Ethnopsychiatry - A review

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Review Article
Ethnopsychiatry - a review
A. A. Gadit
Department of Psychiatry, Hamdard University Hospital, Karachi.
The subject of ethnopsychiatry deals with the study of mental ill-
nesses in cross-cultural perspective including its definition, classifica-
tion, causality and treatment of mentally ill persons in differing contexts.
This review paper describes the evolution of ethnopsychiatry, explaining
the meanings of normal and abnormal in terms of mental health, the con-
cepts about mental illnesses in various cultures, the socio-cultural influ-
ences, treatment issues and shamanism. The emphasis is on understand-
ing the cross-cultural issues in order to understand the mental illness in
its diverse perspective. It also attempts to examine the possibility of col-
laboration between psychiatrists and shamans in the local context.
Ethnopsychiatry: Background, Definition and Concepts
Ethnopsychiatry is the study of mental illness in a cross- cultural
perspective; including its definitions, classification, causality and treat-
ment of mentally ill persons in different cultural contexts. Other names
used in psychiatric literature for ethnopsychiatry are cross cultural psy-
chiatry or transcultural psychiatry.
Concept of Mental illness in the context of ethnopsychiatry
The new transcultural psychiatry demands special consideration
of indigenous notions of causality and for explanatory models based on
folk beliefs.
In the context of ethnopsychiatry mental health has not been an
easy task to define as there is a disagreement over the boundaries of nor-
mal and abnormal behaviour.
How would one define normal mental health? This question is
apparently very simple but the answer is complex. A diversity of opin-
ions exists across the cultures in the world about the conceptual limita-
tions. It appears that a mentally normal person in one society or culture
may not be considered normal in other setups due to existence of a great
deal of trans-cultural variations across the globe.1If a person speaks and
laughs too much, if one is violent or unduly undermined in behaviour,
resorts to deliberate self-harm, disinhibited and odd in expression and
behaviour and/or very unstable in emotional discharge, he can perhaps
be labeled as "psychic or mentally disturbed" in one socio-cultural sect
while not in other.2Human beings are very complex in nature and for
them it is not possible to maintain a particular mood and expression
throughout twenty-four hours of the day. This is a very important point
especially for evaluation of mental health.
Scientists are still concerned about the definition of normal men-
tal health for the simple reason that mental health is the most vital oper-
ational tool when one is talking about the interpersonal communication,
professional and social life. All the factors that affect health of the body
as well as the mind must have to be taken under consideration when one
is adopting a certain lifestyle and is handling day-to-day situations.3
But so far, every attempt to define mental health has
failed since "there exists no psychologically meaningful and
operationally useful description of what is commonly under-
stood to constitute mental health". Attempts were made by
researchers using different approaches:
One approach simply views mental health as the
absence of mental disorder. This perspective is limited for
two reasons. First, while most would agree that the absence
of psychopathology is a necessary condition for mental
health, one must still define mental illness in order to under-
stand, by contrast, mental health. Secondly, this approach
fails to take into account cross-cultural differences in accept-
able behaviour.
Another definition of mental health holds that correct
perception of reality is the key to mental health. In view of
the cross-cultural variations in social norms, this approach
holds little promise. What is "correct" depends on the way in
which given people perceive the world.
Conversely, the view of the uncommon as pathologi-
cal is even less viable since it logically requires the inclusion
of the great achievements of individuals and people with
high IQs. A third criterion of mental health utilizes the con-
cept of adjustment with the environment, which is generally
taken to mean that a person has established a workable
arrangement between personal needs and social relations.
The absence of such an arrangement is a definite counter-
indication of mental health. After all, a person who is hostile
towards the everyday social environment cannot enjoy men-
tal stability. In this sense the "adjustment" definition is use-
ful in separating some obviously abnormal people from the
rest of the population.4
Absence of mental disorder, correct perception of
reality, adjustment to one's environment, and intrapsychic
equilibrium are theories that most frequently appear in
attempts to delineate mental health or normality.
