Impact of Experiences in the United States on Ghanaian Clergy’s Approach to Mental Illness: Implications for Social Work and Human Rights

Impact of Experiences in the United States on Ghanaian Clergy’s Approach to Mental Illness: Implications for Social Work and Human Rights | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Experiences in the United States on Ghanaian Clergy’s Approach to Mental Illness: Implications for Social Work and Human Rights PHILIP KWASI ELIKE This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6214524/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The study explored whether Ghanaian American clergy’s experiences in the United States impacted their views about mental illness. The study used a phenomenological approach and collected data from 8 Ghanaian American Clergy in New York City. Data was transcribed and coded to develop themes. The findings showed that participants’ views about the causes and treatment for mental illness have evolved due to their experiences in the United States. The findings show that (a) mental health literacy creates a positive perception of mental illnesses for the clergy, leading to a move away from the spiritual etiology for mental illness towards the biomedical etiology, (b) the availability of treatment resources in the United States contributed to a shift from spiritual treatment approach of fasting and prayer to a hybrid model of treatment of referring patients to hospitals and therapists for treatment while clergy still pray for them, (c) the humane treatment and support mental health patients receive in the United States changed the clergy’s negative perception of mental illness and reduced the stigma. The conclusion is that the lack of mental health literacy and evidence-based treatment resources leads to relying on spiritual interpretation and treatment for mental illness. Social workers must focus on promoting mental health literacy for the clergy and intensify their advocacy for adequate treatment resources to enhance humane treatment for people with mental health conditions and promote their human rights. Ghanaian American Clergy Experiences in the United States mental illness and human rights mental health literacy treatment resources humane treatment Introduction Spiritual Etiology for Mental Illness Religious interpretation of the cause and treatment of mental illness lingers throughout the history of humanity and persists to the present day. Studies suggest that in every part of the world, there is a strong belief by sections of the population that mental illness is a spiritual illness caused by demonic spirit possession, witchcraft, a curse, sin, or lack of strong personal spirit (Karanci, 2014; Ross et al., 2013; Stefanovic et al., 2016). Spiritual and religious explanations and treatment prescriptions for mental illness are not peculiar to any one religion but permeate most major religions and cultures (Koenig, 2018 ). Some Christian denominations believe that the devil causes mental illness through spiritual attacks. As such, persons who have mental illness should not seek medical or psychological treatment but rather use spiritual means such as fasting and prayer to reclaim the health that the devil has stolen from them (Almanzar, 2017). Christian groups generally have more negative attitudes toward people with mental health difficulties, primarily due to the association of mental illness with personal sin and demonic possession (Lloyd & Panagopoulos, 2022 ). There are, however, some differences in the beliefs about the causes of mental illness among denominations of Christian clergy in the United States. On the one hand, the Pentecostals (e.g., Assemblies of God church, Church of Pentecost, and Church of God) believe essentially that spiritual forces and moral flaws cause mental illness, including depression, and require mainly spiritual treatment. On the other hand, Protestant clergy (Presbyterian churches, Methodist church, Anglican and Episcopal churches) believed that depression is more of a medical or biological cause, but treatment was effective with the combination of religious and medical approaches (Hedman, 2014; Payne, 2009). The belief in the spiritual etiology of mental illness is more dominant among minorities, with African American Pentecostal clergy interpreting mental illness with a spiritual lens (Dempsey, Butler, & Gaither, 2016 ), and persons with mental illness are believed to be possessed by demonic forces or commit sin and are, therefore, being divinely punished (Amerongen & Cook, 2010 ). Studies in Ghana also show religious leaders attributed the cause of mental illness to spiritual factors such as curses, punishment from the gods for violation of religious or cultural norms, witchcraft, and juju, and treatment required spiritual solutions (Arias et al., 2016; Asamoah et al., 2014 ; Kpobi & Swartz, 2018 ). In another study, traditional and faith healers in Ghana believe strongly that every incidence of mental illness is caused by spiritual means, either directly through a spiritual attack that causes the illness or indirectly by the spirits influencing genetic or psychological conditions that lead to mental illness (Kpobi & Swartz, 2018 ). The clergy’s beliefs about causes and treatment for mental illness find a basis in Biblical text. In the book of Deuteronomy 28:28, the bible states that God will punish disobedience with madness. It is stated that “The Lord will afflict you with madness, blindness, and confusion of mind.” Also, the book of Samuel 16: 14–15 states: “But the Spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him.” These and other scriptures add to the belief that mental illness may be the result of supernatural imposition for some wrongdoing. Treatment from the Clergy The clergy has been gatekeepers of mental health in religiously oriented communities (Farrell & Goebert, 2008 ; VanderWaal et al., 2012 ). Studies found that the clergy served as a primary source for the treatment of mental health issues for many religiously oriented individuals (Bledsoe et al., 2013 ; Koenig, 2012; Neigbours et al., 1998; Weaver, 1995 ), and since mental illness is considered by some in the religious community to be caused spiritually, prayer, exorcism, and repentance are often regarded as spiritual approaches to healing (Sullivan et al., 2014). Seeking spiritual treatment for mental illness is not peculiar to only Christians or religiously inclined groups. Minority populations, including African Americans, are known to seek support and treatment for mental health issues primarily from the clergy rather than other professionals, such as psychologists, psychiatrists, and clinical social workers (Anthony et al., 2015; Lindsey et al., 2013). There are compelling reasons why clergy members tend to be a more convenient source for mental health treatment in Ghanaian Christian communities. One significant reason is low mental health literacy, which leads patients to assign spiritual etiology for mental illness and seek the clergy for spiritual solutions. Studies found very low mental health literacy among the population in Ghana (Amadu & Hoedoafia, 2024 ; Arthur, Boardman & McCann, 2021 ), and people with lower mental health literacy are less inclined to seek professional help for mental health issues (Thorne & Ebener, 2020 ), while those with higher mental health literacy are likely to have better attitudes toward seeking professional assistance for mental health issues (Kim et al., 2020 ). The affordability of mental health services is another important factor in the choice of providers, and the clergy becomes the preferred choice for minority populations and persons with low income since their services are mostly free (Harris, 2018; Leavey et al., 2007 ). The income level in Ghana is very low. In 2023, approximately 7.3 million people in Ghana, constituting 24.3% of the population, lived in poverty (Ghana Statistical Service, 2024 ). Such low incomes affect the ability to afford professional health services, hence the dependence on spiritual treatment, including from the clergy. Related to affordability is accessibility. Research shows clergy members are mostly readily available and accessible to congregants without formal and lengthy referral processes (Harris, 2018; Leavey et al., 2007 ), making the clergy’s mental health services easily accessed by the population. Additionally, the non-availability of culturally competent professional mental health providers may also influence why mental health patients will seek help from the clergy instead of mental health professionals. Research shows that Black and Latinx individuals may be less likely to initiate professional treatment for mental illness due in part to a lack of access to culturally competent mental health services or providers who share similar marginalized identities (Turner et al., 2016 ). In a study of Ghanaian immigrants’ discrimination experiences with the healthcare system in the United States, participants indicated that while competence is paramount in their choice of medical service providers, they would prefer and be comfortable with a competent doctor from their own culture because the doctor will understand their issues better (Elike, 2024 ). The clergy share the religious identities of congregants and may be found to be more understanding and accepting of patients in their congregations who face mental health challenges. The mental health treatment referral practices of the clergy have been studied, and the findings indicate that while clergy do refer patients for professional mental health treatment, the rate of referral is very low. Studies of the counseling and referral experiences of clergy in the United States found that clergy’s referral of mental health issues to mental health professionals is as low as 10% (Profit, 2018; Taylor et al., 2000 ). Clergy and religious leaders have been shown to have limited mental health literacy compared to other treatment professionals (Chevalier et al., 2015 ), and they may believe in the spiritual solution for mental health issues, hence their reluctance to refer patients to professionals. Methodology Study Design This study employed a qualitative research design, specifically phenomenology, as described by Van Manen (1990), Moustakas (1994), and Creswell (2007) to explore the evolving views of Ghanaian American Clergy on mental illness and its treatment. A phenomenological approach was used because it allows the description of the experience from the participant's perspective by the researcher and explores the lived experiences of participants, allowing the researcher to maintain the participants’ voice without distorting participants’ points of view in the analysis (Creswell, 2013; Giorgi, 2009 ). A phenomenological design also allows for fewer participants while it provides a significantly more in-depth study of a phenomenon. Participants The participants were recruited from among the Ghanaian American clergy in New York City using a purposeful, convenient sampling strategy. New York City has a large concentration of Ghanaian immigrants, and there are several Ghanaian Ethnic Associations in New York City. Twenty-five individuals who met the criteria were selected for participation. However, as the interviews proceeded, saturation was reached with the eighth (8th) interviewee, and as no new information was forthcoming, the interview ended (Creswell, 2013). The screening for eligibility for inclusion was done via phone calls. A total of eight clergy members were interviewed for the study. Inclusion criteria included the participant being a first-generation Ghanaian American (someone born in Ghana and migrated to the United States), at least 18 years old, and clearly understanding and speaking English. Data collection A semi-structured interview guide developed by the researcher was used for data collection. A researcher’s own-produced data collection instrument is an appropriate tool in a phenomenological study (Chenail, 2011). The semi-structured interview allowed for an in-depth exploration (Creswell, 2013) of participants’ beliefs about mental illness and their experiences with treatment. The interviews were conducted one-on-one and face-to-face at the participants' homes and offices at their convenience. The average duration for each interview was 40 minutes. Data Analysis The audio recordings were transcribed verbatim into text using the Microsoft Word transcription tool. The researcher then listened to the audio recordings of each interview repeatedly while updating the transcript to ensure there were no discrepancies between the audio and the transcript. The researcher read through each transcript repeatedly to attain an overall feeling for the data and then made a list of relevant responses or statements and accorded all statements equal weight of significance (Creswell & Poth, 2018 ; Moustakas, 1994). This deep familiarization with the data enabled the researcher to derive codes and themes from the patterns in the significant statements from respondents (Braun & Clarke, 2019). The analysis involved a combination of semantic and latent coding and theming (Byrne, 2022), which depended on both the surface meaning of the data as presented by the respondents and the use of the researcher’s interpretative lenses as guided by his cultural social, and professional positioning (Braun & Clarke, 2019). The analysis was predominantly inductive, with the coding and themes guided by the meaning derived from the responses rather than a pre-conceived theory or framework. This ensured the preservation of the participants’ voices in interpreting the data (Creswell & Poth, 2018 ; Giorgi, 2009 ). While no software was used, the manual coding using Microsoft Word Table was meticulous to ensure the rigor and trustworthiness of the analysis. Coding software is not required for qualitative