Australian and New Zealand Journal of Psychiatry (1976) 10: 39
CONCEPTS OF MENTAL ILLNESS AMONGST THE RURAL XHOSA PEOPLE IN SOUTH AFRICA* by R. W. S. CHEETHAMt and R. J. CHEETHAMS
SYNOPSIS The rural Xhosa people of South Africa have retained social cohesion through traditional custom, purity of language and the dominant role of ancestor worship, traditional medicine and witchcraft in lifestyle, beliefs and ceremonies. Abstract concepts are limited and ego defence mechanisms include projection, displacement and rationalization but cognitive disturbances per se are not regarded as important. Major attention is paid to severe conative and affective disturbances, ascribed to object or spirit intrusion, witchcraft or sorcery, which necessitate treat. ment by a traditional “witchdoctor”. Therapy is community orientated as far as possible unle.cs uncontrollable violent behaviour necessitates referral to a mental hospital. This paper is a sub-section of a study commenced in 1960 by a multi-disciplined, multi-ethnic team amongst the Gcaleka tribe of the Xhosa people, who, originating from central and north east Africa migrated southwards to an area now known as the Transkei. This beautiful region of high mountains, deep valleys, flowing rivers and a scenic coactline, approximates Belgium in size (Mertens 1973). It is populated by about 3 million AmaXhosa, a per-
*Presented at the First Pacific Congress of Psychiatry; Melbourne, May 1975. ?Professor and Head of Department of Psychiatry, University of Natal, South Africa. $Part-time Lecturer and Research Assistant, University of Natal, South Africa.
centage of whom are still rural people living in isolated areas who speak only Xhosa and who continue to retain their centuries-old tribal structure. Thousands of amaXhosa died of starvation in 1856, subFequent to mass slaughter of lung-diseased cattle (the disease attributed to bewitchment by the British settlers) and destruction of grain in a millenary movement initiated by a girl ‘Nongquase’ (Elliot 1972). The latter and a prophet ‘Mhlakaza’, the alleged medium of the mythical but powerful ‘River People’, said to be half fish and half human with great powers of magic, promised power, riches and elimination of the White man provided that this destruction was carried out as directed with the dire warning that the sky would fall on the people should the ‘River People’s’ wishes not be obeyed. The resultant migration and depopulation left the KentaniWillowvale area the only true Xhosa region and the Gcaleka the only tribe of all the clans which has retained the purity of language, culture and social structure which has been in existence for over 300 years. This tragedy, however, serves to illustrate the significance and intrinsic belief of the rurol Xhosa in superstition, magic and witchcraft. Social Gtmeture of the AmaXbosa.
The basis of social organisation is that of the patrilineal clan (Soga 1931), with the extended family kinship system and a fixed social structure, resistant to any change in strongly held beliefs, convictions and patterns of behaviour, which have maintained individual and social homeostasis through the years. Cardinal to their existence and to social integration, is strict adherence to ancestor worship and strongly
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held allied beliefs, convictions and patterns of behaviour. Social cohesion is maintained through systematised ritual, ceremony and observation of taboo, which pertain mainly to women but also to men and children (Soga 1931). Medicine is the focal point around which all life events, especially illness and disaster, economy and subsistence devolve, ‘igqira’, erroneously called a ‘witchdoctor’ by Whites, the final arbiter and decision maker in these respects except for legal matters which are the responsibility of the Chief or Headman and his councillors. It is important to mention here that the ‘igqira’ is essentially a diagnostician and therapist and the true ‘igqira’ dedicated to the profession of healing and well-being. The ‘ixhwela’, on the other hand, is the ‘herbalist’, a brewer of potions and frequently involved in sorcery. Magic, witchcraft and sorcery in these pre-literate people is closely interwoven into the pattern of living and includes the belief in spirit and object intrusion in the form of the “familiars” such as ‘ichanti‘ or ‘mamlambo’, the Mother of the River who is capable of changing shape but is usually a woman of great beauty, ‘impundulu’, a bird without bowels mainly used by women for purposes of bewitchment, ‘inyoka’, a snake of two types, charmed and evil, used in bewitchment, and ‘tickoloshe’, a short, hairy, powerful, mischievous male river sprite capable of walking invisibly through walls and particularly noted for the size of his penis (Laubscher 1951 and Soga 1931). Magical powers are ascribed to all familiars who appear to be involved in situations specific to themselves, for example, ‘ichanti’ and ‘mamlambo’ are usually involved in hallucinatory processes while ‘impundulu’ is associated with persecutory delusions. This animistic or anthropomorphic attitude, with specific reference to “mental illness”, inevitably ascribed to exogenous causes and sorcery, evil spirits, or familiars, being blamed, provides a material explanation to the rural Xhosa for abnormal behaviour, and action, which otherwise could not be ‘logically’ understood. The ego defence mechanisms to handle anxiety would appear to be those of projection, displacement, symbolization and rationalization which account for the tendency towards paranoidal reactions. They serve a purpose, however, in maintaining social cohesiveness. This principle is intrinsic to a number of pre-literate societies in different areas in the world, although the precise mechanisms vary according to the value system of the specific tribe or clan. ‘Where limited cognitive skills do not suffice recourse is made to the supernatural’ (Lidz, 1973). Remarkable skills in legalistic argument and remembering extended kinship systems exist; in general, however, although the rural Xhosa is hospitable and helpful in times of need he tends to lack drive, initiative and tidiness but is cautious, conservative and lacking in subtlety. At the first meeting he is generally not an emotionally expressive person, but they are usually more expansive amongst them-
selves and on closer acquaintance. As is to be anticipated they are extremely suspicious, especially of change or the introduction of anything which will disrupt the “natural order of things” (Khoti 1960). Theirs is a stereotyped form of life for little individuality exists in their similarity of dress, activities and mode of living without thinking about or questioning the accepted social organisation or directions of Headman or ‘igqira’. The rural Xhosa known as ‘Reds’ or ‘Red Blankets’ by virtue of their red ochre-dyed outer blankets are a colourful people, the women on ceremonial occasions being ornately dressed in several garments and young girls frequently garlanded with beadwork. Each family lives in a collection of huts which surround the cattle kraal, the sacred place for the propitiation of sacrifices to the ancestors. As an example of the animistic Xhosa concept, during such a sacrifice, it is necessary for the slaughtered beast to bellow loudly in order to call the attention of the ancestors to the sacrifice. Method of Study A set of questions previously prepared on the basis of literature pertaining to the AmaXhosa initially were used but, as shown in Cawte (1972) and Kiloh’s (1975) studies, structured data cannot be employed as questions have to be modified constantly according to unexpected answers and circumstances. It was frequently necessary to discuss examples of known psychiatric syndromes in order t o illustrate a question, and, even more important, was the use of idiom which abounds in the descriptive Xhosa language or to use descriptive phrases such as ‘ukupambene’ which means “the mind (or senses) has been removed” i.e. literally taken away by familiars or other means, or, “his heart is very sore” to express depression, a word unknown to them. Individuals were interviewed singly or in groups, but as the Xhosa custom is group-counselling by the Chief, Headman or ‘igqira’, almost invariably the interviewee, in the fields, in the neighbourhood of his or her hut, or trading store, or at the sea, was joined by groups of others, all of whom participated. In this manner it was possible to elicit information from a large group. The study also included interviews from other sources but this paper is confined to information gathered only from the rural Xhosa people. Concepts of Mind Difficult as it is to obtain an acceptable definition of ‘mind’ from psychiatrists generally, it is even more difficult to elicit a concept from the pre-literate ‘Red’. Examples of their concepts are as follows: “The soul lives in the blood and the heart”, the latter and other internal organs known as ‘umbilini’, being regarded as the seat of feeling; however, “blood is vital and more important than the brain”. They accepted that the brain might be the seat of the mind “but mind is rhe person’s health and his actions”. This phrase is highly significant for it forms their frame of reference, and, equally significant: “Blood is more important because you cannot have a mind
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when there is no blood, but you can have no mind and still have blood and be alive”.
