Two main themes arise from the data: 1) Treating mental illness is cultural; and 2) Mistrust hampers collaboration. The theme “Treating mental illness is cultural” presents data on epistemologies of mental illness in children and adolescents; and on interactions between traditional healers and biomedical providers. “Mistrust hampers collaboration” is categorized into two sub-themes: willingness to collaborate and barriers to collaboration.
Treating mental illness – A culturally founded skill
Traditional healers’ narrative on their experiences treating mental illness focused on: explanations for mental suffering in children and adolescents and accounts of their interactions with biomedical health systems. The two issues are closely interlinked. As will be illustrated in this section, different explanations of illness based on different epistemologies resulted in treatment regimes that determined the nature of interaction with the formal health system.
Mixed explanations of mental illness
“What I know is that some of the mental health problems in children and young people is caused by ancestral clan spirits, especially if these spirits want the person initiated into being a traditional healer and the person resists… and not until this person is initiated into traditional healing his mental disorder never heals” – Traditional healer 13, twenty-seven years’ practice
In keeping with traditional healers’ belief in ancestors’ ability to interfere in the lives of the living, ancestral spirits played a major role in explaining mental illness. All traditional healers cited unhappy ancestral spirits as a cause of mental ill-health among children and adolescents. A commonly held view was that ancestral spirits were unhappy because ancient customs and rituals have been abandoned; and that children and adolescents who resisted their destiny to become traditional healers inevitably developed mental illness, which was only curable by initiation into traditional healing.
We also found prevalent perceptions of mental suffering being consequent to conflict between traditional customs and modern ‘born again’ religions, as illustrated by this excerpt “…it happens very much especially to those people who have abandoned issues with traditions and opted for the religion of born again…” This conflict between traditional and modern ‘born again’ religions was considered responsible in particular, for protracted mental ill-health among children and adolescents. Other causes mentioned by all traditional healers were ghosts, spirits and witchcraft, which are sent by enemies and encountered by people who walk outside the house at night, causing them to descend into mental illness. Prosperous families were considered particularly prone to witchcraft from jealous people, leading to mental illness among children.
Traditional healers also ascribed mental ill-health to non-spiritual and non-social causes. All traditional healers implicated substance abuse as a cause of mental illness among adolescents. Substances mentioned were a local potent brew, waragi; narcotic drugs - enjaga; tobacco and aviation fuel, taken singly or in combination. Most also cited high fever and cerebral malaria as a cause of mental disturbances in children. According to them, this category of mental illness was best treated in hospitals and clinics.
A common view was one of unsanitary conditions at birth and early childhood leading to mental illness. The pathway through which such conditions were believed to cause mental disease is through breathing difficulty, as illustrated by this elderly traditional healer with 45 years of practice, “I know that if a baby is born in a dirty environment, or…if a child’s head is not protected from the cold air…that child automatically gets a mental disorder when he grows up…the child’s brain is affected directly…begins by having difficulties in breathing…with time this child gets worse and then one realises that a mental disorder has set in” .
Worms and maggots growing in the child’s brain, were also widely implicated, as explained by the elderly traditional healer: “once a child starts getting difficulty in breathing it means that he has a maggot in his brain…as the child grows the maggot also grows…this can bring about terrible mental disorder.” We found that many of the treatments described by the traditional healers were aimed at expelling these maggots; unless the maggot was expelled, the patient would not get well.
“…usually those who have a maggot in the brain, when it moves, they become very violent … but once the maggot comes out then that person gets completely healed… I remember very well was a 14-year-old girl, who was brought to my place when very violent. So, what I did, I mixed herbs and I poured it through her nose… later she sneezed and two maggots popped out of her nose…” Traditional healer 09, eleven years’ practice.
In summary, three types of explanations for mental illness were found to be part of the epistemology of the traditional healer: Spiritual explanations including ancestors and neo-Pentecostal worship; social explanations including witchcraft and evil-eye, and physical or natural agents like maggots, infections and substance abuse.
No interaction with the formal health system
“…nobody should deceive you that mental illness can be managed by hospitals….” Traditional healer 04, eight years’ practice
Traditional healers’ interaction with clinicians was characterised by views about referral to and from health clinics, and by opinions about the competence of clinical practitioners. We found all traditional healers believed that traditional medicine is the only effective treatment for mental ill-health, due to the spiritual nature of the condition. Several traditional healers cited the inability of clinical providers to expel maggots from patients’ brains.
We found very little experience of referral from health clinics to traditional healers. Two participants reported such referral for mental ill-health, after repeated treatments at the medical clinics had failed to make them better:
“There is one …in the main hospital who one time directed a man with his son to me for management, I hear they had gone to the hospital several times but the boy never got well… I worked on him and he became okay…”- Traditional healer 17, twenty years’ practice.
However, self-referrals were commonly reported, in which patients discharged themselves from health clinics to consult traditional healers.