research, and when qualitative data is not very large and is guided by specific questions, a word processing program such as Microsoft Word is often sufficient (Clarke et al., 2021). Steps taken to ensure rigor and trustworthiness of the analysis include, as stated earlier, reading transcripts several times to get a complete sense of the data and allow immersion in the data. Second, an audit trail was created, which provided details of data analysis and the decisions that led to the generation of the codes and themes. Additionally, member checking was used to verify the accuracy of the data interpretation (Creswell & Poth, 2018 ), where participants were contacted and provided with a summary of preliminary findings, and their views were obtained on the findings. Findings The themes that emerged from the data include (1) Mental health literacy, (2) Treatment resources, (3) Shift in treatment approaches, (4) Humane treatment, and (5) Unchanged views. Mental health literacy The findings show that mental health literacy creates a positive perception about mental illnesses. Participants indicated that, while in Ghana, they lacked education about mental illness and, therefore, attributed mental illness to spiritual causes and prescribed only spiritual treatment through fasting and prayer. However, with exposure to higher mental health literacy in the United States, their understanding and perception of mental illness have changed. One of the compelling statements from participants is presented below: In Ghana, I used to think that persons with mental illness are cursed with spiritual kind of things, or they have done something wrong, or they have sinned against somebody that they have invoked this kind of juju or witchcraft on them that caused the illness. But here in the United States, I have learned about the biological factors that result in mental illness and have seen mental patients treated in the hospital. This has changed my perception of illness. Now, I know mental illness is not always caused by spirits, and I am no longer afraid to associate with persons with mental illness. While the improved mental health literacy has changed the participant's etiology of mental illness from purely spiritual to biomedical, participants have not entirely done away with the spiritual etiology, especially for conditions that have not responded to medical or psychological treatment. One participant put it this way: I now know that mental illness could be caused by biological factors. But I have seen many people with mental illness sent to hospitals and could not be cured, and I believe something without a medical cure is spiritual. Treatment Resources The findings also show that treatment resource availability changes the perception about mental illness. Participants stated that in Ghana, professional treatment resources were unavailable, and the only means of treatment they knew and practiced was the spiritual model through fasting and prayer. However, the availability of treatment resources, including medication and psychotherapy, in the United States contributed to their knowledge about effective treatment for mental illness, which changed their views about mental illness and its treatment. One participant captured this sentiment in the following statement: You know, in Ghana, there was no medical help for people with mental issues as most of the hospitals do not even treat such kinds of diseases, and we have very few psychologists and psychiatrists in Ghana. So, all we do, I remember back in Ghana in our churches, was just pray and fast for people with mental illness. Some of them get well, some too, and they get worse. When I came to the United States, I have seen so many hospitals, psychologists, doctors, and other institutions that help people with mental illness get well. My knowledge of the illness has dramatically improved, and so has my perception of mental health issues has really changed. Another participant similarly put it this way: In Ghana, due to a lack of mental health treatment resources, I only take persons with mental health issues to churches to pray for them, and there is no further treatment. However, there are resources here in the USA to provide treatment and care. I now know that many people with mental illness can be treated with medication and psychotherapy, and they can function well. A shift in treatment approaches Another significant finding of the study is the participants’ shift in treatment approach to mental illness. The participants reported a shift from the sole use of the spiritual model of fasting and prayer as the form of treatment to a hybrid treatment model where they refer patients to hospitals and therapists for professional treatment while the pastors support them with prayer. While in Ghana, all I did was pray for people with mental illness, and even when they don’t get better, I will continue to pray for their healing. But with all I have learned about mental illness in the United States, now I pray for the patient, and then the next step is to refer for medication to calm down the agitated patient while I continue to pray for total healing. So, the best treatment is to combine prayer and medication. Participants emphasized that the clergy should not hold the primary view that mental illness is a spiritual issue requiring a spiritual treatment approach. Instead, mental illness should be viewed as a medical issue requiring medical intervention. “We can no longer just conclude mental illness is a spiritual problem, and then all we are doing is praying for the person. We must view the issue from the medical angle and direct patients to seek medical help.” Another participant also put it this way: When I was in Ghana, I was only praying for them, but now in the United States, I offer my help as a Pastor and a counselor, still praying for the patients, but at the same time, I refer them to get medical assistance wherever possible. Humane treatment The findings show that humane treatment reduces stigma about mental illness. Participants intimated that the humane treatment and support mental health patients receive in the United States have changed their negative perception of mental illness and patients dealing with mental health issues. One participant stated: In Ghana, there was so much stigma about mental health patients, and persons with mental illness are maltreated and sometimes beaten. I used to consider mental patients as useless. But here in the USA, mental patients are treated well by society. So, my perception has changed, and I no longer consider mental patients as useless. Another related it this way: When I came to the United States, I saw that persons with mental illness are treated well by the public. There are institutions that care for them, and they are welcome among the general population. This has changed my approach towards persons with mental illness. While in Ghana, I did not want to go near mental patients, but I now welcome them to the church and even my home and feed them. I see they are not as dangerous as I used to think. This finding emphasizes that we form opinions of issues based on what we perceive around us, which is consistent with the social learning theory. Unchanged views The findings also show some unchanged views about mental illness. While most of the participants expressed that their experiences in the United States have changed their perception of mental illness, two of the eight (25%) participants alluded that their experiences in the United States have not entirely changed their perceptions of mental illness. These participants still believe that Satan and spirits cause mental illness and that mental health patients are not worthy humans. One participant made one such strong statement about patients with mental illness: I have been in the United States for quite a long period, but my perception has never changed concerning mental illness because of what I know about the sickness. Some of the patients told me that they heard voices. I still believe very well that hearing voices might be from Satan. Mental illness is caused by spirits. I do not consider persons with mental illness as normal members of society. I have this mentally ill woman in my church. When I am preaching, she will be shouting and misbehaving, and because people with mental illness misbehave, they are nobody in society. They are nothing, they are not important, they are nothing in society. Another participant believed the accommodating approach in the United States towards persons with mental illness poses a significant threat to the security of the public. In the view of the participant, persons with mental illness should not be allowed to live with the general society but should be secluded from society since they cause harm. The participant stated: The way we treat mental health here in the United States causes a lot of harm to society. So many mental patients live among us and hurt us. And I can say many of the shootings we have in this country are people with mental health issues. I think in the United States, we are too relaxed with mental health issues, and so people with severe mental health issues live in the same house with people and cause harm to society. Discussion This study sought to answer the question of whether the views of Ghanaian American Clergy about mental illness and its treatment evolved with their experiences in the United States. The themes that emerged from the data include (1) Mental health literacy, (2) Treatment resources, (3) Shift in treatment approaches, (4) Humane treatment, and (5) Unchanged views The findings indicate that mental health literacy improves perceptions and beliefs about mental illness. Participants intimated that compared to Ghana, the United States has a better mental health education, which exposed them to a better understanding of mental illness. Ghana, like many less developed countries, has low levels of mental health literacy (Kapungwe et al., 2010 ; Sorsdahl & Stein, 2010 ), and there is no concerted program in place to improve the level of mental health literacy in Ghana (Roberts et al., 2014 ; Wilson & Somhlaba, 2016 ). Research shows that a lower level of mental health literacy is associated with the attribution of mental illness to spiritual causes. In comparison, a higher level of mental health literacy is found to be associated with the biological and psychological etiology of mental illness (Anbesaw et al., 2024 ). The study findings, which show participants' spiritual interpretation and approach to mental illness, while in Ghana, where mental health literacy is very low, are consistent with the other studies. The level of mental health literacy in Ghana is very low to the extent that even health professionals have very little knowledge about mental illness. Adu et al. ( 2021 ), in their study of Ghanaian nurse participants, found that 84% of the participants could not recognize schizophrenia in the vignette. If nurses in Ghana could not recognize schizophrenia, it is not surprising that the clergy, who are not health professionals, would have low levels of mental health literacy. With the low level of mental health literacy, most Ghanaians tend to attribute mental health problems to spiritual causes and prefer to contact a religious group when faced with mental health problems (Ae-Ngibise et al., 2010). The study findings show that the participants’ mental health literacy has improved in the United States due to exposure to mental health education. The finding highlights the importance of ensuring a better understanding of and effective treatment for mental illness in Ghanaian communities through mental health education programs developed and implemented at all levels of Ghanaian society. A good starting point would be incorporating mental health literacy into the elementary to high school education curriculum. Since the clergy is known to be the primary source for help-seeking for persons with mental health issues in Ghana (Asamoah et al., 2014 ; Osafo, 2016 ; Addo-Anum, 2019), improved mental health education training for the clergy is crucial for the delivery of quality mental health to congregants and the general Ghanaian population. Mental health literacy is crucial in the attribution theory about mental illness, and people who have a higher level of mental health literacy are likely to attribute the biomedical etiology to mental illness (Jorm, 2000 ). Another theme that emerged from the study data was how the availability of mental illness treatment resources impacts the perceptions and beliefs about mental illness. Participants indicated that while in Ghana, mental health treatment resources were not available, and the only treatment they believed in and practiced was the spiritual model. However, the availability of treatment resources in the United States changed their beliefs about mental illness. This finding also emphasizes that people’s beliefs are formed based on exposure. Like many other African countries, Ghana has minimal mental health resources. According to the World Health Organization, only about 2% of the 2.3 million people living with mental health conditions in Ghana receive psychiatric treatment and support from health facilities (WHO Regional Office for Africa, 2022 ), with a treatment gap of 98% (Akapule, 2015). Other research shows that Ghana has very low mental health resources and abysmally inadequate mental health institutions and personnel, with one psychiatrist per 1.5 million people and only three major psychiatric hospitals serving the country’s population of nearly 30 million people (Adu-Gyamfi, 2017 ; Robert et al., 2014). The low level of mental health resources in Ghana results from a lack of government investment in the mental health sector. The government of Ghana spends just 1.4% of total government health expenditure on mental health (Ghana News