Reassessing the Mental Health Treatment Gap: What Happens if We Include the Impact of Traditional Healing on Mental Illness?

Abstract

In this Fresh Focus, we reassess what the mental health treatment gap may mean if we consider the role of traditional healing. Based on systematic reviews, patients can use traditional healers and qualitatively report improvement from general psychological distress and symptom reduction for common mental disorders. Given these clinical implications, some high-income countries have scaled up research into traditional healing practices, while at the same time in low-and middle-income countries, where the use of traditional healers is nearly ubiquitous, considerably less research funding has studied or capitalized on this phenomena. The World Health Organization 2003–2020 Mental Health Action Plan called for government health programs to include traditional and faith healers as treatment resources to combat the low- and middle-income country treatment gap. Reflection on the work which emerged during the course of this Mental Health Action Plan revealed areas for improvement. As we embark on the next Mental Health Action Plan, we offer lessons-learned for exploring potential relationships and collaborations between traditional healing and biomedicine.

“When a ripe apple falls, what makes it fall? Is it gravity, pulling it down to earth? A withered stalk? The drying action of the sun? Increased weight? A breath of wind? Or the boy under the tree who wants to eat it? Nothing is the cause of it. It is just the coming together of various conditions necessary for any living, organic, elemental event to take place. And the botanist who finds that the apple has fallen because of the onset of decay in its cellular structure, and all the rest of it, will be no more right or wrong than the boy under the tree who says the apple fell because he wanted to eat it and prayed for it to fall.” - Leo Tolstoy (2005), War and Peace

The 2018 Lancet Commission on Global Mental Health and Sustainable Development highlighted a high global burden of mental and substance use disorders amid scarcely available mental health resources, of which many suffer from inefficient utilization and unequal distribution (Patel et al. 2018). This disconnect between the number of individuals with mental illness and the number seeking treatment is referred to as the “treatment gap” in mental health (Saxena et al. 2007, p. 886). However, these estimates exclude community traditional healers who may already serve populations with psychiatric problems through healing rituals (Nortje et al. 2016). If one moves away from only considering Western developed pharmacological and psychological treatments, then this may present a different picture of the global treatment gap. Mental health professionals, activists, and service users have called for moving away from this monocultural view only including Western mental health healing practices, and they ask for a more contextualized approach to address the worldwide mental health treatment gap (‘Open Letter to the Organisers, Partners and Delegates of the Global Ministerial Mental Health Summit,’ 2018). In this Fresh Focus, we reassess what the mental health treatment gap may mean if we take into account the role of traditional healing. First, we introduce key nomenclature and theories which can illustrate the community role or traditional healing. Then we discuss various perspectives on the traditional healer as mental health provider and collaborator. Finally, we emphasize an empirical approach which builds upon lessons learned from the foundational literature.

At present, there is scarce epidemiological data regarding use of traditional healers and what psychiatric concerns are treated by traditional healers. In a Lancet Psychiatry review, Gureje et al. (2015) reported that patients use traditional and other complimentary forms of medicine for psychiatric problems at rates which vary between 20 and 80% across different populations. In interpreting this wide range, they discussed the inherent difficulties with defining and classifying the diversity of traditional and complementary medicine practices. This field encompasses not just traditional healers but a plethora of other practices such as Ayurvedic medicine, herbal medicine, and Reiki.

If traditional healers have escaped estimates of care coverage, what effect might this have on public mental health? To tackle this question, we turn to qualitative methodologies, e.g. ethnography, which have shed light on traditional healer’s long-standing appeal. For example, in Haiti, Wagenaar et al. (2013) investigated traditional healers who readily availed themselves to marginalized rural populations, and community members preferred these traditional healers for psychological distress, including for suicidal thoughts and behaviors (Wagenaar et al. 2013). In Rwanda and South Africa, patients accessed traditional healers more easily than medical providers (Schierenbeck et al. 2018) including for support of non-biomedical, quality of life issues (Musyimi et al. 2017a, b). In Nepal, traditional healers fostered cultural kinship during the process of treating their patients; rather than verify their patient’s illness against modern medicine, traditional healers discussed shared causality models and conducted semiotic rituals which organized the patient’s inner experiences of illness (Pham et al. 2020a, b). Within the United States (US) and Canada, American Indian (Native American) rituals such as sweat lodges and healing circles faced centuries of post-colonial suppression, and yet these rituals persevered as cultural therapies against the ongoing legacy of conquest, subjugation, impoverishment, assimilation, and dispossession (Gone and Trimble 2012; Wendt et al. 2012; Hartmann et al. 2019; Gone et al. 2020).