The ultimate concept that emerges as most acceptable
by this ongoing debate among a number of experts across the
globe, is the one that say "if a person is able to cope and
function normally in a society, meeting the responsibilities
and expressing balanced attitudes towards day-to-day chal-
lenges and problems then he is mentally sound and possess
normal mental health".5
The concept of mental health needs further elabora-
tion when one incorporates ethnopsychiatric concepts which
embed cross cultural and anthropological factors.
JPMA ( Journal Of Pakistan Medical Association) Vol 53 ,No.10,Oct 2003

Mystical Accounts of Illness
Mental illness is explained and understood in a variety of ways.
An interesting example comes from Maharashtra (India). Common to
Maharashtrian popular culture is a set of beliefs regarding illness and
misfortune, that is frequently the result of possession by a spirit or bhut
bhada. Possession by bhut may sometimes give rise to trances, but more
often it results in ill-health or bad luck. Often possessed persons are not
aware of the suffering from bhut bhada until they come into the vicinity
of a healing temple.
Here the power of the God or saint associated with the temple or
shrine is thought to draw out the possessing spirit, thus encouraging
trance.
Possession in Maharashtra is related to karani which is translated
as black magic. It is thought that bhut bhada is usually brought about by
means of karani. In such instances an angered or envious person will
either ask God to send a bhut upon their enemy, or else will request a
mantrik (magician) or devrishi (shaman) to do so. Thus there exists a set
of common beliefs about the spiritual provenance of illness which under-
pin the widespread resort to healing centres. Throughout Maharashtra
many healing temples specialize in the management and cure of spiritu-
al afflictions. The Muslim shrines or dargahs in Bombay and Puna cater
for many thousands a week who present with a wide variety of afflic-
tions. The temple of the Hindu Mahanubhav pant sect also caters for
spiritual afflictions, in particular, those which give rise to mental illness-
es. The Mahanubhav sect arose in the thirteenth century, forming part of
a wider movement of that time which emphasized bhakti or devotion.
Despite doctrinal differences, however, the Mahanubhav temples
are frequently visited by all Hindus in times of trouble and at the major
Mahanubhav festivals. Apart from similar beliefs, the temple users have
in common poverty and illiteracy rather than sect affiliation.
Cross-Cultural differences and Culture Bound Syndromes
Every culture must deal with mental illness to guarantee its sta-
bility. However, it is important to recognize that standards of mental ill-
nesses are relative because the social context in which a particular
behaviour occurs affects whether it is adjudged normal or abnormal.
Depending upon the situation, the same behaviour may be considered as
mental disorder, declared criminal, or even socially acceptable. For
example, an adolescent who sets fire may seek psychiatric help, be
labeled mentally ill, and receive psychotherapy. The same individual
may have encountered the legal authorities, be labeled a juvenile delin-
quent, and be jailed. Moreover, behaviour which is usually considered
abnormal may be accepted and even admired under certain circum-
stances.
Examples of this are hallucinatory behaviour in a LSD session, or
the production of unintelligible speech in a church in which "speaking in
tongues" is common. Such practices as not wearing clothes, handling
poisonous snakes, and even suicide are often positively sanctioned and
honoured by members of certain groups. The seventeenth century reli-
gious leaders who had witches and heretics burned at the stake were con-
sidered as respectable members of the community, but today they would
be committed to an institution.
Beyond these differences in acceptable behaviour among
groups in the same society, comparisons between Western and non-
western societies demonstrate more striking differences. In Malaya,
a syndrome known as running amok occurs in people who turn wild
with little or no warning and for no apparent reason. The amok run-
ner usually kills several animals or people before being killed by
others. In addition, latah6is a Malay condition involving compul-
sive obscenity. It is precipitated by sudden fright.
