Traditional healers and mental health in South Africa

Abstract

Psychiatric patients access both indigenous healers and services rendered by psychiatric facilities in South Africa. The various groups of healers which are available are clearly not all acceptable to the whole population and variable experiences are reported with different categories of healer and the different treatments provided. An increasing collaboration between psychiatric services and indigenous healers is becoming evident, as in other health services. Reports indicate that many African psychiatric patients seek treatment from indigenous healers while attending psychiatric clinics, in both rural and urban regions. This has led to much discussion and differing viewpoints as to the possible benefits and disadvantages of collaboration and simultaneous use of different treatment modalities. Included in this is the question of the medical competence of traditional healers and the possible neglect of serious conditions.

Use of indigenous healers by psychiatric patients

Even in metropolitan urban areas of South Africa, indigenous healers are still widely used, especially for mental health problems. This is in part related to common beliefs that such problems are caused by bewitchment and that only indigenous healers can treat this, resulting in simultaneous consultations. Despite this, these culturally specific groups are not under-represented among the users of psychiatric services (Ensink et al, 1995) and, indeed, many patients still travel from distant areas to get psychiatric treatment in the city-based facilities.

Indigenous healing systems

It is evident that culture-specific concepts of mental illness and related beliefs will affect the delivery of psychiatric services. An understanding of the systems of indigenous healing by healthcare providers is therefore essential in each region of the country, as these may differ regionally. There are specific names and descriptions used for different categories of disorder. The use of these terms does not exclude conventional mental health services being consulted. The healing modality can include psychosocial and other approaches. The medical competence of the traditional healer is frequently addressed and a regulatory framework has recently been introduced that recognises certain groups of ‘treatments’ in South Africa.

Traditional healers are not a homogeneous group, which makes the situation more complex. The different types of indigenous healers are found in three groupings: the diviners, the herbalists and the faith healers. There are clear differences between these, although it is not unusual for healers to integrate more than one orientation into their practice. Diviners are believed to have access to supernatural powers through their ancestors. This gives them the ability to divine the cause of illness. This ability, it is further believed, may be used in the service of good or evil. The process of diviner training starts when an illness or misfortune is interpreted as a calling from the ancestors (ukuthwasa). This may lead to an apprenticeship and participation in rituals and ceremonies of the healers and their abaqwetu (trainees). Those who become healers gain entry into a mutually supportive healing network. Herbalists function much like pharmacists and dispense a range of herbal products. Faith healers work from within the popular African churches and use prayer, singing and rituals to heal.

Indigenous names and concepts of mental illness

In conventional health systems there persists a lack of understanding of the way in which indigenous names are used by African psychiatric patients. The various categories illustrate the range of mental disturbance attended to by the traditional healer:

• ukuthwasa (calling to be a healer)

• amafufunyana (possession by evil spirits)

• ukuphambana (madness).

Research suggests that patients and families do not use indigenous names in these fixed and rigid ways, but as explanatory categories (Kleinman, 1988; Ensink & Robertson, 1996).

Utilisation studies

The experiences of African psychiatric patients and their families of psychiatric and indigenous services are variable (Ensink & Robertson, 1999). Many described negative experiences and misunderstandings. Some researchers recommend increased engagement with and understanding of the experiences and beliefs of families. Psychiatric services are seen to be able to assist with symptom control and medication but are considered rarely able to deal with the fears of bewitchment. Improved information on the experiences of users of indigenous services would assist with decisions to refer to them. Indigenous healers also need to be informed what psychiatry can provide that users may find useful.

A study undertaken in Cape Town (Ensink & Robertson, 1999) provides some information about the utilisation of and satisfaction with traditional healers, as well as the related concepts of illness. The study found that, in 71% of a sample of 62 patients, traditional healers had been consulted in the previous 12 months – faith healers by 21 (34%), diviners by 15 (24%), herbalists by 8 (13%). Fifty-three per cent had consulted general medical services in the past 12 months. The reported ‘indigenous’ causes included bewitchment, failure to do a Xhosa ritual, stepping over a dangerous track, evil spirits, poisoning with ants and soil from the grave, and witch familiars (e.g. snake of the river, bird of evil, tokeloshe or bogey man). In addition, the study revealed that patients believed the causes of amafufunyana (possession by evil spirits) could in addition be ‘nerves’, relationship problems, drug and alcohol misuse or God’s will.

Indigenous illness names used by patients and families in the study by Ensink & Robertson (1999) are listed in Box 1.

Box 1. Indigenous illness names used by patients and families (n = 62)

Indigenous names

Amafufunyana (11 instances)

Ukuphambana (11)

Amafufunyana/ukuphambana (1)

Amafufunyana/ukuthwasa/ukuphambana (1)

Isiphoso (2)

Umbilini (1)

Ukuthwasa (1)

Umlingo (1)

Isiphephetho (1)

Ukuphoselwa (1)

Bewitchment (1)

Other terminologies

Nerves and related (18 instances)

Nerves (8)

Worried too much (2)

Stress (2)

Workload (2)

Mental exhaustion (1)

Depression (3)

Brain injury (1)

Diabetes (1)

Damaged veins (1)

Pregnancy problems (1)

Overdose (1)

Unsure/no name for illness (3)

Other (12)

A range of psychiatric diagnoses was recorded by the psychiatric services. The majority of patients presented with one or more diagnoses of acute psychosis, organic syndrome or mood disorder.

The majority explained their problem in terms of more than one cause. A combination of indigenous, psychosocial, physical and religious dimensions was frequently invoked.

Competency, regulation and quality assurance

Competency, regulation and quality assurance issues are addressed in South Africa by the Traditional Health Practitioner Act 2003, which aims to ensure the quality of the health services provided by this group. A national body has been established to set training standards and regulate entry into the profession. Professional associations of traditional healers have been established and have been encouraged to develop practice guidelines and a code of ethics.

Discussion

Knowledge of traditional concepts and systems on the part of Western-trained psychiatrists is essential, in particular because of the widespread parallel use of services, as well as the problems experienced with unregulated and sometimes problematic indigenous services. Descriptions of indigenous categories differ from Western ones and need to be understood by all health practitioners. There is a need to improve psychiatric services for the population identified as attending traditional practitioners simultaneously.