Taking into account the diversity of traditional healing, Nortje et al. (2016) and van der Watt et al. (2018) conducted systematic reviews on the traditional healer’s intersection with mental health across multiple nations and cultures. Their reviews revealed a heterogeneous literature with a diversity of methodologies that suggested patients of traditional healers qualitatively report improvement from psychological distress and symptoms of common mental disorders, with some benefits akin to conventional psychotherapy, as well as other forms of relief.

Given the traditional healer’s potential in closing the mental health treatment gap, scholars have long debated the merits of collaboration between traditional healers and medical providers across a wide variety of settings (Rappaport and Rappaport 1981; Ovuga et al. 1999; U.K. Department of Health 2005; Mzimkulu and Simbayi 2006; Ally and Laher 2008; Incayawar et al. 2009; Alexander 2010; Pouchly 2012). In low- and-middle income contexts where this treatment gap is greatest (Saxena et al. 2007), discussion has emerged within regions such as South America (Bouchard 2009), the Caribbean (Koss 1980, 1987), Asia (Bhatia et al. 1975; Kapur 1979; Merriam and Muhamad 2012; Lee 2015) and Africa (Lampropoulos 2001; Meissner 2004; Kaboru et al. 2006; Robertson 2006; Raja and Underhill 2009; Hanlon et al. 2010; Sodi and Bojuwoye 2011; Bojuwoye and Sodi 2010; Burns and Tomita 2015; Gureje et al. 2015; Nortje et al. 2016; van der Watt et al. 2018).

A comprehensive literature review would be enormous and beyond the scope of this Fresh Focus. However, we provide a snapshot of the most recent literature from Africa and Asia, two of the world’s poorest continents (see Table 1). Our PsycInfo search reveals an interest in collaboration across a wide variety of countries, namely Liberia (Herman et al. 2018), Ethiopia (Selamu et al. 2015), Zanzibar (Solera-Deuchar et al. 2020), Nigeria (Osaghae 2020), and Malaysia (Razali et al. 2018). A great majority agree that collaboration between traditional healers and medical providers would improve the overall mental well-being of their communities. However, these publications diverge with respect to their respective takes on collaboration. A few publications endorsed task-shifting with traditional healers, that is training traditional healers in low-intensity mental health interventions, identification and referrals, and other mental health systems roles (Labys et al. 2016; Musyimi et al. 2017a, b). Other publications advocated for more dialogue and communication among traditional healers and medical providers (Abera et al. 2015; Odinka et al. 2015; Kpanake 2015; Razali et al. 2018). Osafo (2016) suggested developing a curricula to support the intersection of traditional healers and biomedical mental healthcare.

Table 1.

Traditional Healing and Mental Health Publications in Africa and Asia Between 2015-2020

