Shamanism, Psychosis and Autonomous Imagination

This paper focuses on traditional healers (balian)in Bali, Indonesia, to raise new argumentsconcerning the nature of the initiatory sufferingsreportedly experienced by shamans in many cultures.Our evidence suggests that a) contrary to ourexpectations, an initiatory madness or illness isexperienced by a minority rather than the majority ofbalian, and b) whether or not a balian undergoesinitiatory sufferings seems to be linked to gender andto the methods of healing employed – thus womenhealers who employ trance possession are those mostlikely to report an initiatory madness or illness.This leads to the central argument of the paper: c)the nature of the initiatory sufferings, where they dooccur, can be clearly distinguished on several groundsfrom the onset of mental illness among Balinese, bothemically in terms of cultural understandings, andetically in terms of objective criteria. Finally wediscuss the concept of ``autonomous imagination,'suggesting that the key to becoming a balian is notovercoming an initiatory madness but gaining controlover this special mode of imagery thought. We furthersuggest that Western ideas concerning the self andself healing, the superficial resemblance of theinitiatory sufferings to schizophrenia, and thedramatic nature of the initiatory sufferings when theyoccur, have combined to give a misleading prominenceto the role of an initiatory madness in shamanism.     

Revisiting the Navajo way: lessons for contemporary healing

Given the paradox of the success of modern medical technology and the growing patient dissatisfaction with present-day medicine, critics have called for a reevaluation of contemporary medical practice. This paper offers a phenomenological analysis of traditional Navajo healers and their ceremonies to highlight key aspects of healing. A phenomenological view of medical practice takes into account three key features: the lifeworld, the lived body, and understanding. Because of their closeness to a phenomenological view, traditional Navajo mythology and healing practices offer insight into the healing process. Contemporary physicians can appreciate the phenomenological elements of Navajo healing ceremonies, including the Mountain Chant. Navajo healers help patients make sense of their illnesses and direct their lives accordingly, an outcome available to contemporary practitioners, who are also gifted with the benefits of new technologies. By examining scientific medicine, Navajo healing practices, and phenomenology as complementary disciplines, the authors provide the groundwork for reestablishing a more therapeutic view of health.     

Explanatory Models and Mental Health Treatment: Is Vodou an Obstacle to Psychiatric Treatment in Rural Haiti?

Vodou as an explanatory framework for illness has been considered an impediment to biomedical psychiatric treatment in rural Haiti by some scholars and Haitian professionals. According to this perspective, attribution of mental illness to supernatural possession drives individuals to seek care from houngan-s (Vodou priests) and other folk practitioners, rather than physicians, psychologists, or psychiatrists. This study investigates whether explanatory models of mental illness invoking supernatural causation result in care-seeking from folk practitioners and resistance to biomedical treatment. The study comprised 31 semi-structured interviews with community leaders, traditional healers, religious leaders, and biomedical providers, 10 focus group discussions with community members, community health workers, health promoters, community leaders, and church members; and four in-depth case studies of individuals exhibiting mental illness symptoms conducted in Haiti's Central Plateau. Respondents invoked multiple explanatory models for mental illness and expressed willingness to receive treatment from both traditional and biomedical practitioners. Folk practitioners expressed a desire to collaborate with biomedical providers and often referred patients to hospitals. At the same time, respondents perceived the biomedical system as largely ineffective for treating mental health problems. Explanatory models rooted in Vodou ethnopsychology were not primary barriers to pursuing psychiatric treatment. Rather, structural factors including scarcity of treatment resources and lack of psychiatric training among health practitioners created the greatest impediments to biomedical care for mental health concerns in rural Haiti.     

Urban-rural contrasts in explanatory models and treatment-seeking behaviours for stroke in Tanzania

Stroke is an emerging problem in sub-Saharan Africa, about which little is known since most research to date has been based on retrospective, hospital-based studies. This anthropological work, designed to complement a large community-based project on stroke incidence, focuses on local understandings and treatment-seeking behaviours in urban (Dar-es-Salaam) and rural (Hai) areas of Tanzania. Semi-structured interviews (n=80) were conducted with 20 stroke patients, 20 relatives of stroke patients, ten traditional healers, and 30 other local residents. In contrast to common expectations, and literature that finds witchcraft beliefs to be most common in rural areas, stroke in urban Dar was widely believed to emanate from supernatural causes (demons and witchcraft), while in rural Hai, explanations drew mostly on 'natural' causes (hypertension, fatty foods, stress). These different beliefs and explanatory models fed into treatment-seeking behaviours. The first option in Hai was hospital treatment, while in Dar-es-Salaam, where belief in demons led to hospital avoidance, it was traditional healers. In both sites, multiple treatment options (serially or simultaneously) were the norm. Analysis of patient and carer narratives suggested that causation beliefs outweighed other factors, such as cost and distance, in shaping effective treatment. Three policy implications are drawn. First, as other studies have also shown, it is important to engage with, rather than dismiss, local explanations and interpretations of stroke. Stroke awareness messages need to take into account the geographical and belief systems differences. Developing an understanding of explanatory models that recognizes that local beliefs arise from dynamic processes of social interaction will be critical to designing effective interventions. Second, there is a clear role for multiple healing systems with possibility of cross-reference in the case of a chronic, disabling condition like stroke, since biomedical treatment cannot offer a 'quick fix' while traditional healers can help people come to terms with their condition. Third, issues of communication between health services and their patients are particularly critical.     

