Traditional Healers and Mental Health Care in the South African Context

Katherine Sorsdahl

Overview of Presentation 1. Explain what a traditional healer is and the varying types 2. Discuss the use of traditional healers for mental health needs

3. Explore how traditional healers view mental illness 4. Describe traditional healer treatment practices 5. Describe the South African Traditional Health Practitioners Bill

The World Health Organization (1976) defines an African traditional healer as: “competent to provide health care by using vegetable, animal and mineral substances and certain other methods based on the social, cultural and religious backgrounds as well as the `prevailing knowledge, attitudes and beliefs regarding physical, mental and social well-being and the causation of disease and disability in the community”.

Types of Traditional Healers: Diviners •

Believed to be specialists in divination within the supernatural context, giving them the ability to divine the cause of illness and misfortune

•

Use bones, seashells and other objects as a tool to communicate with their ancestral spirits

The Sangomas Calling •

A person does not choose to become a sangoma rather they are called to their profession.

•

sangomas are called to the healing profession by their ancestors through the sending of an illness, referred to as thwasa, or intwaso

The Sangomas Training

Types of Traditional Healers: Herbalists •

Recognized as the traditional doctor in the community

•

Specialize in the production of herbal medicine as they possess an extensive knowledge of natural treatments, curative herbs and medicinal mixtures of animal origin.

Types of Traditional Healers: Faith Healers • Integrates Christian ritual and traditional practices, and belongs to one of the Independent African churches. • A calling from God, and treatment often includes prayer, although sometimes prayer is used in combination with holy water, candles, ashes and other aids to prayer. • The literature suggests that faith healers are becoming increasingly popular and there is some research indicating that religious leaders are consulted more frequently than traditional healers.

Who Consults with Traditional Healers for their Mental Health Care Needs •

There is a common assertion that 80% of Black South Africans consult traditional healers for their healthcare needs.

•

A number of small studies conducted in South Africa investigating individuals with a mental illness report that approximately one-half (41-61%) of patients have consulted a traditional healer (Ensink & Robertson, 1999; Freeman et al., 1994; Mkize & Uys, 2004).

Relatively More Recent Data • A national survey was conducted with 3651 adult South Africans between 2002 and 2004, using the World Health Organization Composite International Diagnostic Interview (CIDI) to generate DSM-IV diagnoses for common mood, anxiety, and substance use • We examined the extent to which alternative practitioners were consulted, and predictors of traditional healer visits Type of Practitioner

Total sample

With DSM-IV diagnosis

Without DSM-IV diagnoses

Traditional healer Religious or spiritual advisor

6.4

8.9

5.2

6.9

10.8

5.1

Chiropractor or spiritualist Traditional healer exclusively

2.2

3.2

1.8

2.4

3.6

1.9

Approaches to Investigating Cross Cultural Psychiatry • The universalistic or etic approach advocates the universality of medical and mental illness.

• Emic: to appraise certain phenomena from within a culture with a view to recognising its meaning and relationship with other intra-cultural elements • Today, there appears to be a general consensus that an integration of these two approaches is required in cross-cultural psychiatry

Culture Bound Syndromes •

A great deal of literature in cross-cultural psychiatry focuses on culture bound syndromes.

•

A culture bound syndrome is a combination of psychiatric and somatic symptoms that appear to fall outside conventional Western psychiatric diagnostic categories. They are indigenously thought of as illnesses or afflictions, have local names and are limited to specific “cultural areas”.

•

A study conducted by Ensink and Robertson (1999) attempted to classify culture-bound syndromes according to Western criteria by assessing categories of distress according to 10 traditional healers among children and adolescents.

Culture Bound Syndromes All of the categories were recognized and had specific indigenous names. 1. 2. 3. 4. 5.

ukuthwasa (calling to be a healer); amafufunyane (possession by evil spirits); ukuphambana (madness); isinyama esikolweni (bewitchment at school); and ukuphaphazela (episode of fearfulness).

Explanatory Models of Mental Illness • One way of examining the role of culture in psychiatric disorders is to elicit the explanatory models of traditional healers • An explanatory model (EM) is defined by Kleinman as the “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process”. • These models are linked to particular categories of illness and reveal labels and cultural idioms for expressing the experience of illness.

Explanatory models of mental disorders among traditional healers A few studies have been conducted in South Africa investigating traditional healers’ perceptions of mental illness (Koen, Niehaus, Muller, & Laurent, 2003; Mufamadi, 2001; Mzimkulua & Simbayib, 2006; Robertson, 2006; Thorpe, 1992).

Mufamadi (2001) interviewed 8 traditional healers in Limpopo to investigate how they perceived mental illness, its causes and treatment methods. Symptoms were associated with mental illness, including: aggression, talking incoherently, isolation, shouting loudly, confusion and strange behaviour. She also reported perceived causes such as heredity, witchcraft, sorcery, disregard of cultural norms and spirit possession.