Author (year)	Continent	Country	Title
Ventevogal (2015)	Africa	Burundi	The effects of war: local views and priorities concerning psychosocial and mental health problems as a result of collective violence in Burundi. Borderlands of mental health
Irankunda and Heatherington (2017)	Africa	Burundi	Mental health treatment outcome expediencies in Burundi
Assad et al. (2015)	Africa	Egypt	Role of traditional healers in the pathway to care of patients with bipolar disorder in Egypt
Abera et al. (2015)	Africa	Ethiopia	Parents’ perception of child and adolescent mental health problems and their choice of treatment option in southwest Ethiopia. Child and Adolescent Psychiatry and Mental Health
Selamu et al. (2015)	Africa	Ethiopia	Beyond the biomedical: community resources for mental health care in rural Ethiopia
Fekadu et al. (2019)	Africa	Ethiopia	The psychosis treatment gap and its consequences in rural Ethiopia
Mall et al. (2017)	Africa	Ethiopia	‘Restoring the person’s life’: a qualitative study to inform development of care for people with severe mental disorders in rural Ethiopia
Wondie and Abawa (2019)	Africa	Ethiopia	Westernization versus indigenization in the context of global mental health: training and services in Ethiopia—University of Gondar in focus
Tsigebrhan et al. (2017)	Africa	Ethiopia	Help seeking and suicidality among people with epilepsy in a rural low income country setting: cross-sectional survey. International journal of mental health systems
Ibrahim et al. (2016)	Africa	Ghana	Pathways to psychiatric care for mental disorders: a retrospective study of patients seeking mental health services at a public psychiatric facility in Ghana
Salifu Yendork et al. (2016)	Africa	Ghana	“It’s only ‘madness’ that I know”: analysis of how mental illness is conceptualised by congregants of selected Charismatic churches in Ghana
Osafo (2016)	Africa	Ghana	Seeking paths for collaboration between religious leaders and mental health professionals in Ghana
Gloria et al. (2018)	Africa	Ghana	The experiences of providing caregiving for patients with schizophrenia in the Ghanaian context
Dassah et al. (2018)	Africa	Ghana	‘When I don’t have money to buy the drugs, I just manage.’—Exploring the lived experience of persons with physical disabilities in accessing primary health care services in rural Ghana
Gilbert and Dako-Gyeke (2018)	Africa	Ghana	Lack of mental health career interest among Ghanaian social work students: implications for social work education in Ghana
Kpobi and Swartz (2018a)	Africa	Ghana	‘That is how the real mad people behave’: Beliefs about and treatment of mental disorders by traditional medicine-men in Accra, Ghana
Kpobi and Swartz (2018b)	Africa	Ghana	‘The threads in his mind have torn’: conceptualization and treatment of mental disorders by neo-prophetic Christian healers in Accra, Ghana
Kpobi and Swartz (2019a)	Africa	Ghana	Ghanaian traditional and faith healers’ explanatory models of intellectual disability
Kpobi and Swartz (2019b)	Africa	Ghana	Muslim traditional healers in Accra, Ghana
Kpobi et al. (2018)	Africa	Ghana	Ghanaian traditional and faith healers’ explanatory models for epilepsy. Epilepsy & Behavior
Gureje et al. (2019)	Africa	Ghana, Kenya, Liberia, Nigeria, South Africa	Partnership for mental health development in sub-Saharan Africa (PaM-D): a collaborative initiative for research and capacity building
Makanjuola et al. (2016)	Africa	Ghana, Kenya, Nigeria	Explanatory model of psychosis: impact on perception of self-stigma by patients in three sub-saharan African cities
van der Watt et al. (2017)	Africa	Ghana, Khenya, Nigeria	Collaboration between biomedical and complementary and alternative care providers: barriers and pathways
Peacock (2015)	Africa	Kenya	Navigating the Therapeutic Landscape of Rural Africa: An Investigation of Social Capital and Responses to Depression Among Women in Western Kenya
Musyimi et al. (2017a)	Africa	Kenya	Mental health treatment in Kenya: task-sharing challenges and opportunities among informal health providers
Musyimi et al. (2017b)	Africa	Kenya	Prevalence and determinants of depression among patients under the care of traditional health practitioners in a Kenyan setting: policy implications
Musyimi et al. (2017c)	Africa	Kenya	Quality of life of depressed and suicidal patients seeking services from traditional and faith healers in rural Kenya. Health and quality of life outcomes
Mutiso et al. (2018)	Africa	Kenya	Patterns of concordances in mhGAP-IG screening and DSM-IV/ICD10 diagnoses by trained community service providers in Kenya: a pilot cross-sectional study
Herman et al. (2018)	Africa	Liberia	Closing the mental health treatment gap through the collaboration of traditional and Western medicine in Liberia. International journal of culture and mental health
Esan et al. (2019)	Africa	Ghana, Kenya and Nigeria	A survey of traditional and faith healers providing mental health care in three sub-Saharan African countries
Kauye et al. (2015)	Africa	Malawi	Pathway to care for psychiatric patients in a developing country: Malawi
Kaminga et al. (2019)	Africa	Malawi	Association between referral source and duration of untreated psychosis in pathways to care among first episode psychosis patients in Northern Malawi
Bartholomew (2016)	Africa	Namibia	Mental health in Namibia: Connecting discourses on psychological distress, western treatments and traditional healing
Bartholomew (2018)	Africa	Namibia	Beliefs about the treatment of mental illness among the Namibian Aawambo: An exploratory study
Odinka et al. (2015)	Africa	Nigeria	The sociocultural conceptualisations of schizophrenia and patterns of help seeking in south-east Nigeria
Ikwuka et al. (2016)	Africa	Nigeria	Pathways to mental healthcare in south-eastern Nigeria
Osaghae (2020)	Africa	Nigeria	Contemporary study on the role of traditional healers in Nigeria: A narrative inquiry
Hecker et al. (2016)	Africa	Republic of Congo	Pathological spirit possession as a cultural interpretation of trauma-related symptoms. Psychological Trauma: Theory, Research, Practice, and Policy