Knowledge and practice of traditional healers in oral health in the Bui Division, Cameroon

Background

The extraction of the teeth by traditional healers in Cameroon is an established cultural practice in the central region of the Cameroon. Traditional healers (TH) use herbs and crude un-sterilized instruments and tools for the tooth extraction procedure. The present study investigates the knowledge and practices of traditional healers regarding tooth extraction and the management of its complications.

Methods

A cross sectional design utilizing semi-structured questionnaires was used to collect the data from traditional healers and their patients.

Results

Sixteen traditional healers (TH) were interviewed. All were male and the majority were between 25-35 years old. The most important reason given for the removal of a tooth was "if it has a hole". All reported using herbs to control bleeding and pain after extractions. Only 20% used gloves between patients when extracting a tooth and just over a third (31.3%) gave post-operative instructions. Eighty seven percent managed complications with herbs and 62.5% reported that they would refer their patients to a dentist whenever there are complications. Only a third (31.3%) was familiar with the basic anatomy of a tooth and more than half (56.3%) reported that tooth extractions are the only treatment for dental problems. One hundred and fifty patients were interviewed with a mean age of 29 years. More than two thirds were in the 21-30 year age group and just over half were male. Sixty six percent reported that they visited the TH because it is cheap, 93.3% were satisfied with the treatment they received while 95.3% reported said they never had a problem after an extraction.

Conclusions

Tooth extractions using medicinal plants is well established in Lekie division, Cameroon. Infection control during extraction is not the norm. Traditional healers are willing to co-operate with oral health workers in improving the oral health of their patients. Mutual cooperation, collaboration and integrating TH into primary oral health care services need to be increased.     

Turkish Migrant Women Encountering Health Care in Stockholm: A Qualitative Study of Somatization and Illness Meaning

This paper presents the results from a qualitative study conducted withthe aim of exploring structures of illness meaning among somatizingTurkish-born migrant women (age 31–48) living in a poor and lowstatus suburb of Stockholm in contact with local health care services.Two to three interviews regarding experiences and understanding ofillness were conducted as well as one year, validating follow-upinterviews. Interviews were analysed with a grounded theory approach.Results are presented as the participants' agenda of understanding.Distress was communicated by concrete expressions about the body,emotions, social and life situation. Pain was prominent and oftenlateralised to one side of the body. The use of traditional expressionsof distress ranged from open use to avoidance. Attribution wascharacterised by verbalising links of coherence between health andaspects of life. Psychiatric attribution was rarely accepted or valuedas a tool for recovery, or as helpful in linking bodily symptoms toemotional distress. Three main sources for healing were used: medicalcare in Sweden and in Turkey and traditional treatment. Own capacity toinfluence recovery was mostly regarded as low. Relations to family andthe clinician were regarded as important to recovery. The encounter withlocal health care had brought the participants in contact with apsychological agenda of understanding their illness and new ways ofdealing with illness and healing. Some expressed a feeling of beingmisunderstood whereas some related positive experiences ofre-evaluation. They were all actively trying, but experiencing varyingdegrees of difficulty, to grasp the meaning of the caregiver. Theresults of the study point to the mutual need of exploring meaning inthe clinical encounter to help patients make sense out of differentperspectives of illness and healing. The need for enhanced knowledgeabout this process in a migration context will be discussed.     