EM of mental disorders among traditional healers in Mpumalanga The study adopted a cross-sectional exploratory design, using qualitative methods that included 4 focus group discussions (8 healers in each group) and 18 in-depth interviews). 3 vignettes were presented (schizophrenia, depression, panic disorder ) in addition to a short interview used to elicit explanatory models (Short Explanatory Model InterviewSEMI). Traditional healers’ views on the nature of the problem, cause, consequence, and treatment were elicited.

Basic Concepts: Mental Illness • All healers recognized “mental illness” as a distinct category of illness. • The more frequently reported behaviours included: violence, picking up garbage, talking randomly, walking for long periods of time and undressing in public. “There is a lady that never even bathed herself, she didn’t want to. She didn’t even use the toilet and then she always wanted to go gallivanting because she hears people calling her, that are luring her towards them. She says their names and told us what they are telling her to do. She was very violent, trying to fight with people all the time.”

Basic Concepts: Causes • Witchcraft and possession by evil spirits was the most frequently reported (56%). • The term amafufunyana (12%) was used to describe mental illness caused by witchcraft • Consequence of causal factors (family problems, substance abuse, and poverty) that were left untreated and progressively became more severe (30%). • ukuthwasa (10 %) “The ancestors are trying to tell that person that they should follow the calling and become a traditional healer. The ancestors can cause a number of problems to a person if they do not listen to the calling, even a mental illness. A calling can be viewed as a blessing and a burden”

EM of Schizophrenia • A majority of the healers reported that the patient described in the “schizophrenia” vignette was not suffering from a mental illness (60%; half of which believed it was thwasa) • About 40% of the healers believed that individual was suffering from a mental illness, caused by witchcraft, (25%); some specifically used the term amafufunyana (10%), thwasa (10%), or substance abuse (5%).

EM of Depression • None of the traditional healers in this study believed that the patient described in the vignette was suffering from a mental illness. • A majority of the healers reported that these problems were caused by psychological reasons (62%), or bewitchment (12%). • All of these healers felt they had the capabilities of curing these patients of these problems. • illness

EM of Panic Disorder • 98% reported that Panic Disorder is NOT seen as a mental illness. • 60% did believe the individual in the vignette was suffering from an physical illness ranging from HIV/AIDS, illness of the heart, hypertension (12%), ancestor calling (6%), and stress (16%). • Of the traditional healers who reported these symptoms as not being an illness (40%), the problems reported were stress (16%) and thinking too much (24%).

Summary of Traditional Healers EM •

Psychotic illnesses appear to be the main exemplar of mental illness, often being associated with severe behavioural disturbances.

•

For nonpsychotic disorders, those that did not report the problem to be of a physical nature, often conceptualised these disorders as more stress-related, or a result of “thinking too much”, and believed that people suffering from nonpsychotic disorders did not always require treatment.

Treatment of Mental Illness • All of the healers reported that patients with mental illness would be given “muti” to drink and bathe with, while more than half also described treatment involving sniffing herbs through the nose (52%). • One diviner provided specific details of the ingredients to cure amafufunyana: 1 teaspoon Methylated spirit ½ teaspoon Benzine (colorless, highly flammable liquid- used as a cleaning agent) a few pieces of Indonya (a traditional herb- looks like Epsom salt) 1 teaspoon of vinegar (any type) ½ teaspoon of umdlebe (you grate this particular herb)

Are Traditional Healer Treatments Effective? Since “herbalism” is a branch of traditional medicine based on phytochemical components of herbs that are known to have medicinal properties, it is not unreasonable to suggest that they may possess therapeutic benefits. Some of the most effective cancer drugs available are also plant derived such as Vincristine (from periwinkle), Etoposide (from mayapple) and Taxol (from the pacific yew tree) (Cragg & Newman, 2005).

There is lack of studies available investigating the effectiveness of traditional herbal medicine using the “gold standard” double-blind, placebo-controlled trials.

Summary • Treatments prescribed by traditional healers for mental . illness have often not been rigorously evaluated, nor does it appear that they are always properly prepared or standardized. • Despite the lack of evidence available on the efficacy of traditional healer in treatment mental illness, due to the devastating effects of the HIV epidemic, many countries are looking to all available resources in an attempt to alleviate some of the burden.

Traditional Health Practitioners Bill Traditional Healers Organization (THO) is one of the largest associations for traditional healers in South Africa established in 1970. The draft Traditional Health Practitioners Bill that was approved by parliament in September 2004 was enacted on 11 February 2005. Section 19(1) is a core component of the Act stating "No person shall be entitled to practice as a traditional health practitioner within the Republic unless he or she is registered in terms of this Act".

The Traditional Health Practitioners Act of 2004 was inaugurated in February 2013 and when its regulations are finalised, traditional healers will need to register with the council and only medical certificates issued by healers registered with this council will be accepted by employers.

Acknowledgments Prof. Dan Stein and Alan Flisher Ms. Zane Wilson (SADAG) Thandi: Traditional Healer (AFRICARE) 174 traditional healers who graciously gave up their time to share their practices and experiences with me!