Schierenbeck et al. (2018)	Africa	Rwanda	Collaboration or renunciation? The role of traditional medicine in mental health care in Rwanda and Eastern Cape Province, South Africa
Labys et al. (2016)	Africa	South Africa	Psychosis and help-seeking behavior in rural KwaZulu Natal: unearthing local insights
Audet et al. (2017)	Africa	South Africa	Mixed methods inquiry into traditional healers’ treatment of mental, neurological and substance abuse disorders in rural South Africa
Bantjes and Swartz (2017)	Africa	South Africa	The cultural turn in critical suicidology: What can we claim and what do we know?
Bantjes et al. (2018)	Africa	South Africa	“Our lifestyle is a mix-match”: Traditional healers talk about suicide and suicide prevention in South Africa
Omer and Mufaddel (2018)	Africa	Sudan	Attitudes of patients with psychiatric illness toward traditional healing
Bakow and Low (2018)	Africa	Sudan	A South African experience: Cultural determinants of ukuthwasa
2018	Africa	Tanzania	“Witchdoctors” in White Coats: Politics and Healing Knowledge in Tanzania. Medical Anthropology
Knettel et al. (2018)	Africa	Tanzania	Mental health diagnostic frameworks, imputed causes of mental illness, and alternative treatments in Northern Tanzania: Exploring mental health providers’ perspectives
Schultz and Weisæth (2015)	Africa	Uganda	The power of rituals in dealing with traumatic stress symptoms: cleansing rituals for former child soldiers in Northern Uganda
Johnson et al. (2017)	Africa	Uganda	Views on depression from traditional healing and psychiatry clinics in Uganda: Perspectives from patients and their providers
Abbo et al. (2019)	Africa	Uganda	A narrative analysis of the link between modern medicine and traditional medicine in Africa: a case of mental health in Uganda
Verginer and Juen (2019)	Africa	Uganda	Spiritual Explanatory Models of Mental Illness in West Nile, Uganda
Tol et al. (2018)	Africa	Uganda	Maternal mental health priorities, help-seeking behaviors, and resources in post-conflict settings: a qualitative study in eastern Uganda
Kpanake (2015)	Africa	West Africa	Counseling and Psychotherapy in West Africa: Mazabalo’s Story
Adekson (2016)	Africa	Yoruba	Similarities and Differences Between Yoruba Traditional Healers (YTH) and Native American and Canadian Healers (NACH)
Solera-Deuchar et al. (2020)	Africa	Zanzibar	Establishing views of traditional healers and biomedical practitioners on collaboration in mental health care in Zanzibar: a qualitative pilot study
Kajawu et al. (2016)	Africa	Zimbabwe	What do African traditional medical practitioners do in the treatment of mental disorders in Zimbabwe?
Morgan et al. (2016)	Africa, Asia	India, Nigeria	The incidence of psychoses in diverse settings, INTREPID (2): a feasibility study in India, Nigeria, and Trinidad
Morgan et al. (2015)	Africa, Asia	India, Nigeria	Searching for psychosis: INTREPID (1): systems for detecting untreated and first-episode cases of psychosis in diverse settings
Ægisdóttir et al. (2019)	Africa, Asia	South Africa, Thailand, Turkey	Sociopolitical, cultural, and historical contexts that influence counseling practice in four countries
Nuri et al. (2018)	Asia	Bangladesh	Pathways to care of patients with mental health problems in Bangladesh
Shields et al. (2016)	Asia	India	How can mental health and faith-based practitioners work together? A case study of collaborative mental health in Gujarat, India
Lasrado and Young (2017)	Asia	India	On surviving suicide in South India—exploring support mechanisms from the perspectives of survivors and service providers
Lasrado et al. (2016)	Asia	India	Structuring roles and gender identities within families explaining suicidal behavior in south India
Siddiqui (2016)	Asia	India	Religion and psychoanalysis in India: critical clinical practice
Sood (2016)	Asia	India	The Global Mental Health movement and its impact on traditional healing in India: A case study of the Balaji temple in Rajasthan
Ramakrishnan et al. (2015)	Asia	India, Indonesia	Religious/spiritual characteristics of Indian and Indonesian physicians and their acceptance of spirituality in health care: A cross-cultural comparison
Manchira et al. (2016)	Asia	Indonesia	The association between duration of untreated psychosis in first psychotic episode patients and help seeking behaviors in Jogjakarta, Indonesia
Zarghami et al. (2016)	Asia	Iran	Treatment of Postpartum Mood Disorder in Iran
Razali et al. (2018)	Asia	Malaysia	Complementing the Treatment of a Major Depressive Disorder Patient with Ruqyah Shar ‘iyyah Therapy: A Malaysian Case Study
Shoesmith et al. (2018)	Asia	Malaysia	Reactions to symptoms of mental disorder and help seeking in Sabah, Malaysia
Md. Sa’ad et al. (2017)	Asia	Malaysia	Knowledge and attitude of Malaysia’s Muslim faith healers in dealing with the mentally ill
Abdullah et al. (2016)	Asia	Malaysia	Seeking help at an Islamic spiritual healing centre: Malaysia’s perspective
Pham et al. (2020a)	Asia	Nepal	Satisfaction in the Soul: Common Factors Theory Applied to Traditional Healers in Rural Nepal
Subba et al. (2017)	Asia	Nepal	Improving detection of mental health problems in community settings in Nepal: development and pilot testing of the community informant detection tool
Alosaimi et al. (2015)	Asia	Saudi Arabia	Psychosocial correlates of using faith healing services in Riyadh, Saudi Arabia: a comparative cross-sectional study
Yazici et al. (2016)	Asia	Turkey	The search for traditional religious treatment amongst schizophrenic patients: the current situation
Chowdhury (2016)	Asia	United Arab Emirates	Integration between mental health-care providers and traditional spiritual healers: contextualising Islam in the twenty-first century
Thomas et al. (2015)	Asia	United Arab Emirates	Conceptualising mental health in the United Arab Emirates: The perspective of traditional healers. Mental Health, Religion & Culture
Maricar (2018)	Asia	Singapore	Malay Muslim Healers’ Roles and Experiences in Treating Patients with Mental Health Issues in Singapore