Agency, 2022 ). The study findings suggest that with the lack of adequate professional mental health treatment resources, Ghanaians seeking mental health treatment might believe that the only viable treatment would be spiritual treatment, including from the clergy, and tend to be entrenched in their beliefs in the spiritual etiology for mental illness. However, when people are exposed to adequate available treatment resources, their perceptions about mental illness and its treatment will change. This assessment is consistent with other studies that indicate that the availability of treatment resources determines people's beliefs and acceptance of the treatment model. In their study, Silverman and Teachman ( 2022 ) found that living in a community with more professional treatment providers was associated with a greater likelihood of endorsing the professional treatment approach. Other research found that the greater the availability of treatment providers, the greater the mental health service used by the population (McCarthy et al., 2007; Wei et al., 2005). Additionally, a person who lives in communities where there are more significant numbers of mental health providers and treatment facilities may have increased exposure to others who are seeking mental health treatment, which may reduce mental health stigma and make treatment-seeking appear more normal and appealing (Silverman & Teachman, 2022 ). Another significant finding is the shift in mental illness treatment approach by the clergy from the spiritual model they practiced in Ghana to the embracing of the medical model in the United States. Participants attributed their shift to the mental health literacy they received in the United States and the availability of treatment resources. The clergy will remain an important source of mental treatment in Ghanaian communities no matter what (Ae-Ngibise et al., 2010), and they must adopt evidence-based treatment approaches if the community is to benefit from them. Therefore, mental health policymakers in Ghana must emphasize and promote the development of treatment resources by training clinical social workers, psychiatrists, psychiatric nurses, and psychologists and expanding the number of psychiatric units in all regional hospitals. It also calls for mental health training and education to be incorporated into the training curriculum for the clergy to enhance their help provision capabilities for persons with mental health issues (McDevitt, 2016 ; Schuetze, 2017 ). This will help the clergy understand when and where to refer mental health patients for professional treatment rather than only praying for them. Adu et al. ( 2021 ) emphasize that the lack of facilities and personnel in mental health care in Ghana is a significant challenge to care delivery. Participants also intimated that the humane treatment and support mental health patients receive in the United States have changed their stigmatic perception of mental illness and patients dealing with mental health issues. Research and anecdotal information established the inhumane way persons with mental illness are treated in Ghana and the high level of stigma towards mental illness. It is commonplace to see people with a mental health condition seeking treatment from religious leaders being chained as they are believed to be dangerous and kept in unsanitary conditions in prayer camps in Ghana. Patients are subjected to extended periods of involuntary fasting with denial of food and water and sometimes beaten as a means of exorcising the evil spirits that the clergy believed possessed the patients (Edwards, 2014 ; Human Rights Watch, 2012 ; Ssengooba et al., 2012 ). Persons with mental illness in Ghana are sometimes neglected by some families who do not care for them but leave them on the streets without shelter or clothing to beg for food and receive no form of medical treatment (Bonsu et al., 2023 ). Family neglect of patients may not be out of malice but, in most situations, due to poverty, family breakups, or the burnout or death of a primary caregiver (Acierno et al., 2010 ; Ben David, 2021 ). Some patients, out of hunger, would snatch food from people who would, in turn, subject them to beatings and other forms of maltreatment (Edwards, 2014 ; Mfaofo-M'Carthy & Grishow, 2017 ). While Ghana has laws such as the Persons with Disability Act 2006 and signed the UN Convention on the Rights of People with Disabilities in 2007, the country has a very low level of enforcement of these laws, leaving persons with disabilities unprotected from maltreatment (Ocran, 2019 ). With these types of inhumane treatment, patients with mental illness are reduced to subhuman, thereby increasing the stigma about the illness and the patients. Stigma about mental illness is very high in Ghana (Mfaofo-M'Carthy & Grishow, 2017 ; Dako-Gyeke & Asumang, 2013 ). The United States, compared to Ghana, has a better approach to the care for persons with mental illness, where patients have the support of family and agencies that provide for their safety and care. Persons with mental illness in the United States have the same rights as all other members of society and are protected under several laws, such as the Americans with Disabilities Act, the Civil Rights of Institutionalized Persons Act, and the Individuals with Disabilities Education Act, among others. These laws are primarily enforced by both private and government institutions in the United States (Jo, 2023 ) and provide a good measure of guarantee of respect, dignity, provision of services, and protection for people with disabilities and persons diagnosed with mental illness. While stigma towards mental illness may not be completely absent in the United States (Kold et al., 2023), the legal framework, enforcement, and service provision regimes for persons with mental illness promote a lower level of stigma towards mental illness in the United States, compared to Ghana where the laws are not enforced, and persons with disability continue to be abused and maltreated. An important take from this finding is that for stigma towards mental illness to be reduced, if not eradicated, Ghana must promote dignified treatment and support for persons suffering from mental health conditions by enforcing protective laws and educating the population against all forms of maltreatment of persons with mental health issues. It is important to note that 25% of the participants in the study indicated their original views from Ghana about mental illness and persons with mental illness have not changed despite their experiences in the United States. One participant still believes that Satan and spirits cause mental illness. Another believes that mental health patients are dangerous and should not be allowed to mingle with the public. The view held by this study participants of the dangerousness of people with a mental health condition is, however, not surprising, as a large section of the American public shares the same view. A section of the American public believes in the dangerousness of mental health patients (Link et al., 1999 ; Silton et al., 2011 ; Gilligan, 2017 ). In a study by Pescosolido et al. ( 2019 ) of the American public, 60% of the respondents perceived people with mental illness as being violent toward others and should be committed to an involuntary treatment facility. Incidences of violence such as mass shootings, arson, and shoving of people onto rail lines have been attributed to some form of insanity on the part of the perpetrators. On occasions of violence involving the use of guns, it is common to hear gun-rights advocates in the United States blaming mental health and not the abundance of guns as responsible for the violence. The print and electronic media heighten the narrative of the dangerousness of persons with mental illness. While research shows that persons with mental illness are not more dangerous than the general population (Torrey, 1994 ; Peterson et al., 2010 ), the public continues to hold a negative perception that persons with mental illness are very dangerousness (Pescosolido et al., 2019 ; Slemon et al., 2017 ; Zhang et al., 2020 ). The stigmatic views held about persons with mental illness culminate in discriminatory attitudes against persons with mental illness by the general population (Angermeyer & Dietrich, 2006 ). Even staff who care for mental health patients hold negative attitudes and beliefs about people with mental illness (Hansson et al., 2013 ). There is a need for continuous education and sensitization of the public in every part of the world about mental illness to reduce the stigma and discrimination towards persons with mental illness. Implication for Social Work Social work is the mental health profession that can be considered the closest to organized religion, such as Christianity. Social workers and the clergy provide tangible services, such as food, clothing, housing, and intangible services, such as counseling to community members. In practice, a collaboration between social workers and the clergy would promote the welfare of members of the community. An important area for collaboration would be in the field of mental health. The findings of the study suggest that if the clergy have improved mental health literacy, their approach to mental illness will improve. Social workers can work with local churches to provide mental health education to the clergy about the etiology and treatment resources for mental illness (Mafuriranwa et al., 2024 ). Clergy need targeted education on counseling and mental health (Payne, 2014 ; Ross & Stanford, 2014 ) because while they are at the forefront of handling mental health issues, they may not have the adequate mental health literacy to provide effective help to their congregants and the community members (Farrell & Goebert, 2008 ; Wood et al., 2011 ). With such education, clergy would understand the limits of their treatment capabilities and the need to refer patients for treatment by mental health professionals. The collaboration could also be in the form of churches employing social workers as full-time, part-time, or volunteer staff to assist in providing mental health treatment for congregants alongside the clergy prayer. Including social workers will strengthen the church and clergy's capacity to assist members with mental health issues. LifeWay Research ( 2014 ) found that only 20% of churches provide training for leaders to identify symptoms of mental illness, and only 18% have a skilled mental health professional on staff. This lack of capacity affects the clergy's ability to assist members with mental health issues. Social workers can play important roles in filling the professional care gap in congregations and preparing clergy to identify and refer congregants for care. An advantage of churches having social workers on staff would be that congregants would consider accepting mental health treatment from them since they may be seen as approved by the clergy, and receiving services from social workers would not be considered a lack of faith in God’s treatment through the clergy. This is consistent with research which shows social worker and clergy collaboration tends to increase the rate of participation of congregants in mental health treatment from social workers when referred by the clergy since parishioners would trust the opinion of the clergy in such referrals (Hankerson et al., 2013 ; Schultz et al., 2021 ). The collaboration between social workers and the clergy would not only benefit the clergy but would have reciprocal benefits for social workers as well, as they tend to have a deeper understanding of the spiritual context of health and mental health for religiously oriented individuals and the strengths of spirituality as a resilience factor in coping with adverse health issues. When mental health professionals incorporate spirituality in their treatment regimes, it provides holistic and effective treatment and care for individuals who share spiritual beliefs and also enhances the spiritual competency of the social worker (Koenig & Al Shohaib, 2017 ) and creates a trusting relationship between the patients and the mental health professional and promotes acceptance of treatment from such professionals (Hodge & Horvath, 2011 ). Additionally, when clergy realize that social workers and other mental health professionals have a vested interest and a grasp of spirituality, they may become more willing to refer congregants to such professionals for treatment without fear of patients losing their faith in the church. This will create expanded access to mental health professionals for people needing mental health treatment. In sum, Social workers and other mental health professionals need to collaborate with the clergy since such collaboration would have mutual benefit for all as they educate each other on their respective areas of expertise with the professionals enhancing the understanding of empirical treatment capabilities of the clergy while the clergy enhances the spiritual perspectives of health for the professionals (Bledsoe et al., 2013 ; Rogers et al., 2012 ) creating an inclusive and nurturing environment for patients to receive holistic care. Implications for Human Rights As studies found clergy to play a central role in mental health delivery, their beliefs and treatment practices about mental illness are vital to the well-being and human rights of persons diagnosed with mental illness. First, by providing spiritual treatment that may have no evidence of effectiveness, people with mental health conditions are denied their right to effective treatment. In many instances, patients are involuntarily committed to the spiritual treatment by the clergy and family members, violating their human rights to self-determination. The World Health Organization’s QualityRights initiative sets out to improve the quality of care and support