(b) “those whose brains are later affected after the falling sickness”, and,
This concept of mind as the “initiator of action and required for health”, is important to the AmaXhosa for the mind, therefore, can be removed in a material sense, ‘ukupambene’, and it is this physical removal, or “being affected by bad blood” which differs from most “sophisticated” concepts of psychological disturbances which include cognitive, affective and conative processes. Abnormal psychotic behaviour, which would be regarded in the White as indicative of mental illness constitutes the same threat to the AmaXhosa as it does to the White but a major difference exists in that it is not seen in the same context as a “mental illness”. Furthermore in European society all three components, particularly a disturbance of cognition, are important whereas to the ‘Red’ it is mainly abnormal behaviour and, to an extent. abnormal emotion which constitutes this threat, and generally considered to be caused by outside sources. It would appear therefore, as if ‘insanity’, per se, is not recognized as such or, is a concept gradually being conveyed to them by the White, and to which they refer, but which is not clearly understood.
(c) “those whose brains ‘go’ when very old”.
Conceph 06 Mental Illness The Western observer unconsciously, at least, must tend to be comparative, subjective and open to cnticism in attempting to assess the concepts of mental illness in a culture completely unlike his own. However, as the team included an experienced White Xhosa linguist (W B.C.) and a well educated, medically trained Xhosa man (M.K.), both living and working amongst them this review endeavours to describe the concepts from “within the culture”, undoubtedly utilizing Western frames of reference, but with the recognition and acceptance, as uncritically as is possible, of the vital significance of ancestor worship, witchcraft, ritual, sorcery, spirit and object intrusion, limited cognitive skills and the essential pre-literate anthropomorphic explanation of abnormal or threatening events. The schema to be adopted in this paper is to conform as closely as possible to the relative simplicity of the tribe’s emphasis upon differentiation according to behavioural or conative abnormalities, to major affective or emotional experiences, or a combination of both, Thus these observations will be limited to the recognition of abnormality, the manner in which this presents, the “causes” and appropriate therapy with occasional mention of psychiatric nosology for ease of reference. Reeognilion As far as could be ascertained abnormalities of behaviour are relatively easily recognised but only a limited number of these are regarded as constitutional abnormalities of the brain and mind viz: ( a ) “Those who run around, severely hurt or kill themselves, or who run into the sea and drown”;
All other categories of abnormal behaviour or emotion are attributed to ‘ukuthwasa’ which will be described later, or to exogenous factors which affect “the person’s health and his actions”. Considerable variation in the recognition of the type of disturbance was related to the sex and age of the persons interviewed; the younger age group were more aware of florid psychotic behaviour, the older people, especially the women, appreciative of both, including situations in which, “the heart being very sore”, certain behavioural changes occurred. Differences in the degree of presenting symptomatology also existed, for example, a severe emotional disturbance and frequently a pre-psychotic or psychotic and mediumistic hallucinatory experience was accepted by the tribe as a single entity whereas to the ‘igqira’ this could fall into the category of severe emotional disturbance or a psychotic experience. Nevertheless, it provided a means of description for everyone. Similarly a syndrome ‘isifo esimhlophe’ or ‘the white disease’ which will be described later is generally accepted to be indicative of the person “being called to be an ‘igqira’ ”. The ‘igqira’, however, recognises additional categories of abnormal behaviour which are attributable to “the brain being removed by the ‘familiars’ ”, or “because of bad blood and getting out of gear with the whole body”; “where hair has been removed from the person and hidden in the river by the person bewitching that person” or “disappearance of the mind as a result of jerkings in the case of falling sickness”. These differences in recognition by the ‘igqira’ may be significant in terms of their later explanation, therapy and prognosis. Mental retardation is recognised in the term ‘azililanga’ - unlike the cockerel at sunrise, “he has not crowed”, or by the phrase ‘ingquonda infutshala’, ‘the brain is short’. A sacrifice is undertaken but if unsuccessful the subnormality accepted as such and not regarded as a mental abnormality. If the retardation is not too severe circumcision is undertaken, in due course, and the father even provides cattle for ‘lobola’ (bride price) at a later stage. It is important to note here that the only tribe t o practice the rite of circumcision of their ‘amakweta’ (adolescents) is “essentially an ‘Abe-Nguni’ (Xhosa)” (Soga 1931). SYMPTOMATOLOGY Conetive and Affective Abnormalities In general the rural Xhosa divided abnormalities of behaviour and affect into three main categories according to the presenting symptoms t o which a possible specific Western orientated diagnosis could be postulated. In preference to this, however, and in order to illustrate abnormal behaviour as perceived
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by the ‘Red’ the following are verbatim reports taken from group accounts of the “illnesses”. 1 . “He is the one who runs about, throws his clothes away, eats very little, one may eat too much; he does not sleep, or just for a while and then wakes up. One is very fond of thrashing other people and in this one his actions and his language and what he says does not meet with anybody. In some instances these are people who may d o one thing suddenly and after that he sits quietly and is very inactive at his work, he might also shout and swear and talk nonsense, or there is another who is like that because there is nothing he can feel deeply, he feels like a child and you cannot be able to say whether the person has got any ‘mood’ because his mind is dead. He places the fault on other people but the fault is with him because he ‘bought a familiar’. Or there are others who soil themselves and may rush around”. These symptoms conceivably fall into the categories of mania, schizophrenia, epileptic confusional or acute brain syndromes. It was difficult to determine whether schizophrenia, as a separate syndrome, was recognised by virtue of the characteristic inertia, untidiness and limited ambition of the rural Xhosa (Khoti 1960) and as cognitive abnormalities play a relatively minor role in their assessment. Incongruity of affect, however, had been observed but could “not be caught” (understood). 2. “There are those who did not run and do not eat. This particular one does not behave like before and has to be. urged to do some work, she does not work only because she is lazy because ever since she was born she was not like that. She may cry because her heart is very sore and she may become very thin. Because she is married she should behave as she did before but it is possible that her mind has been removed”.