PsycInfo search parameters: 2015–2020, ((country name) AND (traditional healer OR traditional healing) AND (mental illness OR mental health OR mental disorder))

These conclusions about collaboration drew from a variety of case studies, albeit mostly within low- and middle-income countries over the past two decades ago. For example in Africa, two separate case studies included descriptions of a shaman as an autonomous consultant for psychotherapy (Lambo 1974, 1978; Raja and Underhill 2009). In the Andes, yachactaitas (Quichua healers) and biomedically-trained psychiatrists worked together to offer integrated health care services (Bouchard 2009). In Puerto Rico and Brazil, several mental health services collaborated with Espiritismo, a syncretic religio-philosophical healing system (Koss 1980, 1987), to engage in indigenous therapies such as hand-laying and prayer (Lucchetti et al. 2012). In one instance of Espiritismo and mental health, a patient went to the hospital for complex mental health needs, including hallucinations and aggressive behavior. The patient’s symptoms scarcely improved with mental health treatment alone, however the patient reported considerable improvement once the treatment team collaborated with a local spiritist (Moreira-Almeida and Koss-Chioino 2009). Another young woman suffered from seizures and attributed them to a possessive state by her late grandmother. Though the team volunteered several biomedical interpretations, including dissociation and psychological defense, the team achieved significant headway upon aligning with—rather than against—her explanatory framework (2005).

In South Asia, an Indian mental health service crafted a collaborative care plan with faith-based practitioners (Shields et al. 2016). In Israel, a Bedouin man expressed unresolved anger towards his mother, and as a consequence, he believed he had angered a nearby jinn (supernatural creature). Despite the patient’s supposed diagnosis of paranoid schizophrenia, a Bedouin social worker consulted a traditional healer who absolved the man of wrong doing and by extension helped him to find relief (Al-Krenawi and Graham 1997).

While these case studies present telling examples of collaboration, they have also provoked significant criticism. Looking at several of these case-studies (Bouchard 2009; Durie 2009; Koss 1987; Lucchetti et al. 2012), Bedi (2018) has asserted that they, while well-meaning attempts at culturally adapted psychotherapy, ultimately prioritized Western biomedical approaches over the traditional healer’s potentially psychotherapeutic contribution, i.e., the approaches focused on traditional healers referring patients to biomedicine rather than a focus on learning about the intervention processes of traditional healers.