Imu7is an illness found mainly among the older women of
the Ainu of Japan. It is frequently triggered by a sudden stimulus
such as loud noises or fearful objects including snakes, caterpillars,
and snails. Wild, aggressive behaviour results, followed by running
away in panic. There is occasional loss of consciousness and the
person often experiences considerable embarrassment upon recov-
ery. Among the Bena people of the Eastern Highlands of New
Guinea, men are affected by day-long episodes during which they
become deaf and aggressive towards clansmen, including their
wives and children. They run about randomly in circles and with
clubs and arrows in threatening gestures. Speaking is rare during
these attacks. The episodes are quickly forgotten and there is no
social censure. The Bena believe that the attacks are the work of
malevolent ghosts who are the objects of intense fear.
Piblokto8, sometimes called Arctic hysteria, occurs among
the Polar Eskimos of the Thule district of northern Greenland. This
illness follows a classic four-stage sequence. In the first stage, the
victim is irritable and socially withdrawn. The onset of the second
stage is sudden, the victim becomes wildly excited and may tear off
clothing, break furniture, attempt to walk on ceilings, shout
obscenely, throw objects, eat faeces, or perform other irrational acts
such as plunging into snowdrifts or jumping off icebergs. This
excitement is followed by a third stage characterized by convulsive
seizures, collapse, and stupors sleep or coma, lasting for up to
twelve hours. In the final stage, the victim behaves perfectly nor-
mally and has amnesia regarding the experience.
The windigo9psychosis, also known as the whitiko psy-
chosis, occurs among the Ojibwa Indians of the Northeastern
United States and Canada. Victims who suffer from this belief are
possessed by the spirit of the whitiko monster. Symptoms involve
depression, a state of food nausea, and periods of semi-stupor. They
become obsessed with the idea of being possessed by the spirit and
are subject to homicidal and/or suicidal thoughts. They perceive
those around them as fat, appetizing animals which they wish to eat.
They finally reach a stage of homicidal cannibalism and are usual-
ly killed since the Ojibwa believe that the craving for human flesh
will never leave once it has been fulfilled.
There is also a peculiar group of disordered reactions to
minor stress which have been reported in Puerto Rico. The behav-
iour includes outbursts of verbal and physical hostility, regression to
infantile behaviour, forgetfulness, and loss of interest in personal
appearance.
There are numerous such syndromes which occupy a large

which occupy a large chunk of ethnopsychiatric litera-
ture. These disorders need proper placement in the western clas-
sification system.
Shamans and Other Curers
In the context of ethnopsychiatry, for treatment of men-
tal illnesses, a number of curers were identified. The types of
curers found in a particular society, and the curing acts in which
they engage, stem logically from the aetiologies that are recog-
nized. Personalistic systems, with multiple levels of causation,
logically require curers with supernatural and/or magical skills,
because the primary concern of the patient and his family is not
the immediate cause of illness, but rather "Who?" and "Why?"
In Mali, the people in the tribe want to know why they
are ill and not how they got ill". And in the Indian villages stud-
ied by Dube, the Brahmin or a local peer aims at finding out
what ancestral spirit is angry, and why?
The shaman, with his supernatural powers, and direct
contact with the spirit world, and the "witch doctor", with his
magical powers, both of whom are primarily concerned with
finding out whom, and why, are the logical responses in person-
alistic, multiple causality, aetiological systems. After the who
and why have been determined, treatment for the immediate
cause may be administered by the same person, or the task my
be turned over to a lesser curer, perhaps a herbalist.10
Thus, among the Nyima of the Kordofan mountains in
Sudan, the shaman goes into a trance and discovers the cause
and cure of the disease. But he himself performs no therapeutic
act; this is the field of other healing experts, to whom the patient
will be referred. Naturalistic aetiological systems, with single
level of causation, logically require a very different type of
curer, a "doctor" in the full sense of the word, a specialist in
symptomatic treatment who knows the appropriate herbs, food
restrictions, and other forms of treatment such as cupping, mas-
sage, poultices, enemas, and the like. The curandero or the
Ayurvedic specialist is not primarily concerned with the who or
why.