in mental health to promote the human rights of people with psychosocial, intellectual, or cognitive disabilities worldwide (World Health Organization, 2019 ). There is no concrete research evidence to back the belief in the effectiveness of spiritual treatment for mental illness, and people with mental health conditions spend many years in prayer camps in Ghana without getting well. It is, therefore, encouraging that the study participants (clergy) indicated a shift from the spiritual model to the medical model, which gives congregants receiving treatment from them a brighter prospect of receiving effective treatment and enhancing their human rights. Puras ( 2022 ) posits that there is a need for interventions to focus on the fundamental rights of people with mental health conditions because of the myriad human rights violations against this population. In communities in Ghana where clergy believe in the spiritual etiology of mental illness, an attempt to implement spiritual treatment sometimes results in the gross violation of the human rights of patients in diverse ways. Research has documented blatant human rights violations meted out to persons with mental illness during spiritual treatment at prayer camps in Ghana, where mental health patients are subjected to all manner of inhumane treatment, including beatings, denial of food, and chaining, among others (Edwards, 2014 ; Human Rights Watch, 2012 ; Moro et al., 2022 ; Ssengooba et al., 2012 ). According to the UN Declaration of Human Rights, all persons, including persons with mental illness, have the right to humane treatment (United Nations General Assembly, 1949 ). It is, therefore, a gross violation of the human rights of persons with mental illness to be subjected to inhumane treatment in prayer camps and treatment facilities in Ghana. As stated earlier, while Ghana has laws such as the Persons with Disability Act 2006 and signed the UN Convention on the Rights of People with Disabilities in 2007, the country has a very low level of enforcement of these laws, leaving persons with disabilities unprotected from maltreatment (Ocran, 2019 ) and their human rights violated with impunity. There is a need for the government to promote enforcement of human rights laws to protect people with mental health issues from the continuous abuse and violation of their rights. Participants indicated that the availability of treatment resources in the United States increased their positive view of mental illness and their gravitation toward biomedical treatment approaches. This calls for the need for countries like Ghana, which have very limited mental health resources, to consider mental health resources from the right-based perspective and prioritize their funding and development. Such a demand for increased investment in mental health resources aligns with the obligation under the UN Convention on the Rights of Persons with Disabilities and other rights enshrined in the UN and other international charters. Investing in and improving mental health resources in Ghana will contribute to achieving the Sustainable Development Goal (SDG) 3, which seeks to ensure healthy lives and promote well-being for all persons, including persons with mental illness (Mahomed, 2020). To address challenges in the mental health sector, the Mental Health Act of 2012 was passed in Ghana to address mental health issues in the country and safeguard the protection of the rights of persons with mental illnesses (Magna & Yemoh, 2018 ; Osei, 2012 ). However, the implementation of the law lacked adequate support from the government of Ghana who is supposed to enforce the human rights provisions of the law and provide the necessary healthcare infrastructure that will ensure the care of patients with mental illness that the law aims to protect. According to Walker and Osei (2017), inadequate financial, human, and infrastructure resources for the mental healthcare law served as barriers to its implementation in Ghana, where the central government bears healthcare expenditure. Bedi et al. ( 2021 ) contend that policymakers and institutions give low priority to mental health issues, coupled with inadequate funding from the central government, which contributes to the failure of the Mental Health Act to have any meaningful impact on mental health in Ghana. Consequently, people with mental illness continue to endure human rights violations and are subjected to inhumane treatment in Ghana. This study's findings highlight the need for increased investment in mental health resources to promote effective treatment, reduce stigma, and curtail the rampant abuse and violation of the rights of mental health patients. It is crucial for social workers to advocate for mental health literacy and the development of treatment resources and continue championing the fair and humane treatment of all people, especially people with disabilities who cannot protect themselves. This would not only promote the human rights of individuals in fulfillment of UN charters but also validate the National and International Associations of Social Workers’ values of social justice, dignity, and worth of the person. Limitations This study has the limitation of non-generalizability due to the small sample that may not be generalizable to the Ghanaian American clergy population. However, as in qualitative research in general, the goal of this study was not to generalize the findings but to uncover a more profound and better understanding. Another limitation of the study was possible researcher bias and possible conflicted opinion. The researcher is a social worker and a Ghanaian American practicing clergy. Conflicting opinions may arise when, as a social worker, the researcher might be predisposed to validating only professional treatment approaches, and as a clergy, validating spiritual treatment approaches that might not be empirically based. Seen from another angle, however, the researcher’s dual position can be a strength as he understands both the spiritual and the clinical perspective of mental health issues and assumes a neutral position in the research process. To minimize possible researcher bias, the researcher developed increased self-awareness in consideration of his positionality and how that influences his perception of the phenomenon being studied. Creswell and Poth ( 2018 ) describe this process as bracketing out of the study. The researcher bracketed out by being aware of his presumptions and setting them aside or minimizing them during the research process (Creswell & Poth, 2018 ; Giorgi, 2009 ). Conclusion The findings of the study suggest that when people lack mental health literacy and evidence-based treatment resources, they tend to resort to and rely heavily on spiritual interpretation for illnesses, including mental illness. It highlights the need to provide mental health literacy to the clergy as part of their pre-ordination and continuous in-service training. Mental health literacy should also be included in the curriculum for schools to improve public knowledge of mental health issues. Additionally, there is a need for the government of Ghana, religious institutions, and private sector organizations to provide evidence-based treatment resources, such as psychiatric hospitals and psychotropic medication, and train mental health personnel, such as psychiatric nurses, clinical social workers, and psychiatrists. These actions will help change wrongly held beliefs about mental illness by the population in general and the clergy in particular and help improve mental health in Ghanaian communities. While education about mental illness and the availability of treatment resources appear helpful in changing perceptions about mental illness and improving treatment regimes, negative beliefs and attitudes towards mental illness continue to persist in every part of the world, including advanced societies like the United States. There is a need for relentless action on the part of social workers and other mental health professionals everywhere to continue to educate the population on mental health issues to improve access and care. Notably, social work professionals need to focus on education for the clergy about mental illness to ensure they become credible partners in the management and treatment of mental health issues. Social workers must also intensify their advocacy for adequate treatment resources in Ghanaian communities to improve treatment availability. Declarations Competing Interest The author has no competing interests to declare. Ethical Approval Data for this article was extracted from the author’s dissertation data, of which approval was obtained from the Institutional Review Board of Fordham University, where the researcher was a PhD student. Data and Material Availability The data supporting this study's findings is available upon request from the corresponding author. Funding This research received no funding from public, commercial, or not-for-profit agencies but entirely depended on the researcher’s resources. Author Contribution Dr. Philip Kwasi Elike is the sole author of this manuscript. Data Availability The data supporting this study's findings is available upon request from the corresponding author. References Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick, H. S., Steve, K., Muzzy, W., & Kilpatrick, D. G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health, 100(2), 292–297. Adu-Gyamfi, S. (2017). Mental health service in Ghana: a review of the case. Int J Public Health Sci, 6(4), 299-313. Adu, P., Jurcik, T., & Grigoryev, D. (2021). Mental health literacy in Ghana: Implications for Religiosity, education, and stigmatization. Transcultural Psychiatry, 58(4), 516–531. 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Studies suggest that in every part of the world, there is a strong belief by sections of the population that mental illness is a spiritual illness caused by demonic spirit possession, witchcraft, a curse, sin, or lack of strong personal spirit (Karanci, 2014; Ross et al., 2013; Stefanovic et al., 2016). Spiritual and religious explanations and treatment prescriptions for mental illness are not peculiar to any one religion but permeate most major religions and cultures (Koenig, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Some Christian denominations believe that the devil causes mental illness through spiritual attacks. As such, persons who have mental illness should not seek medical or psychological treatment but rather use spiritual means such as fasting and prayer to reclaim the health that the devil has stolen from them (Almanzar, 2017).\u003c/p\u003e \u003cp\u003eChristian groups generally have more negative attitudes toward people with mental health difficulties, primarily due to the association of mental illness with personal sin and demonic possession (Lloyd \u0026amp; Panagopoulos, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). There are, however, some differences in the beliefs about the causes of mental illness among denominations of Christian clergy in the United States. On the one hand, the Pentecostals (e.g., Assemblies of God church, Church of Pentecost, and Church of God) believe essentially that spiritual forces and moral flaws cause mental illness, including depression, and require mainly spiritual treatment. On the other hand, Protestant clergy (Presbyterian churches, Methodist church, Anglican and Episcopal churches) believed that depression is more of a medical or biological cause, but treatment was effective with the combination of religious and medical approaches (Hedman, 2014; Payne, 2009). The belief in the spiritual etiology of mental illness is more dominant among minorities, with African American Pentecostal clergy interpreting mental illness with a spiritual lens (Dempsey, Butler, \u0026amp; Gaither, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), and persons with mental illness are believed to be possessed by demonic forces or commit sin and are, therefore, being divinely punished (Amerongen \u0026amp; Cook, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudies in Ghana also show religious leaders attributed the cause of mental illness to spiritual factors such as curses, punishment from the gods for violation of religious or cultural norms, witchcraft, and juju, and treatment required spiritual solutions (Arias et al., 2016; Asamoah et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Kpobi \u0026amp; Swartz, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). In another study, traditional and faith healers in Ghana believe strongly that every incidence of mental illness is caused by spiritual means, either directly through a spiritual attack that causes the illness or indirectly by the spirits influencing genetic or psychological conditions that lead to mental illness (Kpobi \u0026amp; Swartz, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe clergy\u0026rsquo;s beliefs about causes and treatment for mental illness find a basis in Biblical text. In the book of Deuteronomy 28:28, the bible states that God will punish disobedience with madness. It is stated that \u0026ldquo;The Lord will afflict you with madness, blindness, and confusion of mind.\u0026rdquo; Also, the book of Samuel 16: 14\u0026ndash;15 states: \u0026ldquo;But the Spirit of the Lord departed from Saul, and an evil spirit from the Lord troubled him.