Case studies from the United Kingdom (UK) and the US have also shed negative light on collaboration. Within the UK, traditional healers among ethnic minority groups drew influence from nearby western health practices with varying results. Some UK traditional healers, inspired by conventional psychotherapists who charged without rebuke, began charging themselves and faced criticism for what some considered to be exploitative practices (Dein et al. 2008). Other traditional healers learned to advertise their professional qualifications, e.g., coming from a long lineage of healers, to legitimize their practice. In actuality, these healers lacked knowledge or training commensurate with what they purportedly inherited (Dein et al. 2008). The UK Department of Health (2005), witnessing this overlap between traditional healers and medical providers, claimed that fundamental differences in consent and confidentiality would prove problematic because two systems in collaboration could not operate with two different sets of ethical rules. In the US, Hansen et al. (1992) discussed the case of demonic possession in an 8 years old boy. During the course of the boy’s treatment, Hansen et al. (1992) noted how family systems therapists and psychiatrists operated at variance with each other. With respect to traditional healers then, adding a third party would only further undermine care.

Beyond case-studies, some collaborations have integrated traditional healing practices with modern mental health services across a large scale, albeit with less frequency than case studies and mostly within high-income countries. This suggests growing investment in indigenous healing practices within high-income settings, rather than low- and middle-income settings where the practices are more widely available. For example, across the US, Canada, Arctic States, New Zealand, and Australia, several high-profile projects have proposed and tested various approaches to collaboration under the funding of the US National Institute of Mental Health (NIMH), the US Indian Health Service, the Aboriginal Healing Foundation, and The Canadian Institutes of Health Research Institute of Aboriginal Peoples’ Health (Reading and Nowgesic 2002; Reading 2003; Rhoades 2009; Wright et al. 2015; Joe et al. 2016; Collins et al. 2019).

One approach incorporates techniques and practices from traditional healing in high-income countries. For instance, in New Zealand a small number of Maori health initiatives integrated locally informed beliefs, practices, and staff members during the patient intake process. They included customary ceremonies, spirituality, and families into treatment, employed tribal elders to oversee the cultural milieu, and emphasized relationship-building and cultural identity during the treatment process (Rankin 1986; Durie 2009). Similarly, the American Lake Veterans Affairs Post-Traumatic Stress Disorder Treatment Program incorporated indigenous Native American pow wows, consultations with a tribal leader, and sweat lodges (Scurfield 1995).

Several substance abuse treatment centers have also applied this approach. One from southwest Alaska integrated Eskimo outdoor activities with clinical treatment (Mills 2003); another from Montana offered a cultural immersion survival camp as an alternative to inpatient treatment (Gone and Calf Looking 2011); and a program in Canada helped residents to “find their purpose” as an aboriginal person (Gone 2008, 2009, 2011, p. 196).

In metropolitan Detroit, the American Health & Family Services health center created and tested a standardized 12-week program for participation and socialization around the sweat lodge ceremony (Gone et al. 2017, 2020). Analyses from the program’s development provided reality-based feedback in regards to incorporating traditional rituals within modern contexts. For example, while interviewed stakeholders expressed a generally welcoming attitude, they raised several areas for potential conflict, including the dissonance between indigenous therapies and the realities of urban life, the difficulties in managing multi-, equal-, and trustworthy-tribal representation among traditional healers, and preserving the integrity of traditional healing in the context of a growing market trend to capitalize on alternative medicine therapies (Hartmann and Gone 2012).

Another large-scale approach to collaboration within high-income countries looks to community traditional healers for treatment delivery. For instance, one Hawaiian clinic incorporated native healers to conduct the ho’oponopono ceremony as a means to resolve family conflict (Shook 1985). Other health centers from the San Francisco Bay Area triaged patients for referral to a traditional healer (Saylors and Daliparthy 2004). In a similar fashion to consulting traditional healers, another high-income country approach partnered large organizations with aboriginal groups. For example, the Looking Forward Aboriginal Mental Health Project and RISING SUN (Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks) partnered with aboriginal groups and providers to promote indigenous healing methods and increase mental health treatment capacity (Wright et al. 2015; Collins et al. 2019).