This, conceivably, could be a unipolar manifestation of a manic depressive illness, an involutional melancholia or even a catatonic state but it is singularly noticeable that little reference is made to any cognitive disabilities. 3. The third category is that of ‘isifo esimhlophe’ referred to originally as an indication that the person was being “called” to be an ‘igqira’. This syndrome appears to be heralded in by ‘mbilini’ which are sensations of palpitation, throbbing, discomfort or subjective feelings of pain in the epigastric region (similar to autonomic nervous system overaction). ‘Mbilini’ is associated with increased sensitivity and emotional instability related to increased excitement or depression. This emotional state, usually accompanied by abnormal behaviour, sometimes in a state of clear consciousness, is generally known to the ‘Red’ as ‘ukuthwasa’. It is often accompanied by psychotic behaviour and, in the “natural” ‘ukuthwasa’, invariably with hallucinatory experiences which inevitably involve the ancestors as the ‘igqira’ must have the guidance of the accompanying ancestral spirit for the rest of his or her life to assist in their
mediumistic powers. The other type of ‘ukuthwasa’, regarded as due to bewitchment, often consists of ‘mbilini’ with psychotic behaviour but without hallucinatory experiences. These variations are probably recognised by the ‘amagqira’ for although all ‘amagqira’ allegedly have been subjected t o ‘mbilini‘ and “natural” ‘ukuthwasa’ in all the ‘igqira’ interviewed during this study little evidence of psychotic thinking or behaviour was observed in these intelligent, highly perceptive individuals. As also observed by Laubscher (1951) it is likely that the ‘mbilini’ and ‘ukuthwasa’ in their instance varied in intensity and degree and was probably some highly emotionally disturbing, but not psychotic state. On the other hand, they may conceivably fall into the category of spirit possession described by Yap (1969). One very helpful, informative ‘igqiri’ (“S”) stated that she experienced ‘mbilini’ at the age of 18, and on close questioning, it was evident that she had been suffering from a severe depressive episode, possibly endogenous in origin, as she became very fat “after treatment”. On the other hand two novitiates who were interviewed, and obviously under surveillance and treatment, were undoubtedly mildly psychotic. It would be unwise to speculate as to their ultimate success in their profession as both were obviously schizoid. Despite the epidemiological literature that depression is infrequent amongst Africans not only was this often described (and personally observed) but the ‘Reds’ were well aware of the high incidence of the heart being very sore. Suicide, however, is uncommon. the highest incidence occurring in the male between 23-30 and often the result of being scolded or reprimanded (which they find difficulty in tolerating) or in the woman aged about 35 with 4-5 children. It was thought not to be related to any form of mental illness but to worry or to the heart being very sore as in one person, prior to hanging himself, repeatedly saying: “My heart is very, very sore; why am I being tortured like this?”. Another who drowned in the river “had been called by the ‘River People’” and appears t o have been schizophrenic. Nevertheless, although depression is not regarded as a mental illness, and suicide never discussed, those who are obviously depressed are kept under constant surveillance. Cognitive Changes
Obsessions and compulsions were seldom observed, as measured in terms of Western standards of diligence, meticulousness, punctuality, etc. It is our thesis, however, that obsessional attitudes d o exist in many instances but that these can only be determined according to the rural Xhosa value system, in their strict adherence to ritual, custom and taboo and the extreme anxiety which arises when propitiation rites are not observed, although this is frequently suppressed. This appears indicative of super-ego development but directed in a manner foreign to the West which certainly would not accept certain aspects of their behaviour as being super-ego directed.
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R. W. S. CHEETHAM AND R. J. CHEETHAM Illusions and pai ticularly visual and auditory hallucinations are an essential component of the rural Xhosa value system, especially the hypnagogic variety occurring in the twilight state early in the morning, many of which may be dream states, and representative of wish-fulfilment or an expression of unconscious guilt. Auditory and visual hallucinations appear to have “status value” particularly as the content is usually that of an ancestor and related to propitiation or other ceremonies obviously referable to the significance of their beliefs and the previously mentioned essential role of the ancestor in the ‘igqira’s’ activities. When hallucinations are expressed in states of clear consciousness they are accepted as expressed as, for example, paranoid auditory hallucinations which may be regarded as a warning from the ancestors. Even when these are associated with florid psychotic phenomena the behavioural and affective disturbances are of far greater significance as abnormalities in need of therapy. One example given was “we do see people who talk alone to themselves or to others who are not there. These may be talking to the ancestors or it is because they have worries and talk to themselves about it. These we do not take to the ‘igqira’”.
In this brief reference to cognitive disturbances, such as delusional states, it is apparent that mention only is possible of aspects such as circumstantiality, very common to the Xhosa even in normal conversation, perseveration and thought blocking, either as a conscious or unconscious form of denial or due to their particular stage of cognitive development. In keeping with the social system over-valued ideas, ideas of inference and reference, and passivity feelings are common, not necessarily indicative of psychotic thought processes but constructed around their belief patterns and serve as a means of alleviating anxiety. Delusional patterns, both systematised and unsystematised were evident, again as an emotional defence mechanism, and delusions of sin and guilt were described associated mainly with obvious depressive episodes. Of considerable importance and significance to this paper, however, is that, almost invariably, expressed delusions were regarded as exaggerated statements or taken at their “face value” particularly in the absence of florid abnormal behaviour or major affective disturbance and in a state of relatively clear consciousness. For instance, an individual making obviously delusional and extravagant claims to “many, many cattle” (their symbol of wealth) was regarded as an entertainer or liar, whilst nihilistic delusions were considered to be “their own fault for having bought a familiar”. In a mildly delirious patient we heard complaining of “being on fire” the attitude was “let her suffer, she is burning because of her wrong doings”. Another rural woman was punished subsequent to “confessing” to having bewitched and causing the death of three children in the area yet on enquiry it was obvious they had died of gastro-enteritis. Close questioning elicited that she was suffering
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from involutional melancholia and her “confessions” delusional in content. Aetiology Apart from the three “constitutional” types and ‘ukuthwasa’ mentioned earlier, all “mental illness” has an extraneous cause relating to: failure to propitiate the ancestors with the necessary sacrifices or rituals; non-observance of taboos and the consequent ancestral displeasure; bewitchment in which the mind has been removed through a sorcerer who has obtained a potion or evil influence from an ‘ixhwela’; object intrusion-in which removal of the mind has occurred through the actions of one of the familiars such as ‘tickoloshe’ making incisions under the hair line; spirit intrusion - evil spirits sent by sorcerers; bad blood and the foam reaching the brain; excessive worry over matters which “have been kept to himself”. Hereditary aspects were ‘observed’ but obviously not recognised as such in a genetic context. Case histories were given of patients or relatives whose children had suffered similar behavioural or affective abnormalities but, in those described to us, an extraneous factor was inevitably regarded as the cause despite the coincidences. This applies in many instances where individuals are “called” as in one obvious paranoid schizophrenic who was suffering from persecutory delusions and auditory hallucinations (from the ancestors warning him of a plot to kill him). His wife confidentially informed us that “he was being called” as his mother was “just like him” and had been an ‘igqira’. Also “coincidental” were the number of ‘amagqira’ of whom a parent or grandparent had also suffered from ‘isifo esimhlophe’. Methods of Treatment These have been “community orientated” for centuries and immediately an abnormality is observed the patient inevitably taken to the ‘igqira’ who institutes his or her own ritual of ‘telling’ the patient the symptoms of the illness, to the accompaniment of chants and the response ‘siyavuma’ (we agree) from the relatives. The response varies in intensity and the ‘igqira’, being extremely perceptive to the responses of patient and relatives to the direct statements, is able to ascertain which of his comments are accurate or not and to concentrate on those which create the more positive reactions. In the subsequent ritual of passing of the hands over the head, face, neck, thorax, abdomen and extremities, deformities can be determined. Subsequent therapy is highly elaborate with the introduction, inter alia, of emetics or purgatives, or application of ‘muti’ (herbal medicines) to external orifices causing sneezing, coughing, etc., depending upon the ‘igqira’s’ diagnosis and the need or otherwise to expel evi1
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influences or counteract the actions of familiars in many cases. Another method used is t o prick the skin of a patient with a needle attached t o a cow’s horn containing ‘special muti’ possessed of magical powers. Not infrequently an injunction to perform some ritual sacrifice either to request assistance from the ancestors or to placate them for a rite forgotten, or not undertaken, is advised.