\u0026rdquo; These and other scriptures add to the belief that mental illness may be the result of supernatural imposition for some wrongdoing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTreatment from the Clergy\u003c/h2\u003e \u003cp\u003eThe clergy has been gatekeepers of mental health in religiously oriented communities (Farrell \u0026amp; Goebert, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; VanderWaal et al., \u003cspan citationid=\"CR136\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Studies found that the clergy served as a primary source for the treatment of mental health issues for many religiously oriented individuals (Bledsoe et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Koenig, 2012; Neigbours et al., 1998; Weaver, \u003cspan citationid=\"CR139\" class=\"CitationRef\"\u003e1995\u003c/span\u003e), and since mental illness is considered by some in the religious community to be caused spiritually, prayer, exorcism, and repentance are often regarded as spiritual approaches to healing (Sullivan et al., 2014). Seeking spiritual treatment for mental illness is not peculiar to only Christians or religiously inclined groups. Minority populations, including African Americans, are known to seek support and treatment for mental health issues primarily from the clergy rather than other professionals, such as psychologists, psychiatrists, and clinical social workers (Anthony et al., 2015; Lindsey et al., 2013).\u003c/p\u003e \u003cp\u003eThere are compelling reasons why clergy members tend to be a more convenient source for mental health treatment in Ghanaian Christian communities. One significant reason is low mental health literacy, which leads patients to assign spiritual etiology for mental illness and seek the clergy for spiritual solutions. Studies found very low mental health literacy among the population in Ghana (Amadu \u0026amp; Hoedoafia, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Arthur, Boardman \u0026amp; McCann, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), and people with lower mental health literacy are less inclined to seek professional help for mental health issues (Thorne \u0026amp; Ebener, \u003cspan citationid=\"CR128\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), while those with higher mental health literacy are likely to have better attitudes toward seeking professional assistance for mental health issues (Kim et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe affordability of mental health services is another important factor in the choice of providers, and the clergy becomes the preferred choice for minority populations and persons with low income since their services are mostly free (Harris, 2018; Leavey et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). The income level in Ghana is very low. In 2023, approximately 7.3\u0026nbsp;million people in Ghana, constituting 24.3% of the population, lived in poverty (Ghana Statistical Service, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Such low incomes affect the ability to afford professional health services, hence the dependence on spiritual treatment, including from the clergy. Related to affordability is accessibility. Research shows clergy members are mostly readily available and accessible to congregants without formal and lengthy referral processes (Harris, 2018; Leavey et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2007\u003c/span\u003e), making the clergy\u0026rsquo;s mental health services easily accessed by the population.\u003c/p\u003e \u003cp\u003eAdditionally, the non-availability of culturally competent professional mental health providers may also influence why mental health patients will seek help from the clergy instead of mental health professionals. Research shows that Black and Latinx individuals may be less likely to initiate professional treatment for mental illness due in part to a lack of access to culturally competent mental health services or providers who share similar marginalized identities (Turner et al., \u003cspan citationid=\"CR131\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In a study of Ghanaian immigrants\u0026rsquo; discrimination experiences with the healthcare system in the United States, participants indicated that while competence is paramount in their choice of medical service providers, they would prefer and be comfortable with a competent doctor from their own culture because the doctor will understand their issues better (Elike, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The clergy share the religious identities of congregants and may be found to be more understanding and accepting of patients in their congregations who face mental health challenges.\u003c/p\u003e \u003cp\u003eThe mental health treatment referral practices of the clergy have been studied, and the findings indicate that while clergy do refer patients for professional mental health treatment, the rate of referral is very low. Studies of the counseling and referral experiences of clergy in the United States found that clergy\u0026rsquo;s referral of mental health issues to mental health professionals is as low as 10% (Profit, 2018; Taylor et al., \u003cspan citationid=\"CR126\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). Clergy and religious leaders have been shown to have limited mental health literacy compared to other treatment professionals (Chevalier et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2015\u003c/span\u003e), and they may believe in the spiritual solution for mental health issues, hence their reluctance to refer patients to professionals.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis study employed a qualitative research design, specifically phenomenology, as described by Van Manen (1990), Moustakas (1994), and Creswell (2007) to explore the evolving views of Ghanaian American Clergy on mental illness and its treatment. A phenomenological approach was used because it allows the description of the experience from the participant's perspective by the researcher and explores the lived experiences of participants, allowing the researcher to maintain the participants\u0026rsquo; voice without distorting participants\u0026rsquo; points of view in the analysis (Creswell, 2013; Giorgi, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). A phenomenological design also allows for fewer participants while it provides a significantly more in-depth study of a phenomenon.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe participants were recruited from among the Ghanaian American clergy in New York City using a purposeful, convenient sampling strategy. New York City has a large concentration of Ghanaian immigrants, and there are several Ghanaian Ethnic Associations in New York City. Twenty-five individuals who met the criteria were selected for participation. However, as the interviews proceeded, saturation was reached with the eighth (8th) interviewee, and as no new information was forthcoming, the interview ended (Creswell, 2013). The screening for eligibility for inclusion was done via phone calls. A total of eight clergy members were interviewed for the study. Inclusion criteria included the participant being a first-generation Ghanaian American (someone born in Ghana and migrated to the United States), at least 18 years old, and clearly understanding and speaking English.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured interview guide developed by the researcher was used for data collection. A researcher\u0026rsquo;s own-produced data collection instrument is an appropriate tool in a phenomenological study (Chenail, 2011). The semi-structured interview allowed for an in-depth exploration (Creswell, 2013) of participants\u0026rsquo; beliefs about mental illness and their experiences with treatment. The interviews were conducted one-on-one and face-to-face at the participants' homes and offices at their convenience. The average duration for each interview was 40 minutes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe audio recordings were transcribed verbatim into text using the Microsoft Word transcription tool. The researcher then listened to the audio recordings of each interview repeatedly while updating the transcript to ensure there were no discrepancies between the audio and the transcript. The researcher read through each transcript repeatedly to attain an overall feeling for the data and then made a list of relevant responses or statements and accorded all statements equal weight of significance (Creswell \u0026amp; Poth, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Moustakas, 1994). This deep familiarization with the data enabled the researcher to derive codes and themes from the patterns in the significant statements from respondents (Braun \u0026amp; Clarke, 2019). The analysis involved a combination of semantic and latent coding and theming (Byrne, 2022), which depended on both the surface meaning of the data as presented by the respondents and the use of the researcher\u0026rsquo;s interpretative lenses as guided by his cultural social, and professional positioning (Braun \u0026amp; Clarke, 2019). The analysis was predominantly inductive, with the coding and themes guided by the meaning derived from the responses rather than a pre-conceived theory or framework. This ensured the preservation of the participants\u0026rsquo; voices in interpreting the data (Creswell \u0026amp; Poth, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Giorgi, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). While no software was used, the manual coding using Microsoft Word Table was meticulous to ensure the rigor and trustworthiness of the analysis. Coding software is not required for qualitative research, and when qualitative data is not very large and is guided by specific questions, a word processing program such as Microsoft Word is often sufficient (Clarke et al., 2021). Steps taken to ensure rigor and trustworthiness of the analysis include, as stated earlier, reading transcripts several times to get a complete sense of the data and allow immersion in the data. Second, an audit trail was created, which provided details of data analysis and the decisions that led to the generation of the codes and themes. Additionally, member checking was used to verify the accuracy of the data interpretation (Creswell \u0026amp; Poth, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), where participants were contacted and provided with a summary of preliminary findings, and their views were obtained on the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eThe themes that emerged from the data include (1) Mental health literacy, (2) Treatment resources, (3) Shift in treatment approaches, (4) Humane treatment, and (5) Unchanged views.\u003c/p\u003e\n\u003ch3\u003eMental health literacy\u003c/h3\u003e\n\u003cp\u003eThe findings show that mental health literacy creates a positive perception about mental illnesses. Participants indicated that, while in Ghana, they lacked education about mental illness and, therefore, attributed mental illness to spiritual causes and prescribed only spiritual treatment through fasting and prayer. However, with exposure to higher mental health literacy in the United States, their understanding and perception of mental illness have changed. One of the compelling statements from participants is presented below:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIn Ghana, I used to think that persons with mental illness are cursed with spiritual kind of things, or they have done something wrong, or they have sinned against somebody that they have invoked this kind of juju or witchcraft on them that caused the illness. But here in the United States, I have learned about the biological factors that result in mental illness and have seen mental patients treated in the hospital. This has changed my perception of illness. Now, I know mental illness is not always caused by spirits, and I am no longer afraid to associate with persons with mental illness.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile the improved mental health literacy has changed the participant's etiology of mental illness from purely spiritual to biomedical, participants have not entirely done away with the spiritual etiology, especially for conditions that have not responded to medical or psychological treatment. One participant put it this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI now know that mental illness could be caused by biological factors. But I have seen many people with mental illness sent to hospitals and could not be cured, and I believe something without a medical cure is spiritual.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Resources\u003c/h2\u003e \u003cp\u003eThe findings also show that treatment resource availability changes the perception about mental illness. Participants stated that in Ghana, professional treatment resources were unavailable, and the only means of treatment they knew and practiced was the spiritual model through fasting and prayer. However, the availability of treatment resources, including medication and psychotherapy, in the United States contributed to their knowledge about effective treatment for mental illness, which changed their views about mental illness and its treatment. One participant captured this sentiment in the following statement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eYou know, in Ghana, there was no medical help for people with mental issues as most of the hospitals do not even treat such kinds of diseases, and we have very few psychologists and psychiatrists in Ghana. So, all we do, I remember back in Ghana in our churches, was just pray and fast for people with mental illness. Some of them get well, some too, and they get worse. When I came to the United States, I have seen so many hospitals, psychologists, doctors, and other institutions that help people with mental illness get well. My knowledge of the illness has dramatically improved, and so has my perception of mental health issues has really changed.