Traditional Healing
Apart from using herbs, some healers understand the
importance of rehabilitation for psychiatric patients. The
Kenyan healer interviewed by a researcher11 stated that in most
cases the patients worked for him:
"After a week some recover; then I do not let them stay
idle. They cultivate, fetch water, I send them to the market and
to the flour mill, and they cut grass in the compound".They
carry out these jobs until they are discharged home. He is
reported as being quite careful in the way he allocates jobs to
his patients, and he would not send a patient to cultivate or to
the market unless he was sure the patient was well enough for
these tasks.
A similar account is given by another researcher12 of a
a traditional healer in Nigeria. He found that acutely excited patients
were restrained by the use of chains, but these were used on individual
patients for no more than two weeks. By the end of this period, their excite-
ment was usually controlled by herbal preparations, including rauwolfia ser-
pentina. During the whole period of treatment, attention was paid to the
patients' psychological needs, and as they recovered they were progressive-
ly involved in increasing amounts of work in and around the healer's com-
pound. This study demonstrates the eclecticism of some traditional healers,
who initiate integrated program of pharmacological, psychological, and
social treatments, an approach which is widely acknowledged to character-
ize the Western psychiatry.
The humoral disease theory of the Greeks may have developed from
the Ayurvedic concepts. In the mental sphere, it is believed that excessive
heat can cause excitement; excessive cold can lead to depression and exces-
sive bile to hostility.
A healing method currently used in the West which has an affinity to
these techniques, is the laying on of hands. This was used by the kings of
England and France throughout the fourteenth to seventeenth centuries to
treat scrophula, a tuberculous infection of the skin, which was consequently
known as the King's Evil. The healing power of the king's touch was
believed to stem from his divinity, and as monarchs became regarded as
increasingly human, this practice waned.
The spiritualist healer is believed to be an instrument of the healing
act of a spirit, frequently of a deceased doctor. The healer usually becomes
aware of possession by a tingling sensation in his finger tips. When this
occurs the healer places his hands on that part of the patient's body to which
he is guided by the spirit. Hence, there is a diagnostic as well as a therapeu-
tic skill being exercised. The patient feels an intense heat emanating from the
healer's hands and penetrating his body. The healer usually strokes the
patient's body, and sometimes shakes hands after each stroke, symbolically
discarding the sickness that has been drawn out of the patient. There is a
bowl of water by the healer's side in which he washes his hands after the
spiritual healing of each patient. Reference has been made to the use of
water in traditional exorcism rituals to wash away the evil spirits. In modern
spiritualism we can identify elements common to the traditional healing
techniques described above. In particular, we note the combination of the
extraction of illness by physical contact with the healer and the use of spirit
possession for diagnosis and healing. Like many traditional healers, the spir-
itualist aim to locate the sources of tension in a person's social relationships
as these might be responsible for the lack of physical well-being.
The traditional healing techniques applied to psychiatric conditions
in developing cultures throughout the world have survived in a recognizable
form in the West, where they coexist, more or less peacefully, with modern
psychiatry. The practitioners of most of these techniques operate outside
conventional medicine. However, the psychotherapists, whether medically
qualified or not, can be seen as the direct heirs of the traditional diviner. The
triumphs of Western psychiatry lie in the field of pharmacology and not in
the area of social management, which is well understood and practiced by
traditional healers. On the other hand, Western psychiatry may benefit from
a closer study of the herbal remedies employed by healers to treat their psy-
chiatrically ill clients.

Alternative therapies flourish in areas in which conven-
tional medicine is unsatisfactory, costly and associated with side
effects.