syncretic Zionist religious movement described in principle as a combination of a primitive Christian religious belief with baptism by total immersion, and indigenous ancestor worship and belief in witchcraft and sorcery; even their bibles are kept bidden t o prevent a sorcerer removing a page with evil intent.
Should ‘isifo esimhlophe’ be diagnosed the individual is treated with extensive ‘muti’ and ritual treatment is advocated for the state of ‘ukuthwasa’. The patient then spends four t o five years with the ‘igqira’ in treatment and subsequently in training. In severe emotional or psychotic conditions which the ‘igqira’ decides to treat, the patient is constantly under surveillance, treated and then trained; herbs used obviously possess a powerful sedating effect on a number of patients
Social integration, the whole social system related to ancestor worship, ritual and belief has provided security to its members for generations. It is to be anticipated therefore that individuals nurtured in a society such as this which is strongly resistant to change must either be emotionally disturbed or view with grave suspicion circumstances, events or any threat to their accepted value system. Thus doctors, and particularly psychiatrists, attempting to apply Western orientated procedures inevitably must be confronted with the problem of establishing a positive doctor-patient relationship which is so essential especially as they d o not represent the traditional authority figure and furthermore have not “been called” in the accepted cultural manner. From personal experience major difficulties frequently arise in arriving at a satisfactory diagnostic evaluation. Even more problematical and difficult is the institution of effective therapeutic techniques in the treatment of the ever increasing number of rural Africans suffering from an increasing incidence of psychiatric illness and psychosomatic disorder. There is thus. as exemplified by Galdston (1971), not only the urgency but also “clearly and widely” the need for in-depth comprehensive research in these aspects by anthropology and psychiatry. Both disciplines face a challenge in respect of the health of the rural African admitted to general hospitals in the city and a pre-requisite should be the active participation in this research and in these studies by registered African medical practitioners.
Should a patient refuse to undergo the ritual treatment deterioration in symptomatology occurs. The ‘igqira’ on the other hand may state that he or she is unable to treat the patient who is then usually taken to another ‘igqira’ and frequently given the same opinion probably as a severe illness beyond the scope of their own treatment is recognisd. These categories of patients are then referred to the magistrate or European doctor for admission to the nearby mental hospital. In addition uncontrollably violent patients are also referred to the mental hospital but referral to the institution is deferred as far as possible and attempts are invariably made to retain and treat the patient within the community unless the violence is so uncontrolled as to constitute a serious threat to person or property. Even those in a state of mania or catatonic excitement are adroitly restrained with the minimum of local injury by means of soft thongs applied to the wrists and ankles. They are “kept out of sight of sorcerers’’ in the maize fields by day and huts by night and provided with the necessary food and water. The influence of superstition is such, however, that ex-mental hospital patients are regarded with suspicion, as occurs in “developed” societies, but for an entirely different reason.
COMMENTS I t would be interesting to study the psychodynamics and psychopathology involved, suffice to say in this paper that probably the essential ego defence mechanisms appear to be those of repression, regression, rationalization, substitution and particularly by virtue of the social system and belief in witchcraft, sorcery and suspicion, displacement and projection. This observation, however, has more serious connotations. Although the Western psychiatrist may be aware of all these aspects the application of Western analytic or dynamically orientated therapy is virtually impossible by virtue of the fixed, deeply-rooted, ingrained value systems. Even in the townships witchcraft abounds or is replaced by the
CONCLU6ION
Finally, if the observation in this paper that obsessional attitudes do exist amongst the rural Xhosa as determined according to their value system and not assessed through Western standards and frames of reference, this principle must apply to many and diverse cultures, their members hitherto not regarded as being obsessional and is a pointer to the reevaluation of many “primitive” people where projection and paranoidal attitudes exist resultant upon an underlying obsessive compulsive attitude towards ancestor worship, propitiation, ritual and sacrifice.
ACKNOWLEDGEMENTS Sincere appreciation is expressed to the South African Medical Research Council for the interest displayed and the award of a grant to assist in compiling our research results and to the Department of Health for financial assistance to present this paper. In particular our deep gratitude to the late Mr. W. B. Caley, Mr. M. Khoti and Miss C. Goosen for their invaluable teamwork, interpretation and contribution to this study.
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REFERENCES Broster, J. A. (1967). Red Blanket Valley. H . Kearttand, Johannesburg. Cawte, J. A. (1972). Cruel, Poor and Brutal Nations. Honolulu University Press, Hawaii. Cheetham, R. W. S., Sibisi, H., and Cheetham, R. J. ( 1974). Psychiatric problems encountered in urban Zulu adolescents with specific reference to changes in sex education. Australian and New Zealand Journal of Psychiotry, 8: 41. Elliot, A, (1972). The Magic World of the Xhosa. Collins, London. Galdston, I. ( 197 1 ). The Interface Between Psychiafry and Anthropelogy. Brunner/Mazel, New York. Graves, G. D., Krupinski, J., Stoller, A., and Harcourt, A. (1971). A survey of community attitudes towards mental illness, part 1. Australian and New Zealand Journal of Psychiatry, 5: 18. Khoti, M. B. (1960). Personal communications.
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Kiloh, L. G. (1975). Psychiatry amongst the Australian Aborigines. British Journal of Psychiatry, 126: 1. Laubscher, B. J. E. (1951). Sex, Custonr and Psychopathology. Routledge and Kegan Paul Ltd., London. Lidz, R. W., Lidz, T., and Burton-Bradley, G. (1973). Culture, personality and social structure: cargo cultism. Journal of Nervous and Mental Diseases, 15% 370. Mertens, A., and Broster, J. A. (1973). African Elegance, Purnell, Cape Town. Soga, J. H. (1931). The Ama-Xhosa: Life and Customs. Lovedale Press, Lovedale, South Africa and Kegan Paul, Trench & Trubner & Co. Ltd., London. Yap, P. (1969). The culture-bound reaction syndromes, in Mental Health Research in Asia and the Pacific. (eds. Candiall, W., and Lin, T. Y.) East-West Centre Press, Honolulu, Hawaii.