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant similarly put it this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIn Ghana, due to a lack of mental health treatment resources, I only take persons with mental health issues to churches to pray for them, and there is no further treatment. However, there are resources here in the USA to provide treatment and care. I now know that many people with mental illness can be treated with medication and psychotherapy, and they can function well.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eA shift in treatment approaches\u003c/h2\u003e \u003cp\u003eAnother significant finding of the study is the participants\u0026rsquo; shift in treatment approach to mental illness. The participants reported a shift from the sole use of the spiritual model of fasting and prayer as the form of treatment to a hybrid treatment model where they refer patients to hospitals and therapists for professional treatment while the pastors support them with prayer.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eWhile in Ghana, all I did was pray for people with mental illness, and even when they don\u0026rsquo;t get better, I will continue to pray for their healing. But with all I have learned about mental illness in the United States, now I pray for the patient, and then the next step is to refer for medication to calm down the agitated patient while I continue to pray for total healing. So, the best treatment is to combine prayer and medication.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants emphasized that the clergy should not hold the primary view that mental illness is a spiritual issue requiring a spiritual treatment approach. Instead, mental illness should be viewed as a medical issue requiring medical intervention. \u003cem\u003e\u0026ldquo;We can no longer just conclude mental illness is a spiritual problem, and then all we are doing is praying for the person. We must view the issue from the medical angle and direct patients to seek medical help.\u0026rdquo;\u003c/em\u003e Another participant also put it this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhen I was in Ghana, I was only praying for them, but now in the United States, I offer my help as a Pastor and a counselor, still praying for the patients, but at the same time, I refer them to get medical assistance wherever possible.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHumane treatment\u003c/h2\u003e \u003cp\u003eThe findings show that humane treatment reduces stigma about mental illness. Participants intimated that the humane treatment and support mental health patients receive in the United States have changed their negative perception of mental illness and patients dealing with mental health issues. One participant stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIn Ghana, there was so much stigma about mental health patients, and persons with mental illness are maltreated and sometimes beaten. I used to consider mental patients as useless. But here in the USA, mental patients are treated well by society. So, my perception has changed, and I no longer consider mental patients as useless.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother related it this way:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhen I came to the United States, I saw that persons with mental illness are treated well by the public. There are institutions that care for them, and they are welcome among the general population. This has changed my approach towards persons with mental illness. While in Ghana, I did not want to go near mental patients, but I now welcome them to the church and even my home and feed them. I see they are not as dangerous as I used to think.\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThis finding emphasizes that we form opinions of issues based on what we perceive around us, which is consistent with the social learning theory.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eUnchanged views\u003c/h2\u003e \u003cp\u003eThe findings also show some unchanged views about mental illness. While most of the participants expressed that their experiences in the United States have changed their perception of mental illness, two of the eight (25%) participants alluded that their experiences in the United States have not entirely changed their perceptions of mental illness. These participants still believe that Satan and spirits cause mental illness and that mental health patients are not worthy humans. One participant made one such strong statement about patients with mental illness:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI have been in the United States for quite a long period, but my perception has never changed concerning mental illness because of what I know about the sickness. Some of the patients told me that they heard voices. I still believe very well that hearing voices might be from Satan. Mental illness is caused by spirits. I do not consider persons with mental illness as normal members of society. I have this mentally ill woman in my church. When I am preaching, she will be shouting and misbehaving, and because people with mental illness misbehave, they are nobody in society. They are nothing, they are not important, they are nothing in society.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant believed the accommodating approach in the United States towards persons with mental illness poses a significant threat to the security of the public. In the view of the participant, persons with mental illness should not be allowed to live with the general society but should be secluded from society since they cause harm. The participant stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe way we treat mental health here in the United States causes a lot of harm to society. So many mental patients live among us and hurt us. And I can say many of the shootings we have in this country are people with mental health issues. I think in the United States, we are too relaxed with mental health issues, and so people with severe mental health issues live in the same house with people and cause harm to society.\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study sought to answer the question of whether the views of Ghanaian American Clergy about mental illness and its treatment evolved with their experiences in the United States. The themes that emerged from the data include (1) Mental health literacy, (2) Treatment resources, (3) Shift in treatment approaches, (4) Humane treatment, and (5) Unchanged views\u003c/p\u003e \u003cp\u003eThe findings indicate that mental health literacy improves perceptions and beliefs about mental illness. Participants intimated that compared to Ghana, the United States has a better mental health education, which exposed them to a better understanding of mental illness. Ghana, like many less developed countries, has low levels of mental health literacy (Kapungwe et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Sorsdahl \u0026amp; Stein, \u003cspan citationid=\"CR122\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), and there is no concerted program in place to improve the level of mental health literacy in Ghana (Roberts et al., \u003cspan citationid=\"CR106\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Wilson \u0026amp; Somhlaba, \u003cspan citationid=\"CR141\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Research shows that a lower level of mental health literacy is associated with the attribution of mental illness to spiritual causes. In comparison, a higher level of mental health literacy is found to be associated with the biological and psychological etiology of mental illness (Anbesaw et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The study findings, which show participants' spiritual interpretation and approach to mental illness, while in Ghana, where mental health literacy is very low, are consistent with the other studies. The level of mental health literacy in Ghana is very low to the extent that even health professionals have very little knowledge about mental illness. Adu et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), in their study of Ghanaian nurse participants, found that 84% of the participants could not recognize schizophrenia in the vignette. If nurses in Ghana could not recognize schizophrenia, it is not surprising that the clergy, who are not health professionals, would have low levels of mental health literacy. With the low level of mental health literacy, most Ghanaians tend to attribute mental health problems to spiritual causes and prefer to contact a religious group when faced with mental health problems (Ae-Ngibise et al., 2010).\u003c/p\u003e \u003cp\u003eThe study findings show that the participants\u0026rsquo; mental health literacy has improved in the United States due to exposure to mental health education. The finding highlights the importance of ensuring a better understanding of and effective treatment for mental illness in Ghanaian communities through mental health education programs developed and implemented at all levels of Ghanaian society. A good starting point would be incorporating mental health literacy into the elementary to high school education curriculum. Since the clergy is known to be the primary source for help-seeking for persons with mental health issues in Ghana (Asamoah et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Osafo, \u003cspan citationid=\"CR95\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Addo-Anum, 2019), improved mental health education training for the clergy is crucial for the delivery of quality mental health to congregants and the general Ghanaian population. Mental health literacy is crucial in the attribution theory about mental illness, and people who have a higher level of mental health literacy are likely to attribute the biomedical etiology to mental illness (Jorm, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2000\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother theme that emerged from the study data was how the availability of mental illness treatment resources impacts the perceptions and beliefs about mental illness. Participants indicated that while in Ghana, mental health treatment resources were not available, and the only treatment they believed in and practiced was the spiritual model. However, the availability of treatment resources in the United States changed their beliefs about mental illness. This finding also emphasizes that people\u0026rsquo;s beliefs are formed based on exposure. Like many other African countries, Ghana has minimal mental health resources. According to the World Health Organization, only about 2% of the 2.3\u0026nbsp;million people living with mental health conditions in Ghana receive psychiatric treatment and support from health facilities (WHO Regional Office for Africa, \u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), with a treatment gap of 98% (Akapule, 2015). Other research shows that Ghana has very low mental health resources and abysmally inadequate mental health institutions and personnel, with one psychiatrist per 1.5\u0026nbsp;million people and only three major psychiatric hospitals serving the country\u0026rsquo;s population of nearly 30\u0026nbsp;million people (Adu-Gyamfi, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Robert et al., 2014). The low level of mental health resources in Ghana results from a lack of government investment in the mental health sector. The government of Ghana spends just 1.4% of total government health expenditure on mental health (Ghana News Agency, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The study findings suggest that with the lack of adequate professional mental health treatment resources, Ghanaians seeking mental health treatment might believe that the only viable treatment would be spiritual treatment, including from the clergy, and tend to be entrenched in their beliefs in the spiritual etiology for mental illness. However, when people are exposed to adequate available treatment resources, their perceptions about mental illness and its treatment will change. This assessment is consistent with other studies that indicate that the availability of treatment resources determines people's beliefs and acceptance of the treatment model. In their study, Silverman and Teachman (\u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found that living in a community with more professional treatment providers was associated with a greater likelihood of endorsing the professional treatment approach. Other research found that the greater the availability of treatment providers, the greater the mental health service used by the population (McCarthy et al., 2007; Wei et al., 2005). Additionally, a person who lives in communities where there are more significant numbers of mental health providers and treatment facilities may have increased exposure to others who are seeking mental health treatment, which may reduce mental health stigma and make treatment-seeking appear more normal and appealing (Silverman \u0026amp; Teachman, \u003cspan citationid=\"CR118\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother significant finding is the shift in mental illness treatment approach by the clergy from the spiritual model they practiced in Ghana to the embracing of the medical model in the United States. Participants attributed their shift to the mental health literacy they received in the United States and the availability of treatment resources. The clergy will remain an important source of mental treatment in Ghanaian communities no matter what (Ae-Ngibise et al., 2010), and they must adopt evidence-based treatment approaches if the community is to benefit from them. Therefore, mental health policymakers in Ghana must emphasize and promote the development of treatment resources by training clinical social workers, psychiatrists, psychiatric nurses, and psychologists and expanding the number of psychiatric units in all regional hospitals. It also calls for mental health training and education to be incorporated into the training curriculum for the clergy to enhance their help provision capabilities for persons with mental health issues (McDevitt, \u003cspan citationid=\"CR88\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Schuetze, \u003cspan citationid=\"CR112\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This will help the clergy understand when and where to refer mental health patients for professional treatment rather than only praying for them. Adu et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) emphasize that the lack of facilities and personnel in mental health care in Ghana is a significant challenge to care delivery.