Although biomedicine was considered limited in approach, addressing only the physical causes of disease, all informants had referred patients to biomedical clinics. The commonly cited reasons for referral were for rehydration, or for blood transfusion. Others referred patients whom they deemed to have biomedical conditions, particularly malaria, which they were not well suited to manage. One older, more experienced traditional healer mentioned that it was his policy to treat a patient thrice only, following which he would refer to medical clinics. However, such referrals were reportedly not well received by clinicians, if it was known that the patient had consulted a traditional healer:
“One time I referred a child to Mbale Hospital after I had smeared herbs on the child. On arrival, the doctors chased the patient away accusing them of being dirty…I always send patients to them for management, but for them they have never done so.” Traditional healer 10, ten years’ practice
Despite great skepticism of the effectiveness of biomedicine on mental illness, some traditional healers integrate biomedical elements into their mental health treatment regime. One example is the traditional healer who professed to routine use of largactil® on violent patients who were brought to him, prior to administering his herbal treatments:
“…I love using it because it really puts a person to sleep…I’m a traditional healer but I have found out that [largactil®] is a very effective drug when it comes to calming down the person with mental health disorders especially when they are violent...” – Traditional healer 02, forty-five years’ practice
The view that clinical practitioners are not competent to manage mental health conditions was unanimous. The reasons cited were that clinical practitioners do not comprehend spiritual matters and are poorly placed to treat conditions with a spiritual origin. It was widely acknowledged that they could manage conditions that arose from malaria and other fevers. To prove this point, many of the traditional healers cited examples of patients who had been repeatedly treated at health clinics but only got better after visiting traditional healers. According to the traditional healers, the remedies provided in clinics are temporary; the only lasting effect was believed to come from traditional healers.
Mistrust hampers collaboration
“I don’t see it happening easily because those doctors despise all our work. They regard it as satanic and dirty” – Traditional healer 09, eleven years’ practice.
Even if nearly all traditional healers expressed willingness to collaborate with clinicians in alleviating mental suffering in children and adolescents, their willingness was conditional on clinicians’ reciprocating this goodwill, which was considered unlikely. All the participants believed that clinical providers are not willing to collaborate with traditional healers as they consider them dirty, unsanitary and of a lower education status:
“You know they regard us as …illiterate and of low class…they regard themselves as people of high class…” – Traditional healer 02, forty-five years’ practice
Different from their views on clinicians, we found the traditional healers unanimous in their conviction that patients would welcome their collaboration with the formal health system. According to the traditional healers, all patients needed was to get well, so it did not matter through which means they received treatment. They also argued that patients would cease to consult them in secrecy once collaboration was implemented.
“I see that they will be happy for the collaboration because they will no longer come to the traditional healers in hiding as they do now. They will consult us openly as they do with the clinics” – Traditional healer 12, ten years’ practice.
We found several perceived barriers to collaboration among the traditional healers. Some of the barriers such as the competence of peers were intrinsic to the traditional healers themselves. Traditional healers viewed their peers who are not ‘specialized’ in mental illness as largely being incompetent for handling CAMH and mental ill-health in general. Advertisement in news media was viewed as a sign of incompetence. It was widely held that competent traditional healers need no advertisement to enhance their reputation; Competence was thought to increase with experience and years of practice.
“What I would like to tell you is that a real traditional healer does not advertise him / herself over the radio or TV, so once you see one doing this, then know that this person is incompetent in his work…you know there is a lot of joblessness in Uganda, so we have so many who call themselves that they are traditional healers, when they are not, they are simply looking money so that they are able to put food on the table.” – Traditional healer 07, thirty-four years’ practice.
Another intrinsic barrier perceived by the traditional healers is their lack of English language knowledge. According to the traditional healers, clinical providers would use English language as a means for excluding the less educated traditional healers
“The barrier I foresee…our counterparts the doctors want always to use English so as to push us away…I see that as a problem” – Traditional healer 07, thirty-four years’ practice.
We found that traditional healers did not trust biomedical practitioners. In addition to the belief that medical providers viewed them negatively, most traditional healers thought that clinicians would extract knowledge from the traditional healers and use it for their own credit.
“Working with them is not easy because they don’t like us at all, we are like co-wives who don’t like each other and share one man…” – Traditional healer 18, fifty years’ practice
“What I see is that the formal health worker will only take our ideas and use them, therefore, this will only benefit them by them getting more money and traditional healers will not benefit at all.” – Traditional healer 13, twenty-seven years’ practice
To eliminate barriers, necessary conditions for collaboration were described. Most of the traditional healers mentioned the government as needing to take a lead in integrating them with formal health systems, without which collaboration wouldn’t be possible. The required government intervention mostly suggested was a law or policy recognising traditional healers and compelling clinicians to collaborate with traditional healers;
“Once government makes a policy for us to be recognized as formal health workers things will just fall in place”- Traditional healer 15, thirty-seven years’ practice
“…If a law is put in place then they will accept.”- Traditional healer 6, fourteen years’ practice
Alongside laws and policies, increased recognition by government, sensitisation of communities, traditional healers and medical providers was cited as a necessary condition for successful collaboration.