Professor R. W. S. Cheetham Department of Psychiatry, Faculty of Medicine University of Natal P.O. Box 17039, Congella 4013 South Africa Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
CONCEPTS OF MENTAL ILLNESS AMONGST THE RURAL XHOSA PEOPLE IN SOUTH AFRICA* by R. W. S. CHEETHAMt and R. J. CHEETHAMS
SYNOPSIS The rural Xhosa people of South Africa have retained social cohesion through traditional custom, purity of language and the dominant role of ancestor worship, traditional medicine and witchcraft in lifestyle, beliefs and ceremonies. Abstract concepts are limited and ego defence mechanisms include projection, displacement and rationalization but cognitive disturbances per se are not regarded as important. Major attention is paid to severe conative and affective disturbances, ascribed to object or spirit intrusion, witchcraft or sorcery, which necessitate treat. ment by a traditional “witchdoctor”. Therapy is community orientated as far as possible unle.cs uncontrollable violent behaviour necessitates referral to a mental hospital. This paper is a sub-section of a study commenced in 1960 by a multi-disciplined, multi-ethnic team amongst the Gcaleka tribe of the Xhosa people, who, originating from central and north east Africa migrated southwards to an area now known as the Transkei. This beautiful region of high mountains, deep valleys, flowing rivers and a scenic coactline, approximates Belgium in size (Mertens 1973). It is populated by about 3 million AmaXhosa, a per-
*Presented at the First Pacific Congress of Psychiatry; Melbourne, May 1975. ?Professor and Head of Department of Psychiatry, University of Natal, South Africa. $Part-time Lecturer and Research Assistant, University of Natal, South Africa.
centage of whom are still rural people living in isolated areas who speak only Xhosa and who continue to retain their centuries-old tribal structure. Thousands of amaXhosa died of starvation in 1856, subFequent to mass slaughter of lung-diseased cattle (the disease attributed to bewitchment by the British settlers) and destruction of grain in a millenary movement initiated by a girl ‘Nongquase’ (Elliot 1972). The latter and a prophet ‘Mhlakaza’, the alleged medium of the mythical but powerful ‘River People’, said to be half fish and half human with great powers of magic, promised power, riches and elimination of the White man provided that this destruction was carried out as directed with the dire warning that the sky would fall on the people should the ‘River People’s’ wishes not be obeyed. The resultant migration and depopulation left the KentaniWillowvale area the only true Xhosa region and the Gcaleka the only tribe of all the clans which has retained the purity of language, culture and social structure which has been in existence for over 300 years. This tragedy, however, serves to illustrate the significance and intrinsic belief of the rurol Xhosa in superstition, magic and witchcraft. Social Gtmeture of the AmaXbosa.
The basis of social organisation is that of the patrilineal clan (Soga 1931), with the extended family kinship system and a fixed social structure, resistant to any change in strongly held beliefs, convictions and patterns of behaviour, which have maintained individual and social homeostasis through the years. Cardinal to their existence and to social integration, is strict adherence to ancestor worship and strongly
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held allied beliefs, convictions and patterns of behaviour. Social cohesion is maintained through systematised ritual, ceremony and observation of taboo, which pertain mainly to women but also to men and children (Soga 1931). Medicine is the focal point around which all life events, especially illness and disaster, economy and subsistence devolve, ‘igqira’, erroneously called a ‘witchdoctor’ by Whites, the final arbiter and decision maker in these respects except for legal matters which are the responsibility of the Chief or Headman and his councillors. It is important to mention here that the ‘igqira’ is essentially a diagnostician and therapist and the true ‘igqira’ dedicated to the profession of healing and well-being. The ‘ixhwela’, on the other hand, is the ‘herbalist’, a brewer of potions and frequently involved in sorcery. Magic, witchcraft and sorcery in these pre-literate people is closely interwoven into the pattern of living and includes the belief in spirit and object intrusion in the form of the “familiars” such as ‘ichanti‘ or ‘mamlambo’, the Mother of the River who is capable of changing shape but is usually a woman of great beauty, ‘impundulu’, a bird without bowels mainly used by women for purposes of bewitchment, ‘inyoka’, a snake of two types, charmed and evil, used in bewitchment, and ‘tickoloshe’, a short, hairy, powerful, mischievous male river sprite capable of walking invisibly through walls and particularly noted for the size of his penis (Laubscher 1951 and Soga 1931). Magical powers are ascribed to all familiars who appear to be involved in situations specific to themselves, for example, ‘ichanti’ and ‘mamlambo’ are usually involved in hallucinatory processes while ‘impundulu’ is associated with persecutory delusions. This animistic or anthropomorphic attitude, with specific reference to “mental illness”, inevitably ascribed to exogenous causes and sorcery, evil spirits, or familiars, being blamed, provides a material explanation to the rural Xhosa for abnormal behaviour, and action, which otherwise could not be ‘logically’ understood. The ego defence mechanisms to handle anxiety would appear to be those of projection, displacement, symbolization and rationalization which account for the tendency towards paranoidal reactions. They serve a purpose, however, in maintaining social cohesiveness. This principle is intrinsic to a number of pre-literate societies in different areas in the world, although the precise mechanisms vary according to the value system of the specific tribe or clan. ‘Where limited cognitive skills do not suffice recourse is made to the supernatural’ (Lidz, 1973). Remarkable skills in legalistic argument and remembering extended kinship systems exist; in general, however, although the rural Xhosa is hospitable and helpful in times of need he tends to lack drive, initiative and tidiness but is cautious, conservative and lacking in subtlety. At the first meeting he is generally not an emotionally expressive person, but they are usually more expansive amongst them-
selves and on closer acquaintance. As is to be anticipated they are extremely suspicious, especially of change or the introduction of anything which will disrupt the “natural order of things” (Khoti 1960). Theirs is a stereotyped form of life for little individuality exists in their similarity of dress, activities and mode of living without thinking about or questioning the accepted social organisation or directions of Headman or ‘igqira’. The rural Xhosa known as ‘Reds’ or ‘Red Blankets’ by virtue of their red ochre-dyed outer blankets are a colourful people, the women on ceremonial occasions being ornately dressed in several garments and young girls frequently garlanded with beadwork. Each family lives in a collection of huts which surround the cattle kraal, the sacred place for the propitiation of sacrifices to the ancestors. As an example of the animistic Xhosa concept, during such a sacrifice, it is necessary for the slaughtered beast to bellow loudly in order to call the attention of the ancestors to the sacrifice. Method of Study A set of questions previously prepared on the basis of literature pertaining to the AmaXhosa initially were used but, as shown in Cawte (1972) and Kiloh’s (1975) studies, structured data cannot be employed as questions have to be modified constantly according to unexpected answers and circumstances. It was frequently necessary to discuss examples of known psychiatric syndromes in order t o illustrate a question, and, even more important, was the use of idiom which abounds in the descriptive Xhosa language or to use descriptive phrases such as ‘ukupambene’ which means “the mind (or senses) has been removed” i.e. literally taken away by familiars or other means, or, “his heart is very sore” to express depression, a word unknown to them. Individuals were interviewed singly or in groups, but as the Xhosa custom is group-counselling by the Chief, Headman or ‘igqira’, almost invariably the interviewee, in the fields, in the neighbourhood of his or her hut, or trading store, or at the sea, was joined by groups of others, all of whom participated. In this manner it was possible to elicit information from a large group. The study also included interviews from other sources but this paper is confined to information gathered only from the rural Xhosa people. Concepts of Mind Difficult as it is to obtain an acceptable definition of ‘mind’ from psychiatrists generally, it is even more difficult to elicit a concept from the pre-literate ‘Red’. Examples of their concepts are as follows: “The soul lives in the blood and the heart”, the latter and other internal organs known as ‘umbilini’, being regarded as the seat of feeling; however, “blood is vital and more important than the brain”. They accepted that the brain might be the seat of the mind “but mind is rhe person’s health and his actions”. This phrase is highly significant for it forms their frame of reference, and, equally significant: “Blood is more important because you cannot have a mind
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when there is no blood, but you can have no mind and still have blood and be alive”.