\u003c/p\u003e \u003cp\u003eParticipants also intimated that the humane treatment and support mental health patients receive in the United States have changed their stigmatic perception of mental illness and patients dealing with mental health issues. Research and anecdotal information established the inhumane way persons with mental illness are treated in Ghana and the high level of stigma towards mental illness. It is commonplace to see people with a mental health condition seeking treatment from religious leaders being chained as they are believed to be dangerous and kept in unsanitary conditions in prayer camps in Ghana. Patients are subjected to extended periods of involuntary fasting with denial of food and water and sometimes beaten as a means of exorcising the evil spirits that the clergy believed possessed the patients (Edwards, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Human Rights Watch, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Ssengooba et al., \u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Persons with mental illness in Ghana are sometimes neglected by some families who do not care for them but leave them on the streets without shelter or clothing to beg for food and receive no form of medical treatment (Bonsu et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Family neglect of patients may not be out of malice but, in most situations, due to poverty, family breakups, or the burnout or death of a primary caregiver (Acierno et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Ben David, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Some patients, out of hunger, would snatch food from people who would, in turn, subject them to beatings and other forms of maltreatment (Edwards, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Mfaofo-M'Carthy \u0026amp; Grishow, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). While Ghana has laws such as the Persons with Disability Act 2006 and signed the UN Convention on the Rights of People with Disabilities in 2007, the country has a very low level of enforcement of these laws, leaving persons with disabilities unprotected from maltreatment (Ocran, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). With these types of inhumane treatment, patients with mental illness are reduced to subhuman, thereby increasing the stigma about the illness and the patients. Stigma about mental illness is very high in Ghana (Mfaofo-M'Carthy \u0026amp; Grishow, \u003cspan citationid=\"CR89\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Dako-Gyeke \u0026amp; Asumang, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe United States, compared to Ghana, has a better approach to the care for persons with mental illness, where patients have the support of family and agencies that provide for their safety and care. Persons with mental illness in the United States have the same rights as all other members of society and are protected under several laws, such as the Americans with Disabilities Act, the Civil Rights of Institutionalized Persons Act, and the Individuals with Disabilities Education Act, among others. These laws are primarily enforced by both private and government institutions in the United States (Jo, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and provide a good measure of guarantee of respect, dignity, provision of services, and protection for people with disabilities and persons diagnosed with mental illness. While stigma towards mental illness may not be completely absent in the United States (Kold et al., 2023), the legal framework, enforcement, and service provision regimes for persons with mental illness promote a lower level of stigma towards mental illness in the United States, compared to Ghana where the laws are not enforced, and persons with disability continue to be abused and maltreated. An important take from this finding is that for stigma towards mental illness to be reduced, if not eradicated, Ghana must promote dignified treatment and support for persons suffering from mental health conditions by enforcing protective laws and educating the population against all forms of maltreatment of persons with mental health issues.\u003c/p\u003e \u003cp\u003eIt is important to note that 25% of the participants in the study indicated their original views from Ghana about mental illness and persons with mental illness have not changed despite their experiences in the United States. One participant still believes that Satan and spirits cause mental illness. Another believes that mental health patients are dangerous and should not be allowed to mingle with the public. The view held by this study participants of the dangerousness of people with a mental health condition is, however, not surprising, as a large section of the American public shares the same view. A section of the American public believes in the dangerousness of mental health patients (Link et al., \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Silton et al., \u003cspan citationid=\"CR116\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Gilligan, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). In a study by Pescosolido et al. (\u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) of the American public, 60% of the respondents perceived people with mental illness as being violent toward others and should be committed to an involuntary treatment facility. Incidences of violence such as mass shootings, arson, and shoving of people onto rail lines have been attributed to some form of insanity on the part of the perpetrators. On occasions of violence involving the use of guns, it is common to hear gun-rights advocates in the United States blaming mental health and not the abundance of guns as responsible for the violence. The print and electronic media heighten the narrative of the dangerousness of persons with mental illness. While research shows that persons with mental illness are not more dangerous than the general population (Torrey, \u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Peterson et al., \u003cspan citationid=\"CR102\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), the public continues to hold a negative perception that persons with mental illness are very dangerousness (Pescosolido et al., \u003cspan citationid=\"CR100\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Slemon et al., \u003cspan citationid=\"CR120\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR149\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The stigmatic views held about persons with mental illness culminate in discriminatory attitudes against persons with mental illness by the general population (Angermeyer \u0026amp; Dietrich, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Even staff who care for mental health patients hold negative attitudes and beliefs about people with mental illness (Hansson et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). There is a need for continuous education and sensitization of the public in every part of the world about mental illness to reduce the stigma and discrimination towards persons with mental illness.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eImplication for Social Work\u003c/h2\u003e \u003cp\u003eSocial work is the mental health profession that can be considered the closest to organized religion, such as Christianity. Social workers and the clergy provide tangible services, such as food, clothing, housing, and intangible services, such as counseling to community members.\u003c/p\u003e \u003cp\u003eIn practice, a collaboration between social workers and the clergy would promote the welfare of members of the community. An important area for collaboration would be in the field of mental health. The findings of the study suggest that if the clergy have improved mental health literacy, their approach to mental illness will improve. Social workers can work with local churches to provide mental health education to the clergy about the etiology and treatment resources for mental illness (Mafuriranwa et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Clergy need targeted education on counseling and mental health (Payne, \u003cspan citationid=\"CR98\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Ross \u0026amp; Stanford, \u003cspan citationid=\"CR110\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) because while they are at the forefront of handling mental health issues, they may not have the adequate mental health literacy to provide effective help to their congregants and the community members (Farrell \u0026amp; Goebert, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Wood et al., \u003cspan citationid=\"CR147\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). With such education, clergy would understand the limits of their treatment capabilities and the need to refer patients for treatment by mental health professionals. The collaboration could also be in the form of churches employing social workers as full-time, part-time, or volunteer staff to assist in providing mental health treatment for congregants alongside the clergy prayer. Including social workers will strengthen the church and clergy's capacity to assist members with mental health issues. LifeWay Research (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) found that only 20% of churches provide training for leaders to identify symptoms of mental illness, and only 18% have a skilled mental health professional on staff. This lack of capacity affects the clergy's ability to assist members with mental health issues. Social workers can play important roles in filling the professional care gap in congregations and preparing clergy to identify and refer congregants for care. An advantage of churches having social workers on staff would be that congregants would consider accepting mental health treatment from them since they may be seen as approved by the clergy, and receiving services from social workers would not be considered a lack of faith in God\u0026rsquo;s treatment through the clergy. This is consistent with research which shows social worker and clergy collaboration tends to increase the rate of participation of congregants in mental health treatment from social workers when referred by the clergy since parishioners would trust the opinion of the clergy in such referrals (Hankerson et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Schultz et al., \u003cspan citationid=\"CR114\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe collaboration between social workers and the clergy would not only benefit the clergy but would have reciprocal benefits for social workers as well, as they tend to have a deeper understanding of the spiritual context of health and mental health for religiously oriented individuals and the strengths of spirituality as a resilience factor in coping with adverse health issues. When mental health professionals incorporate spirituality in their treatment regimes, it provides holistic and effective treatment and care for individuals who share spiritual beliefs and also enhances the spiritual competency of the social worker (Koenig \u0026amp; Al Shohaib, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) and creates a trusting relationship between the patients and the mental health professional and promotes acceptance of treatment from such professionals (Hodge \u0026amp; Horvath, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Additionally, when clergy realize that social workers and other mental health professionals have a vested interest and a grasp of spirituality, they may become more willing to refer congregants to such professionals for treatment without fear of patients losing their faith in the church. This will create expanded access to mental health professionals for people needing mental health treatment.\u003c/p\u003e \u003cp\u003eIn sum, Social workers and other mental health professionals need to collaborate with the clergy since such collaboration would have mutual benefit for all as they educate each other on their respective areas of expertise with the professionals enhancing the understanding of empirical treatment capabilities of the clergy while the clergy enhances the spiritual perspectives of health for the professionals (Bledsoe et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Rogers et al., \u003cspan citationid=\"CR108\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) creating an inclusive and nurturing environment for patients to receive holistic care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplications for Human Rights\u003c/h2\u003e \u003cp\u003eAs studies found clergy to play a central role in mental health delivery, their beliefs and treatment practices about mental illness are vital to the well-being and human rights of persons diagnosed with mental illness.