Beyond Critique: Rethinking Roles for the Anthropology of Mental Health

The current supremacy of the ‘bio-bio-bio’ model within the discipline of psychiatry has progressively marginalized social science approaches to mental health. This situation begs the question, what role is there for the anthropology of mental health? In this essay, I contend that there are three essential roles for the anthropology of mental health in an era of biological psychiatry. These roles are to (i) provide a meaningful critique of practices, beliefs, and movements within current psychiatry; (ii) illuminate the socio-cultural, clinical, and familial context of suffering and healing regarding emotional distress/mental illness; and (iii) act as a catalyst for positive change regarding healing, services and provisions for people with emotional distress/mental illness. My argument is unified by my contention that a credible anthropology of mental health intending to make a societal contribution should offer no opposition without proposition. In other words, any critique must be counter-balanced by the detailing of solutions and proposals for change. This will ensure that the anthropology of mental health continues to contribute critical knowledge to the understanding of mental suffering, distress, and healing. Such social and cultural approaches are becoming especially important given the widespread disenchantment with an increasingly dominant biological psychiatry.     

Explanatory models of medically unexplained symptoms: a qualitative analysis of the literature

Background Medically unexplained symptoms (MUS) are common in primary health care. Both patients and doctors are burdened with the symptoms that negatively affect patients' quality of life. General practitioners (GPs) often face difficulties when giving patients legitimate and convincing explanations for their symptoms. This explanation is important for reassuring patients and for maintaining a good doctor-patient communication and relationship.Objective To provide an overview of explanatory models for MUS.Study design We performed a systematic search of reviews in PsycINFO and PubMed about explanatory models of MUS. We performed a qualitative analysis of the data according to the principles of constant comparative analysis to identify specific explanatory models.Results We distinguished nine specific explanatory models of MUS in the literature: somatosensory amplification, sensitisation, sensitivity, immune system sensitisation, endocrine dysregulation, signal filter model, illness behaviour model, autonomous nervous system dysfunction and abnormal proprioception. The nine different explanatory models focus on different domains, including somatic causes, perception, illness behaviour and predisposition. We also found one meta-model, which incorporates these four domains: the cognitive behavioural therapy model.Conclusion Although GPs often face difficulties when providing explanations to patients with MUS, there are multiple explanatory models in the scientific literature that may be of use in daily medical practice.     

To see that which cannot be seen: ontological differences and public health policies in Southern Chile

In this article, I explore different visual practices performed by Pehuenche Indigenous healers and state public health professionals in Southern Chile. While non‐Indigenous health workers seek to make ‘traditional’ Pehuenche healing visible within or alongside their own ‘modern’ practices, Pehuenche people are concerned with making visible the evil spirits whose ‘eating’ of persons produces illness. Focusing in particular on different healing practices triggered by the existence of Pehuenche spiritual illnesses that are ‘seen’ by both Indigenous healers and state professionals, this article discusses how different ontologies ground differences between the Indigenous healers and what they ‘see’; as well as how a broader and substantive binary between Pehuenche and non‐Pehuenche realities goes above and beyond these multiplicities. By exploring and discussing the endurance of Pehuenche cosmo‐political relations in a world inhabited by visible and invisible eaters, I hope to create awareness about how a failure to recognize these different realities limits current multicultural policies in Southern Chile, and Indigenous health policies more broadly. At a more theoretical level, the following ethnographic account sheds light on unresolved tensions between the ways ontological difference has been conceptualized within the so‐called ‘ontological turn’ in anthropology and within the field of Science and Technology Studies (STS).     

Measles, Hmong, and Metaphor: Culture Change and Illness Management under Conditions of Immigration

When 19 Hmong families and three healers in St. Paul, Minnesota, were interviewed regarding their understanding of measles and the ways in which they cared for children with the disease, their responses spanned the range between Hmong animistic cosmology and Western theories of disease. The metaphors of growth that were used to describe the disease link language, cosmology, causation, body processes, and illness management practices. This study discusses the themes of cyclical time, disease-causing spirits, the natural/supernatural dichotomy, and agricultural metaphors as applied to disease, as well as the growing adaptation to, use of, and interpretation of Western medicine by these immigrants.     

Gender and Biomedical/Traditional Mental Health Utilization Among the Bedouin-Arabs of the Negev

Twenty Bedouin-Arab non-psychotic subjects in Israel (10 male, 10 female) utilized biomedical and traditional healing mental health care systems. Common patterns of utilization were observed: first to family/friends, then to a general practitioner, next to a traditional healer, and finally to a psychiatrist. Men were more familiar with the biomedical system, and women with the traditional. Women, more than men, made group utilization decisions; men, more than women, saw traditional healers outside their home communities. Gender differences were found in symptomatology and in patient construction of etiology. The biomedical system successfully addressed physical symptoms. The traditional system struck a stronger therapeutic alliance, tended to diagnose more comprehensibly, and was perceived by many patients as being more clinically beneficial. Biomedical practitioners can learn from traditional healers how to read a client's ecological map, incorporate the family/community in treatment, and communicate in the patient's cultural idiom. In their search for models of traditional/biomedical system integration, scholars should turn to patients themselves, who are currently living such integration.     