(b) “those whose brains are later affected after the falling sickness”, and,
This concept of mind as the “initiator of action and required for health”, is important to the AmaXhosa for the mind, therefore, can be removed in a material sense, ‘ukupambene’, and it is this physical removal, or “being affected by bad blood” which differs from most “sophisticated” concepts of psychological disturbances which include cognitive, affective and conative processes. Abnormal psychotic behaviour, which would be regarded in the White as indicative of mental illness constitutes the same threat to the AmaXhosa as it does to the White but a major difference exists in that it is not seen in the same context as a “mental illness”. Furthermore in European society all three components, particularly a disturbance of cognition, are important whereas to the ‘Red’ it is mainly abnormal behaviour and, to an extent. abnormal emotion which constitutes this threat, and generally considered to be caused by outside sources. It would appear therefore, as if ‘insanity’, per se, is not recognized as such or, is a concept gradually being conveyed to them by the White, and to which they refer, but which is not clearly understood.
(c) “those whose brains ‘go’ when very old”.
Conceph 06 Mental Illness The Western observer unconsciously, at least, must tend to be comparative, subjective and open to cnticism in attempting to assess the concepts of mental illness in a culture completely unlike his own. However, as the team included an experienced White Xhosa linguist (W B.C.) and a well educated, medically trained Xhosa man (M.K.), both living and working amongst them this review endeavours to describe the concepts from “within the culture”, undoubtedly utilizing Western frames of reference, but with the recognition and acceptance, as uncritically as is possible, of the vital significance of ancestor worship, witchcraft, ritual, sorcery, spirit and object intrusion, limited cognitive skills and the essential pre-literate anthropomorphic explanation of abnormal or threatening events. The schema to be adopted in this paper is to conform as closely as possible to the relative simplicity of the tribe’s emphasis upon differentiation according to behavioural or conative abnormalities, to major affective or emotional experiences, or a combination of both, Thus these observations will be limited to the recognition of abnormality, the manner in which this presents, the “causes” and appropriate therapy with occasional mention of psychiatric nosology for ease of reference. Reeognilion As far as could be ascertained abnormalities of behaviour are relatively easily recognised but only a limited number of these are regarded as constitutional abnormalities of the brain and mind viz: ( a ) “Those who run around, severely hurt or kill themselves, or who run into the sea and drown”;
All other categories of abnormal behaviour or emotion are attributed to ‘ukuthwasa’ which will be described later, or to exogenous factors which affect “the person’s health and his actions”. Considerable variation in the recognition of the type of disturbance was related to the sex and age of the persons interviewed; the younger age group were more aware of florid psychotic behaviour, the older people, especially the women, appreciative of both, including situations in which, “the heart being very sore”, certain behavioural changes occurred. Differences in the degree of presenting symptomatology also existed, for example, a severe emotional disturbance and frequently a pre-psychotic or psychotic and mediumistic hallucinatory experience was accepted by the tribe as a single entity whereas to the ‘igqira’ this could fall into the category of severe emotional disturbance or a psychotic experience. Nevertheless, it provided a means of description for everyone. Similarly a syndrome ‘isifo esimhlophe’ or ‘the white disease’ which will be described later is generally accepted to be indicative of the person “being called to be an ‘igqira’ ”. The ‘igqira’, however, recognises additional categories of abnormal behaviour which are attributable to “the brain being removed by the ‘familiars’ ”, or “because of bad blood and getting out of gear with the whole body”; “where hair has been removed from the person and hidden in the river by the person bewitching that person” or “disappearance of the mind as a result of jerkings in the case of falling sickness”. These differences in recognition by the ‘igqira’ may be significant in terms of their later explanation, therapy and prognosis. Mental retardation is recognised in the term ‘azililanga’ - unlike the cockerel at sunrise, “he has not crowed”, or by the phrase ‘ingquonda infutshala’, ‘the brain is short’. A sacrifice is undertaken but if unsuccessful the subnormality accepted as such and not regarded as a mental abnormality. If the retardation is not too severe circumcision is undertaken, in due course, and the father even provides cattle for ‘lobola’ (bride price) at a later stage. It is important to note here that the only tribe t o practice the rite of circumcision of their ‘amakweta’ (adolescents) is “essentially an ‘Abe-Nguni’ (Xhosa)” (Soga 1931). SYMPTOMATOLOGY Conetive and Affective Abnormalities In general the rural Xhosa divided abnormalities of behaviour and affect into three main categories according to the presenting symptoms t o which a possible specific Western orientated diagnosis could be postulated. In preference to this, however, and in order to illustrate abnormal behaviour as perceived
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by the ‘Red’ the following are verbatim reports taken from group accounts of the “illnesses”. 1 . “He is the one who runs about, throws his clothes away, eats very little, one may eat too much; he does not sleep, or just for a while and then wakes up. One is very fond of thrashing other people and in this one his actions and his language and what he says does not meet with anybody. In some instances these are people who may d o one thing suddenly and after that he sits quietly and is very inactive at his work, he might also shout and swear and talk nonsense, or there is another who is like that because there is nothing he can feel deeply, he feels like a child and you cannot be able to say whether the person has got any ‘mood’ because his mind is dead. He places the fault on other people but the fault is with him because he ‘bought a familiar’. Or there are others who soil themselves and may rush around”. These symptoms conceivably fall into the categories of mania, schizophrenia, epileptic confusional or acute brain syndromes. It was difficult to determine whether schizophrenia, as a separate syndrome, was recognised by virtue of the characteristic inertia, untidiness and limited ambition of the rural Xhosa (Khoti 1960) and as cognitive abnormalities play a relatively minor role in their assessment. Incongruity of affect, however, had been observed but could “not be caught” (understood). 2. “There are those who did not run and do not eat. This particular one does not behave like before and has to be. urged to do some work, she does not work only because she is lazy because ever since she was born she was not like that. She may cry because her heart is very sore and she may become very thin. Because she is married she should behave as she did before but it is possible that her mind has been removed”.