Outside high-income settings, one large-scale initiative took on a different form of collaboration: mutual understanding. This initiative, known as the Partnership for Mental Health Development in Sub-Saharan Africa (PaM-D), brought together traditional healers, primary healthcare workers, and service users across Ghana, Kenya, and Nigeria to discuss psychotherapy from multiple perspectives and to explore the idea of collaborative shared care (CSC) for psychosis (Gureje et al. 2019). Their efforts yielded considerable research output in the form of manuals, large-scale literature reviews, and further studies (Gureje et al. 2015; Makanjuola et al. 2016; Nortje et al. 2016; van der Watt et al. 2017, 2018). However, a focus on sharing and education is not without its criticisms as well. For example, Tanzanian traditional healers expressed distrust with sharing knowledge given years of colonial mistreatment (Kayombo et al. 2007). Another criticism points at the tendency for curricula to focus on “cultural competence,” that is training clinicians to “provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs” (Sue 2001; Betancourt et al. 2002, p. 3). Cultural competence, while well-meaning, can, per Wendt et al. (2012), problematically take an overly process and competency based approach, rely on a checklist of beliefs and behaviors, falsely assume universal specificity within a cultural group, and essentialize cultural influences on health related behaviors.

Overall, if we put aside PaM-D’s exception, the most researched collaborations with traditional healers in mental healthcare come from high-income countries, despite the near ubiquitous involvement of traditional healers is addressing psychological distress in low-and middle-income countries (Gureje et al. 2015; Nortje et al. 2016). Instead, in low- and middle-income countries, biomedicine has rapidly expanded, and a shift away from traditional healers is occurring because of stigmatization from the biomedical community not unlike what has occurred in the US and other high-income countries (Peacock 2015). We now have a unique opportunity in history and public health to study traditional practices from low- and middle-income countries and their effects on mental well-being while they are still widely used. In recognition of traditional healing’s potential to reduce mental health treatment gaps and to offset a larger stigma originally targeted at traditional healing, the 2013–2020 WHO Mental Health Action Plan has recommended for government health programs to include traditional and faith healers as treatment resources (WHO 2013). To this end, we encourage further exploration of the relationships between traditional healing and psychotherapy and the implementation of flexible, collaborative models between traditional healers and biomedicine.

As we embark on the next WHO Mental Health Action Plan, it behooves us to reflect on the lessons-learned thus far. First, cross-cultural systematic reviews suggest we heavily leaned on ethnography and other informal methodologies to navigate the subtleties of traditional healing and culturally relevant mental healthcare (Nortje et al. 2016; Van der Watt et al. 2018). This produced a theoretical richness while leaving traditional healing at the margins of scientific rigor framed as evidence-based practice. However, we are now at a point in methodological and empirical innovation where we can meaningfully revisit the landscapes of traditional healing to understand what healing occurs and how it is happening. Possible approaches range from “analytic ethnography” (Lofland 1995) to N = 1 multiple case series (Snodgrass 2016; Ramaiya et al. 2018) to biocultural studies of healing (Winkelman 2010) to population-based data on traditional healing (Luitel et al. 2017) to using ecological momentary assessment (Maldonado-Bouchard et al. 2015) and new experience-near applications, such as passive mobile sensing (Poudyal et al. 2019), as well as approaches and methods informed by neuroscience (Seligman 2018).

Second, although qualitative findings support the traditional healer’s role in addressing psychological distress throughout high- and low- and middle-income countries, considerable research gaps linger between nations and regions leading to a patchwork with understanding for the global impact. For example, Asia and Africa share a rich history of traditional healing amid scarce mental health resources, and yet our PsycInfo search for the most recent research revealed publications three times less in Asia when compared to Africa.

Third, some collaborations between traditional and biomedical practices evolved in tandem with our understanding of how traditional healing and collaboration works. For instance, Western concepts such as qualification, knowledge, and confidentiality mapped poorly onto traditional frameworks such as lineage, heritage, and transparency (The UK Department of Health 2003; Dein et al. 2008). Well-meaning attempts such as culturally adapted psychotherapy and cultural competence have focused more on the biomedical therapies of conventional psychotherapists rather than the indigenous, “culturally commensurate” therapies offered by indigenous healers (Wendt et al. 2012, p. 13). Furthermore, structural inequalities may prevent low- and middle-income countries from producing the same large-scale collaborations as found within high-income countries. The one exception, PaM-D, suggests that within low- and middle-income countries a more resource-practical approach exists—engendering mutual understanding and informal collaboration between traditional healers and biomedical providers.