\u003c/p\u003e \u003cp\u003eFirst, by providing spiritual treatment that may have no evidence of effectiveness, people with mental health conditions are denied their right to effective treatment. In many instances, patients are involuntarily committed to the spiritual treatment by the clergy and family members, violating their human rights to self-determination. The World Health Organization\u0026rsquo;s QualityRights initiative sets out to improve the quality of care and support in mental health to promote the human rights of people with psychosocial, intellectual, or cognitive disabilities worldwide (World Health Organization, \u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). There is no concrete research evidence to back the belief in the effectiveness of spiritual treatment for mental illness, and people with mental health conditions spend many years in prayer camps in Ghana without getting well. It is, therefore, encouraging that the study participants (clergy) indicated a shift from the spiritual model to the medical model, which gives congregants receiving treatment from them a brighter prospect of receiving effective treatment and enhancing their human rights. Puras (\u003cspan citationid=\"CR104\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) posits that there is a need for interventions to focus on the fundamental rights of people with mental health conditions because of the myriad human rights violations against this population.\u003c/p\u003e \u003cp\u003eIn communities in Ghana where clergy believe in the spiritual etiology of mental illness, an attempt to implement spiritual treatment sometimes results in the gross violation of the human rights of patients in diverse ways. Research has documented blatant human rights violations meted out to persons with mental illness during spiritual treatment at prayer camps in Ghana, where mental health patients are subjected to all manner of inhumane treatment, including beatings, denial of food, and chaining, among others (Edwards, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Human Rights Watch, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Moro et al., \u003cspan citationid=\"CR91\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ssengooba et al., \u003cspan citationid=\"CR124\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). According to the UN Declaration of Human Rights, all persons, including persons with mental illness, have the right to humane treatment (United Nations General Assembly, \u003cspan citationid=\"CR134\" class=\"CitationRef\"\u003e1949\u003c/span\u003e). It is, therefore, a gross violation of the human rights of persons with mental illness to be subjected to inhumane treatment in prayer camps and treatment facilities in Ghana. As stated earlier, while Ghana has laws such as the Persons with Disability Act 2006 and signed the UN Convention on the Rights of People with Disabilities in 2007, the country has a very low level of enforcement of these laws, leaving persons with disabilities unprotected from maltreatment (Ocran, \u003cspan citationid=\"CR93\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and their human rights violated with impunity. There is a need for the government to promote enforcement of human rights laws to protect people with mental health issues from the continuous abuse and violation of their rights.\u003c/p\u003e \u003cp\u003eParticipants indicated that the availability of treatment resources in the United States increased their positive view of mental illness and their gravitation toward biomedical treatment approaches. This calls for the need for countries like Ghana, which have very limited mental health resources, to consider mental health resources from the right-based perspective and prioritize their funding and development. Such a demand for increased investment in mental health resources aligns with the obligation under the UN Convention on the Rights of Persons with Disabilities and other rights enshrined in the UN and other international charters. Investing in and improving mental health resources in Ghana will contribute to achieving the Sustainable Development Goal (SDG) 3, which seeks to ensure healthy lives and promote well-being for all persons, including persons with mental illness (Mahomed, 2020).\u003c/p\u003e \u003cp\u003eTo address challenges in the mental health sector, the Mental Health Act of 2012 was passed in Ghana to address mental health issues in the country and safeguard the protection of the rights of persons with mental illnesses (Magna \u0026amp; Yemoh, \u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Osei, \u003cspan citationid=\"CR97\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). However, the implementation of the law lacked adequate support from the government of Ghana who is supposed to enforce the human rights provisions of the law and provide the necessary healthcare infrastructure that will ensure the care of patients with mental illness that the law aims to protect. According to Walker and Osei (2017), inadequate financial, human, and infrastructure resources for the mental healthcare law served as barriers to its implementation in Ghana, where the central government bears healthcare expenditure. Bedi et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) contend that policymakers and institutions give low priority to mental health issues, coupled with inadequate funding from the central government, which contributes to the failure of the Mental Health Act to have any meaningful impact on mental health in Ghana. Consequently, people with mental illness continue to endure human rights violations and are subjected to inhumane treatment in Ghana.\u003c/p\u003e \u003cp\u003eThis study's findings highlight the need for increased investment in mental health resources to promote effective treatment, reduce stigma, and curtail the rampant abuse and violation of the rights of mental health patients. It is crucial for social workers to advocate for mental health literacy and the development of treatment resources and continue championing the fair and humane treatment of all people, especially people with disabilities who cannot protect themselves. This would not only promote the human rights of individuals in fulfillment of UN charters but also validate the National and International Associations of Social Workers\u0026rsquo; values of social justice, dignity, and worth of the person.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has the limitation of non-generalizability due to the small sample that may not be generalizable to the Ghanaian American clergy population. However, as in qualitative research in general, the goal of this study was not to generalize the findings but to uncover a more profound and better understanding. Another limitation of the study was possible researcher bias and possible conflicted opinion. The researcher is a social worker and a Ghanaian American practicing clergy. Conflicting opinions may arise when, as a social worker, the researcher might be predisposed to validating only professional treatment approaches, and as a clergy, validating spiritual treatment approaches that might not be empirically based. Seen from another angle, however, the researcher\u0026rsquo;s dual position can be a strength as he understands both the spiritual and the clinical perspective of mental health issues and assumes a neutral position in the research process. To minimize possible researcher bias, the researcher developed increased self-awareness in consideration of his positionality and how that influences his perception of the phenomenon being studied. Creswell and Poth (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) describe this process as bracketing out of the study. The researcher bracketed out by being aware of his presumptions and setting them aside or minimizing them during the research process (Creswell \u0026amp; Poth, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Giorgi, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of the study suggest that when people lack mental health literacy and evidence-based treatment resources, they tend to resort to and rely heavily on spiritual interpretation for illnesses, including mental illness. It highlights the need to provide mental health literacy to the clergy as part of their pre-ordination and continuous in-service training. Mental health literacy should also be included in the curriculum for schools to improve public knowledge of mental health issues. Additionally, there is a need for the government of Ghana, religious institutions, and private sector organizations to provide evidence-based treatment resources, such as psychiatric hospitals and psychotropic medication, and train mental health personnel, such as psychiatric nurses, clinical social workers, and psychiatrists. These actions will help change wrongly held beliefs about mental illness by the population in general and the clergy in particular and help improve mental health in Ghanaian communities.\u003c/p\u003e \u003cp\u003eWhile education about mental illness and the availability of treatment resources appear helpful in changing perceptions about mental illness and improving treatment regimes, negative beliefs and attitudes towards mental illness continue to persist in every part of the world, including advanced societies like the United States. There is a need for relentless action on the part of social workers and other mental health professionals everywhere to continue to educate the population on mental health issues to improve access and care. Notably, social work professionals need to focus on education for the clergy about mental illness to ensure they become credible partners in the management and treatment of mental health issues. Social workers must also intensify their advocacy for adequate treatment resources in Ghanaian communities to improve treatment availability.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eCompeting Interest\u003c/strong\u003e \u003cp\u003eThe author has no competing interests to declare.\u003c/p\u003e \u003ch2\u003eEthical Approval\u003c/h2\u003e \u003cp\u003eData for this article was extracted from the author\u0026rsquo;s dissertation data, of which approval was obtained from the Institutional Review Board of Fordham University, where the researcher was a PhD student.\u003c/p\u003e \u003ch2\u003eData and Material Availability\u003c/h2\u003e \u003cp\u003eThe data supporting this study's findings is available upon request from the corresponding author.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis research received no funding from public, commercial, or not-for-profit agencies but entirely depended on the researcher\u0026rsquo;s resources.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. Philip Kwasi Elike is the sole author of this manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting this study's findings is available upon request from the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAcierno, R., Hernandez, M. 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A study from the North of England. \u003cem\u003eMental Health Religion \u0026amp; Culture\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(8), 769\u0026ndash;783.\u003c/li\u003e\n \u003cli\u003eZhang, Z., Sun, K., Jatchavala, C., Koh, J., Chia, Y., Bose, J., ... \u0026amp; Ho, R. (2020). Overview of stigma against psychiatric illnesses and advancements of anti-stigma activities in six Asian societies. \u003cem\u003eInternational journal of environmental research and public health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(1), 280.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ghanaian American Clergy, Experiences in the United States, mental illness and human rights, mental health literacy, treatment resources, humane treatment","lastPublishedDoi":"10.21203/rs.3.rs-6214524/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6214524/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe study explored whether Ghanaian American clergy\u0026rsquo;s experiences in the United States impacted their views about mental illness. The study used a phenomenological approach and collected data from 8 Ghanaian American Clergy in New York City. Data was transcribed and coded to develop themes. The findings showed that participants\u0026rsquo; views about the causes and treatment for mental illness have evolved due to their experiences in the United States. The findings show that (a) mental health literacy creates a positive perception of mental illnesses for the clergy, leading to a move away from the spiritual etiology for mental illness towards the biomedical etiology, (b) the availability of treatment resources in the United States contributed to a shift from spiritual treatment approach of fasting and prayer to a hybrid model of treatment of referring patients to hospitals and therapists for treatment while clergy still pray for them, (c) the humane treatment and support mental health patients receive in the United States changed the clergy\u0026rsquo;s negative perception of mental illness and reduced the stigma. The conclusion is that the lack of mental health literacy and evidence-based treatment resources leads to relying on spiritual interpretation and treatment for mental illness. Social workers must focus on promoting mental health literacy for the clergy and intensify their advocacy for adequate treatment resources to enhance humane treatment for people with mental health conditions and promote their human rights.\u003c/p\u003e","manuscriptTitle":"Impact of Experiences in the United States on Ghanaian Clergy’s Approach to Mental Illness: Implications for Social Work and Human Rights","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 13:56:42","doi":"10.21203/rs.3.rs-6214524/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4fdc989b-ce17-48ec-85f2-898d4ab5587f","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-28T14:25:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-27 13:56:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6214524","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6214524","identity":"rs-6214524","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}