This, conceivably, could be a unipolar manifestation of a manic depressive illness, an involutional melancholia or even a catatonic state but it is singularly noticeable that little reference is made to any cognitive disabilities. 3. The third category is that of ‘isifo esimhlophe’ referred to originally as an indication that the person was being “called” to be an ‘igqira’. This syndrome appears to be heralded in by ‘mbilini’ which are sensations of palpitation, throbbing, discomfort or subjective feelings of pain in the epigastric region (similar to autonomic nervous system overaction). ‘Mbilini’ is associated with increased sensitivity and emotional instability related to increased excitement or depression. This emotional state, usually accompanied by abnormal behaviour, sometimes in a state of clear consciousness, is generally known to the ‘Red’ as ‘ukuthwasa’. It is often accompanied by psychotic behaviour and, in the “natural” ‘ukuthwasa’, invariably with hallucinatory experiences which inevitably involve the ancestors as the ‘igqira’ must have the guidance of the accompanying ancestral spirit for the rest of his or her life to assist in their
mediumistic powers. The other type of ‘ukuthwasa’, regarded as due to bewitchment, often consists of ‘mbilini’ with psychotic behaviour but without hallucinatory experiences. These variations are probably recognised by the ‘amagqira’ for although all ‘amagqira’ allegedly have been subjected t o ‘mbilini‘ and “natural” ‘ukuthwasa’ in all the ‘igqira’ interviewed during this study little evidence of psychotic thinking or behaviour was observed in these intelligent, highly perceptive individuals. As also observed by Laubscher (1951) it is likely that the ‘mbilini’ and ‘ukuthwasa’ in their instance varied in intensity and degree and was probably some highly emotionally disturbing, but not psychotic state. On the other hand, they may conceivably fall into the category of spirit possession described by Yap (1969). One very helpful, informative ‘igqiri’ (“S”) stated that she experienced ‘mbilini’ at the age of 18, and on close questioning, it was evident that she had been suffering from a severe depressive episode, possibly endogenous in origin, as she became very fat “after treatment”. On the other hand two novitiates who were interviewed, and obviously under surveillance and treatment, were undoubtedly mildly psychotic. It would be unwise to speculate as to their ultimate success in their profession as both were obviously schizoid. Despite the epidemiological literature that depression is infrequent amongst Africans not only was this often described (and personally observed) but the ‘Reds’ were well aware of the high incidence of the heart being very sore. Suicide, however, is uncommon. the highest incidence occurring in the male between 23-30 and often the result of being scolded or reprimanded (which they find difficulty in tolerating) or in the woman aged about 35 with 4-5 children. It was thought not to be related to any form of mental illness but to worry or to the heart being very sore as in one person, prior to hanging himself, repeatedly saying: “My heart is very, very sore; why am I being tortured like this?”. Another who drowned in the river “had been called by the ‘River People’” and appears t o have been schizophrenic. Nevertheless, although depression is not regarded as a mental illness, and suicide never discussed, those who are obviously depressed are kept under constant surveillance. Cognitive Changes
Obsessions and compulsions were seldom observed, as measured in terms of Western standards of diligence, meticulousness, punctuality, etc. It is our thesis, however, that obsessional attitudes d o exist in many instances but that these can only be determined according to the rural Xhosa value system, in their strict adherence to ritual, custom and taboo and the extreme anxiety which arises when propitiation rites are not observed, although this is frequently suppressed. This appears indicative of super-ego development but directed in a manner foreign to the West which certainly would not accept certain aspects of their behaviour as being super-ego directed.
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R. W. S. CHEETHAM AND R. J. CHEETHAM Illusions and pai ticularly visual and auditory hallucinations are an essential component of the rural Xhosa value system, especially the hypnagogic variety occurring in the twilight state early in the morning, many of which may be dream states, and representative of wish-fulfilment or an expression of unconscious guilt. Auditory and visual hallucinations appear to have “status value” particularly as the content is usually that of an ancestor and related to propitiation or other ceremonies obviously referable to the significance of their beliefs and the previously mentioned essential role of the ancestor in the ‘igqira’s’ activities. When hallucinations are expressed in states of clear consciousness they are accepted as expressed as, for example, paranoid auditory hallucinations which may be regarded as a warning from the ancestors. Even when these are associated with florid psychotic phenomena the behavioural and affective disturbances are of far greater significance as abnormalities in need of therapy. One example given was “we do see people who talk alone to themselves or to others who are not there. These may be talking to the ancestors or it is because they have worries and talk to themselves about it. These we do not take to the ‘igqira’”.
In this brief reference to cognitive disturbances, such as delusional states, it is apparent that mention only is possible of aspects such as circumstantiality, very common to the Xhosa even in normal conversation, perseveration and thought blocking, either as a conscious or unconscious form of denial or due to their particular stage of cognitive development. In keeping with the social system over-valued ideas, ideas of inference and reference, and passivity feelings are common, not necessarily indicative of psychotic thought processes but constructed around their belief patterns and serve as a means of alleviating anxiety. Delusional patterns, both systematised and unsystematised were evident, again as an emotional defence mechanism, and delusions of sin and guilt were described associated mainly with obvious depressive episodes. Of considerable importance and significance to this paper, however, is that, almost invariably, expressed delusions were regarded as exaggerated statements or taken at their “face value” particularly in the absence of florid abnormal behaviour or major affective disturbance and in a state of relatively clear consciousness. For instance, an individual making obviously delusional and extravagant claims to “many, many cattle” (their symbol of wealth) was regarded as an entertainer or liar, whilst nihilistic delusions were considered to be “their own fault for having bought a familiar”. In a mildly delirious patient we heard complaining of “being on fire” the attitude was “let her suffer, she is burning because of her wrong doings”. Another rural woman was punished subsequent to “confessing” to having bewitched and causing the death of three children in the area yet on enquiry it was obvious they had died of gastro-enteritis. Close questioning elicited that she was suffering
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from involutional melancholia and her “confessions” delusional in content. Aetiology Apart from the three “constitutional” types and ‘ukuthwasa’ mentioned earlier, all “mental illness” has an extraneous cause relating to: failure to propitiate the ancestors with the necessary sacrifices or rituals; non-observance of taboos and the consequent ancestral displeasure; bewitchment in which the mind has been removed through a sorcerer who has obtained a potion or evil influence from an ‘ixhwela’; object intrusion-in which removal of the mind has occurred through the actions of one of the familiars such as ‘tickoloshe’ making incisions under the hair line; spirit intrusion - evil spirits sent by sorcerers; bad blood and the foam reaching the brain; excessive worry over matters which “have been kept to himself”. Hereditary aspects were ‘observed’ but obviously not recognised as such in a genetic context. Case histories were given of patients or relatives whose children had suffered similar behavioural or affective abnormalities but, in those described to us, an extraneous factor was inevitably regarded as the cause despite the coincidences. This applies in many instances where individuals are “called” as in one obvious paranoid schizophrenic who was suffering from persecutory delusions and auditory hallucinations (from the ancestors warning him of a plot to kill him). His wife confidentially informed us that “he was being called” as his mother was “just like him” and had been an ‘igqira’. Also “coincidental” were the number of ‘amagqira’ of whom a parent or grandparent had also suffered from ‘isifo esimhlophe’. Methods of Treatment These have been “community orientated” for centuries and immediately an abnormality is observed the patient inevitably taken to the ‘igqira’ who institutes his or her own ritual of ‘telling’ the patient the symptoms of the illness, to the accompaniment of chants and the response ‘siyavuma’ (we agree) from the relatives. The response varies in intensity and the ‘igqira’, being extremely perceptive to the responses of patient and relatives to the direct statements, is able to ascertain which of his comments are accurate or not and to concentrate on those which create the more positive reactions. In the subsequent ritual of passing of the hands over the head, face, neck, thorax, abdomen and extremities, deformities can be determined. Subsequent therapy is highly elaborate with the introduction, inter alia, of emetics or purgatives, or application of ‘muti’ (herbal medicines) to external orifices causing sneezing, coughing, etc., depending upon the ‘igqira’s’ diagnosis and the need or otherwise to expel evi1
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influences or counteract the actions of familiars in many cases. Another method used is t o prick the skin of a patient with a needle attached t o a cow’s horn containing ‘special muti’ possessed of magical powers. Not infrequently an injunction to perform some ritual sacrifice either to request assistance from the ancestors or to placate them for a rite forgotten, or not undertaken, is advised.