We now organize lessons-learned in the form of recommendations for designing, implementing, and evaluating the role of traditional healers and meaningful collaboration between traditional healers and medical providers in addressing the global mental health treatment gap:

1. For funders supporting research in low- and middle-income countries, there is a need to take stock of research gaps in understanding the mechanisms and potential contribution of traditional healing. For example, far more large-scale collaborations take place in high- rather than low- and middle-income countries on traditional healing, despite its widespread practice in the latter settings. More research in Africa and Asia has the potential to inform the importance and role of traditional healing in managing psychological distress and mental illness.

2. For mental health program designers and implementers, before developing a collaborative care project within a local context, create a team which works across the boundaries of culture, medicine, and psychiatry, and review the relationship between the local context’s indigenous healing practices and mental well-being. Reviewing the literature should avoid the bias introduced by exclusively judging evidence based on biomedical criteria (e.g., GRADE recommendations) because the traditional healing landscape and practice are more often described in ethnographic, qualitative, and other social science literature. Concepts such as fidelity, adherence, and manualized care may not easily translate into ways of understanding traditional healing, and this has led to a mix of stigmatization and dismissing traditional healing’s effects on the one hand, and romanticizing and glorifying its effects without justification on the other hand (Krippner and Combs 2002; Castillo 2004; Sidky 2010; Nortje et al. 2016). Community-based participatory approaches may be better suited to designing mental health programs incorporating traditional healing. Collaborative curricula are another approach to working with traditional healers (Pouchly 2012).

3. Despite the inherent biases within qualitative methodologies, purely quantitative approaches can present the illusion of precision and accuracy, reduce the complexity of our social world, and miss out on deeper indigenous meanings (Kirmayer and Ban 2013). Thus, future researchers should integrate the flexibility and richness of qualitative methodologies. Altogether, a mixed methods approach best captures the driving force which has naturally preserved indigenous healing practices, demonstrates if and how traditional healers address the treatment gap in mental health and/or confound pre-existing pathways to biomedical mental healthcare, and validates the traditional healer’s potential psychotherapeutic role within biomedicine.

4. Qualitative theoretical orientations and interview protocols can help researchers impose structure while eliciting illness narratives, explanatory frameworks, and details about the traditional healer’s techniques. Specific schools of qualitative thought, e.g. grounded theory, can add theoretical alignment, analytical precision, and conceptual refinement to ostensibly incompatible methodologies such as ethnography (Timmermans and Tavory 2007). Nevertheless, researchers should remain leery of protocols whose rigidity may confound their own content validity (Groleau et al. 2006; Craig et al. 2010; Creswell 2018).

5. For epidemiological data surrounding traditional healing utilization, the research team should deliver a structured and locally validated survey instrument which at the same time avoids exclusive reliance on conventional medical and psychological terminology (Sorsdahl 2010; Pham et al. 2020b). Similarly, Researchers can use structured rating scales to empirically measure a presenting patient’s possible psychopathology, traditional healing outcomes, and psychotherapeutic factors in common between traditional healing and conventional psychotherapists (Kohrt et al. 2015a, b; Pham et al. 2020b).

6. Once researchers have created a foundational knowledge base, they can then utilize implementation science research methods, e.g., the Consolidated Framework for Implementation Research (CFIR), to study how collaboration succeeds or fails based on programmatic, contextual, provider, and client-level factors (Padek et al. 2015; Powell et al. 2015; Waltz et al. 2015).

7. We also caution against models which delegate traditional healers to function simply as referral agents to other mental health providers or delivery agents of simplified manualized psychotherapies. In doing so, biomedicine would subsume the traditional healer’s role while neglecting efficacious treatments based upon local, culturally congruent causality models which escape the confines of formal counseling, psychotherapeutic techniques, and biomedical principles in general. Instead, collaboration should facilitate traditional healers to safely practice in line with their theories and approaches. Through iterative changes, the collaborative care model can constantly grow and adapt according to shifting needs among patients and providers within culturally diverse treatment models.

Ultimately, understanding the contributions and value of traditional healing to individual, family, and societal well-being and mental health is crucial before these resources are potentially sidelined or lost in the march to reduce the biomedical treatment gap.