Circle of healing: traditional storytelling, part three

Southcentral Foundation had to overcome several organizational and procedural hurdles when developing their Circle of Healing program. Among these hurdles was finding a way to credential Alaska Native healers so the Foundation could be reimbursed for their services and pay the healers, and so the healers could work in the hospital along with the staff delivering Western and alternative medical treatment. Southcentral Foundation chose to develop a process for certifying Alaska Native healers as tribal doctors. Rita Blumenstein is the first such person to be certified. Lisa Dolchok is the second. An important strength of Lisa’s presentation is that she helps us broaden our understanding of healing from an Alaska Native perspective. So often we equate healing with curing, and while it can have this dimension, Lisa reminds us there is much more to it. She echoes LouAnn Benson’s presentation in asserting that healing can address illness of the spirit or wounds to the soul.     

Traditional healers in Nigeria: perception of cause, treatment and referral practices for severe malaria

Malaria remains one of the main causes of mortality among young children in sub-Saharan Africa. In Nigeria traditional healers play an important role in health care delivery and the majority of the population depend on them for most of their ailments. The aim of this study was to investigate the perceptions of traditional healers regarding causes, symptoms, treatment of uncomplicated malaria and referral practices for severe malaria with a view to developing appropriate intervention strategies aimed at improving referral practices for severe malaria. A qualitative study was carried out in Ugwogo-Nike, a rural community in south-east Nigeria, which included in-depth interviews with 23 traditional healers. The traditional healers believed that the treatment of severe malaria, especially convulsions, with herbal remedies was very effective. Some traditional healers were familiar with the signs and symptoms of malaria, but malaria was perceived as an environmentally related disease caused by heat from the scorching sun. The majority of traditional healers believed that convulsions are inherited from parents, while a minority attributed them to evil spirits. Most (16/23) will not refer cases to a health facility because they believe in the efficacy of their herbal remedies. The few that did refer did so after several stages of traditional treatment, which resulted in long delays of about two weeks before appropriate treatment was received. The fact that traditional healers are important providers of treatment for severe malaria, especially convulsions, underlines the need to enlist their support in efforts to improve referral practices for severe malaria.     

Commodity Fetichismo The Holy Spirit,and the turn to Pentecostal and African Independent Churches in Central Mozambique

Pentecostal and African Independent Churches have rapidly spread throughout central Mozambique in the aftermath of war and in the midst of a recent structural adjustment program that has hastened commoditization of community life and intensified local inequalities. This extraordinary expansion signals a shift away from reliance on “traditional” healers to treat persistent afflictions believed to have spiritual causes. Survey data and illness narratives collected from recent church recruits and local residents during research in 2002 and 2003 in the city of Chimoio reveal that healers have increased fees and tailored treatments to clients searching for good fortune in ways that have alienated many other help seekers in this changing social environment. While traditional healing has been celebrated in the international health world, community attitudes are less generous; many healers are increasingly viewed with suspicion because of their engagement with malevolent occult forces to foment social conflict, competition, and confrontation for high fees. Church healing approaches offer free and less divisive spiritual protection reinforced by social support in a new collectivity. One vital source of church popularity derives from pastors' efforts to tap the already considerable community anxiety over rising healer fees and their socially divisive treatments in an insecure environment.     

Spirits and spiritist therapy in Southern Brazil: A case study of an innovative,syncretic healing group

This paper examines the treatment of patients by a group of Spiritist healers in southern Brazil. After describing and analyzing a healing session, the practices are shown to be deviant from conventional Spiritism in two directions: (1) they employ a technique, called apometry, that they claim makes possible the transportation of a part of the patient's body to the astral world where it is treated by disincarnate doctors who do past life regressions; and (2) although a conventional Spiritist disobsession is performed, the healers invoke rival Afro-Brazilian spirits who often are shown to have caused the patient's symptoms.Building on the work of Csordas (1983), 1 hypothesize that the discourse employed by the healers moves the patient to a new reality or phenomenological world in which s/he is healed not in the sense of being restored to the state in which s/he existed prior to the onset of illness, but in the sense of being rhetorically moved into a state dissimilar from both pre-illness and illness reality... (Csordas 1983:346). The new state, in this case, is the world of Spiritism. Unlike the Catholic Pentecostals Csordas studied who already were members of a primary group of believers, however, the patients treated by the Brazilian healers are mostly unaffiliated individuals who face the increasing uncertainty and insecurity of life in disorganized, anomic, urban Brazil. By encompassing modern science on the one hand, and aspects of the Afro-Brazilian traditions on the other, this healing group appeals to the often distraught white middle and lower-middle classes, providing them with therapeutic meaning that in many cases leads to healing, conversion, and the sense of security and safety that often accompanies identifying with and belonging to a religious group.     