syncretic Zionist religious movement described in principle as a combination of a primitive Christian religious belief with baptism by total immersion, and indigenous ancestor worship and belief in witchcraft and sorcery; even their bibles are kept bidden t o prevent a sorcerer removing a page with evil intent.
Should ‘isifo esimhlophe’ be diagnosed the individual is treated with extensive ‘muti’ and ritual treatment is advocated for the state of ‘ukuthwasa’. The patient then spends four t o five years with the ‘igqira’ in treatment and subsequently in training. In severe emotional or psychotic conditions which the ‘igqira’ decides to treat, the patient is constantly under surveillance, treated and then trained; herbs used obviously possess a powerful sedating effect on a number of patients
Social integration, the whole social system related to ancestor worship, ritual and belief has provided security to its members for generations. It is to be anticipated therefore that individuals nurtured in a society such as this which is strongly resistant to change must either be emotionally disturbed or view with grave suspicion circumstances, events or any threat to their accepted value system. Thus doctors, and particularly psychiatrists, attempting to apply Western orientated procedures inevitably must be confronted with the problem of establishing a positive doctor-patient relationship which is so essential especially as they d o not represent the traditional authority figure and furthermore have not “been called” in the accepted cultural manner. From personal experience major difficulties frequently arise in arriving at a satisfactory diagnostic evaluation. Even more problematical and difficult is the institution of effective therapeutic techniques in the treatment of the ever increasing number of rural Africans suffering from an increasing incidence of psychiatric illness and psychosomatic disorder. There is thus. as exemplified by Galdston (1971), not only the urgency but also “clearly and widely” the need for in-depth comprehensive research in these aspects by anthropology and psychiatry. Both disciplines face a challenge in respect of the health of the rural African admitted to general hospitals in the city and a pre-requisite should be the active participation in this research and in these studies by registered African medical practitioners.
Should a patient refuse to undergo the ritual treatment deterioration in symptomatology occurs. The ‘igqira’ on the other hand may state that he or she is unable to treat the patient who is then usually taken to another ‘igqira’ and frequently given the same opinion probably as a severe illness beyond the scope of their own treatment is recognisd. These categories of patients are then referred to the magistrate or European doctor for admission to the nearby mental hospital. In addition uncontrollably violent patients are also referred to the mental hospital but referral to the institution is deferred as far as possible and attempts are invariably made to retain and treat the patient within the community unless the violence is so uncontrolled as to constitute a serious threat to person or property. Even those in a state of mania or catatonic excitement are adroitly restrained with the minimum of local injury by means of soft thongs applied to the wrists and ankles. They are “kept out of sight of sorcerers’’ in the maize fields by day and huts by night and provided with the necessary food and water. The influence of superstition is such, however, that ex-mental hospital patients are regarded with suspicion, as occurs in “developed” societies, but for an entirely different reason.
COMMENTS I t would be interesting to study the psychodynamics and psychopathology involved, suffice to say in this paper that probably the essential ego defence mechanisms appear to be those of repression, regression, rationalization, substitution and particularly by virtue of the social system and belief in witchcraft, sorcery and suspicion, displacement and projection. This observation, however, has more serious connotations. Although the Western psychiatrist may be aware of all these aspects the application of Western analytic or dynamically orientated therapy is virtually impossible by virtue of the fixed, deeply-rooted, ingrained value systems. Even in the townships witchcraft abounds or is replaced by the
CONCLU6ION
Finally, if the observation in this paper that obsessional attitudes do exist amongst the rural Xhosa as determined according to their value system and not assessed through Western standards and frames of reference, this principle must apply to many and diverse cultures, their members hitherto not regarded as being obsessional and is a pointer to the reevaluation of many “primitive” people where projection and paranoidal attitudes exist resultant upon an underlying obsessive compulsive attitude towards ancestor worship, propitiation, ritual and sacrifice.
ACKNOWLEDGEMENTS Sincere appreciation is expressed to the South African Medical Research Council for the interest displayed and the award of a grant to assist in compiling our research results and to the Department of Health for financial assistance to present this paper. In particular our deep gratitude to the late Mr. W. B. Caley, Mr. M. Khoti and Miss C. Goosen for their invaluable teamwork, interpretation and contribution to this study.
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REFERENCES Broster, J. A. (1967). Red Blanket Valley. H . Kearttand, Johannesburg. Cawte, J. A. (1972). Cruel, Poor and Brutal Nations. Honolulu University Press, Hawaii. Cheetham, R. W. S., Sibisi, H., and Cheetham, R. J. ( 1974). Psychiatric problems encountered in urban Zulu adolescents with specific reference to changes in sex education. Australian and New Zealand Journal of Psychiotry, 8: 41. Elliot, A, (1972). The Magic World of the Xhosa. Collins, London. Galdston, I. ( 197 1 ). The Interface Between Psychiafry and Anthropelogy. Brunner/Mazel, New York. Graves, G. D., Krupinski, J., Stoller, A., and Harcourt, A. (1971). A survey of community attitudes towards mental illness, part 1. Australian and New Zealand Journal of Psychiatry, 5: 18. Khoti, M. B. (1960). Personal communications.
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Kiloh, L. G. (1975). Psychiatry amongst the Australian Aborigines. British Journal of Psychiatry, 126: 1. Laubscher, B. J. E. (1951). Sex, Custonr and Psychopathology. Routledge and Kegan Paul Ltd., London. Lidz, R. W., Lidz, T., and Burton-Bradley, G. (1973). Culture, personality and social structure: cargo cultism. Journal of Nervous and Mental Diseases, 15% 370. Mertens, A., and Broster, J. A. (1973). African Elegance, Purnell, Cape Town. Soga, J. H. (1931). The Ama-Xhosa: Life and Customs. Lovedale Press, Lovedale, South Africa and Kegan Paul, Trench & Trubner & Co. Ltd., London. Yap, P. (1969). The culture-bound reaction syndromes, in Mental Health Research in Asia and the Pacific. (eds. Candiall, W., and Lin, T. Y.) East-West Centre Press, Honolulu, Hawaii.
Professor R. W. S. Cheetham Department of Psychiatry, Faculty of Medicine University of Natal P.O. Box 17039, Congella 4013 South Africa Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
