. common explanations for mental illness in addition to We found this flexibility in thinking very heartening and explanations from religious/magical views such as God’s felt that our participants understood their problems and will or an attack by the evil spirit [60]. Another finding appraised solutions in fairly multidimensional ways. from North-western Ethiopia was that psychosocial and supernatural retribution were predominant explanations Conclusions of mental illness, but less common for physical illnesses Most research about etiological beliefs have investigated [61]. Mamah et  al. [62] carried out a study on Kenyan peoples’ beliefs about mental illness in general but there youths’ perceptions about mental illness where they is virtually no scholarship on young peoples’ private found that spiritual explanations were highly prevalent. theories of their own mental illness in Kenya. We have However, in contrast to our study, the attribution to a provided subjective explanations of Kenyan youths’ per- spiritual cause was not alluded to, which is also similar to ceptions of their mental illness. Three key themes, psy - the findings by Ikwuka et al. [53]. This study was carried chosocial triggers of distress, biological conditions, and out at a public hospital based in the country capital and psychopathologies limiting interventions and subjective the participants interviewed had acquired a high school views on cure were private theories that we unpacked. education with free access to the services offered at the When these private theories were mapped onto the hospital’s youth clinic; these factors may have influenced attributional framework we imposed on the PTI-P we findings. In addition, we did not specifically explore spir - found that those who attributed their distress to an itual attribution further in our interviewing. internal locus of control had a positive outlook towards therapy and behavior change. External factors were Mbuthia et al. Child Adolesc Psychiatry Ment Health (2018) 12:28 Page 13 of 15 Authors’ contributions mainly ascribed to be the cause of negative emotions JWM carried out the research as a fulfillment of the Masters of Science in and thoughts leading to psychological illness. Stigma and clinical psychology at the University of Nairobi, department of psychiatry. MK self-stigma particularly were challenging attributions that was her primary mentor who helped with conceptualizing and analyzing the study, CO was the second mentor to JWM and helped with translation of the needed socio-cultural awareness and youth empower- tool and proofreading the manuscript, FF was the third mentor who helped in ment work. Our limited data suggests that certain aspects conceptualizing and proofreading the manuscript, MWK helped in proof read- of our participants’ lives emanated from uncontrollable ing the manuscript. All authors read and approved the final manuscript. events that shaped their locus of control to be external- Author details ized. Mental health care of young adults could benefit Department of Psychiatry, College of Health Sciences, University of Nai- from exploration of their personal beliefs and attribu- robi, P.O.Box 19676, Nairobi 00202, Kenya. Research Department of Clinical Health and Educational Psychology, University College London, Gower Street, tions about their illness and cure in order to provide the London WC1E 6BT, UK. Department of Behavioural Sciences and Learning, best-adapted treatment for them and consequently make Linköping University, Linköping, Sweden. the mental health care more attuned to their concerns Acknowledgements and needs. We thank all the participants who took part in the research interviews making this study possible and to the clinicians and staff members at the Youth Clinic Limitations and next steps run by the Department of Mental Health, Kenyatta National Hospital who facilitated data collection. Acknowledgements are also due to the direct and We interviewed participants after they had a psycho- indirect support of the three grants mentioned above. therapy session with their therapist and diagnoses were already established by then. This might have influenced Competing interests The authors declare that they have no competing interests. the clients’ thoughts and perceptions on mental illness and cure. However, the designed interview guide was Availability of data and materials structured in such a way that the client’s personal percep- Coded qualitative data is available in form of word Tables and excel sheets. tions on these issues were explored, independent from Consent for publication therapist’s thoughts. The study was carried out in an All participants consented for the findings of the work to be published. urban setting with young adults, hence cannot be entirely Ethics approval and consent to participate generalized to youth living in rural or remote setting who The study was reviewed by the Kenyatta National Hospital and University of may experience unique challenges in addition to their ill- Nairobi Ethical Review Committee No. KNH/UoN P105/02/2015. Patients who ness or those living in more marginal conditions, how- agreed to participate were issued an explanation of the research protocol. Refusal to participate in the study did not affect the way in which the partici- ever the clinic serves as a referral for clients from all over pants were subsequently treated. The consent from was signed by both the the country. The experiences of our participants would participants and a witness. most likely generalize to some other participants in the Funding population. JWM received seed funding from NIMH funded Partnership for Mental Health We strongly feel that focusing on addressing expe- Development in Sub-Saharan Africa (PaMD), CJO is a Co-I on the PaMD project riences of young people in phenomenological ways and MK was awarded PRIME-K seed award as part of NIH funded MEPI/PRIME- K AWARD NUMBER 1R24TW008889. offer insights into their psychosocial and intrapsychic processes. Future research efforts should be directed Publisher’s Note towards using this approach to understand attributions Springer Nature remains neutral with regard to jurisdictional claims in pub- of mental illness in young people in diverse contexts, lished maps and institutional affiliations. and more research is needed from resource-scarce con- Received: 2 January 2018 Accepted: 17 April 2018 text to understand mental health service implementa- tion challenges. We believe that mental health needs of young people is an area requiring further phenomeno- logical grounded theory based research. Such exercises References would build an edifice of theoretical constructs useful for 1. Boldero J, Fallon B. Adolescent help-seeking: what do they get help for understanding what mental health, mental illness, and and from whom? J Adolesc. 1995;18:193–209. https ://doi.org/10.1006/ jado.1995.1013. psychotherapies mean for young people in Kenya. And 2. 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Child and Adolescent Psychiatry and Mental HealthSpringer Journals

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