A new approach to decision making in primary health care

The village health worker has two basic tasks: (1) to prevent health problems; (2) to identify and provide effective management of illness in the village. The village health worker has limited education and the length of basic health training is usually 12 weeks. This training can only be considered appropriate if it enables the village health worker to practise effectively within the cultural, social, economic and educational constraints of the village. How far does the training help this worker to work with other members of the village community to prevent illness? These others include mothers, children, school teachers, village leaders, religious leaders, traditional birth attendants, and traditional healers; training needs to be problem-oriented. The management decisions that have to be made in situations of shortage of resources are complex to analyse. A W.H.O. research project has been undertaken to determine the feasibility of developing and using flow charts to provide alternative and more appropriate methods to help the village health worker to provide optimal management in suboptimal situations. Some examples of these new methods are presented.     

Urban Philippine healers and their contrasting clienteles

This paper is concerned with medical pluralism in a Philippine setting. It reports on results of a study of four indigenous healers and their patients in Cebu City. The city is a modern medical center in the Philippines, with more than 500 practicing physicians. But its indigenous healers also treat numerous patients, and many patients utilize both physicians and healers during the course of an illness. Of the four healers discussed in this paper, two had the largest followings of any healers in the city at the time of the study, the other two had very modest practices. Significant social and medical contrasts between the clienteles of these healers are described in the paper, and the implications of these differences are discussed with respect to decisions people make about their health care in an area with diverse medical resourses.     

Socio-Cultural Determinants of Health-Seeking Behaviour on the Kenyan Coast: A Qualitative Study

Background

Severe childhood illnesses present a major public health challenge for Africa, which is aggravated by a suboptimal response to the child''s health problems with reference to the health-seeking behaviour of the parents or guardians. We examined the health-seeking behaviour of parents at the Kenyan coast because understanding impediments to optimal health-seeking behaviour could greatly contribute to reducing the impact of severe illness on children''s growth and development.

Methods and Results

Health-seeking behaviour, and the factors influencing this behaviour, were examined in two traditional communities. We held in-depth interviews with 53 mothers, fathers and caregivers from two rural clinics at the Kenyan Coast. Biomedical medicine (from health facilities and purchased over the counter) was found to be the most popular first point of treatment. However, traditional healing still plays a salient role in the health care within these two communities. Traditional healers were consulted for various reasons: a) attribution of causation of ill-health to supernatural sources, b) chronic illness (inability of modern medicine to cure the problem) and c) as prevention against possible ill-health. In developing an explanatory model of decision-making, we observed that this was a complex process involving consultation at various levels, with elders, but also between both parents, depending on the perceived nature and chronicity of the illness. However, it was reported that fathers were the ultimate decision makers in relation to decisions concerning where the child would be taken for treatment.

Conclusions

Health systems need to see traditional healing as a complementary system in order to ensure adequate access to health care. Importantly, fathers also need to be addressed in intervention and education programs.     

Mental health services and traditional healing in Indonesia: Are the roles compatible?

This study reports on the presentation of illness complaints by 90 individuals to nine traditional healers in three Indonesian cities. Focus is on the nature of problems, client explanations and expectations, healer treatment and subsequent outcome as judged by clients. Selected clients were observed and interviewed by a psychiatrist and one other health professional, and followed in a subsequent home visit. Complaints were categorized according to dimensions of acuteness and chronicity of problem, presumed self-limited characteristics, and psychological, general medical and other factors. Sixty-five percent of all clients had received prior treatment for the same problem in a biomedical health care setting. The study holds practical implications for policies regarding relations between health and mental health services and traditional healers in Indonesia. The authors wish to acknowledge support from the following institutions; The Institute for Health Research and Development, Ministry of Health, Republic of Indonesia (LITBANGKES) for financial support; The Asia Foundation, Jakarta; The World Health Organization, Southeast Asia Office; The Cultural Learning Institute, East West Center, Honolulu, Hawaii.     

Swimming from island to island: healing practice in Tonga

The health care system of the Pacific island nation of Tonga serves as an example of enduring medical pluralism which incorporates traditional and Western medical practice and accommodates contemporary political and social change. Biomedicine is represented by the hospital and the community health centers; traditional medicine is practiced in homes by healers. Both types of therapies are popularly utilized for different ailments or for the same problem at different points in the illness. Contemporary healing is described and is also analyzed as an expression of social change occurring in Tonga as a result of a political movement toward democracy.