Extraction and Exorcism
The scientific view of illness of any kind is firmly based
on the concept of a disturbance of normal bodily function. The
causes of the disturbance may include external agents such as
excessive intake of alcohol or intolerable psychological pressures,
but these are considered to operate on the internal milieu to pro-
duce the illness. In many traditional cultures, illness is conceptu-
alized in a concrete way as an external object which has intruded
into the body. Such alien objects do not merely cause the illness,
they are the illness. Thus, the healing procedure consists of
removal of the offending substance, which may be either inani-
mate or animate, from the sufferer's body. The techniques
described above exemplify the most concrete form of extraction
of illness. The next step in extraction involves the transfer of an
invisible illness principle from the subject to an external inani-
mate object. In these cases the illness is ascribed to harmful spir-
its who have to be lured from the sufferer's body. In Thailand the
spirits are induced to leave by placing a sticky ball of rice on var-
ious parts of the patient's body, starting from the tips of the toes
and working upwards to the top of the head.13 The names of spir-
its are called out during this procedure and the patient is asked to
pray with the healer. The rice-ball is then thrown away, indicating
that the spirits have departed. Among the Eskimos of Alaska,
insanity and episodic hysteria are usually ascribed to the intrusion
of spirits. The healer has the patient lie down near an inanimate
object, such as a log of wood or a saw, and then, with sweeping
motions, he brushes the sickness from the patient onto the object.
When the transfer has been accomplished, the object is broken
into pieces.
Water as a cleansing agent is, of course, a component of
many rituals, but has a special place in the transfer of spirits caus-
ing illness. A ceremony marking the recovery from psychosis is
performed by the native healers of the Yoruba in Nigeria.14 The
patient is dressed in a new white cloth and has his head shaved
while standing waist-deep in a swiftly flowing river. Three doves
are used as living sponges to wash away the evil from the patient.
They are then either drowned or decapitated and their bodies
flung downstream. The patient takes off his white wrapper, which
also floats away. The devil is borne away by the river on the bod-
ies of the doves and on the white cloth, and any one touching
them will contract the illness. An early account15 of spirit expul-
sion in Abyssinia States,"The favorite remedies are amulets and
severe tom-toming, and screeching without cessation, till the pos-
sessed, doubtless distracted with the noise, rushes violently out of
the house, pelted and beaten, and driven to the nearest brook,
where the Zar quits him, and he becomes well." A river also fea-
tures in another exorcism ritual described by Gelfand16 among the
Shona. The native healer, or ngaga, treats a possessed woman by
standing her next to a sheep or hen in the forest. He says to the
sheep, "I am giving away this spirit" and the sufferer, then prays to her
dead mother, telling her that today she has thrown out this bad spirit and
asking her not to allow it to return to her, but to allow it to enter someone
else. After this, the nganga takes a few grains of each crop that is grown
and puts them into a black cloth. He then stands on the bank of a river and
throws the bundle into the water.
The native healer commands or beseeches the spirit causing the
madness to leave the patient and enter into an animal. The patient's head is
commonly the focus of activities aimed at extracting the spirit. When this
has been achieved, the animal is either killed, presumably putting an end
to the spirit, or driven off with precautions ensuring that it will not return.
An additional feature is the use of water to cleanse the patient of evil, and
sometimes the introduction of flowing water to carry the spirits away for-
ever, since rivers never run backwards.
Possession and Divination
Possession states fulfill a variety of functions in different cultures,
some religious and some secular. Their appearance may mark a change in
the role or status of the subject. Thus, the Gnau of New Guinea recognize
a condition known as bengbeng. Affected people breathe in a rapid and
uneven manner, while rapid cries are seemingly jerked out of them and
their bodies convulse in time with the cries. They stride around chanting
incomprehensibly, speak messages from spirits, or utter warnings. Their
cries or jerks may reach a crescendo to the point of collapse, or else fade
away into stillness or silence.
Possession states are commonly entered into by the traditional heal-
er as a technique either to determine the causes of illness or else to heal the
sick. The diagnostic powers of the possessed healer are presumably
strengthened by the spirit that has entered him or her. Frequently, the heal-
er's behaviour changes as he or she becomes possessed and appears to be
under the control of a greater force than his or her own will. A dramatic
manifestation of this is a change in the quality of the voice, and often in
the content of speech which sounds like some strange tongue. Healers who
"speak in tongues" in this way usually have a trained interpreter standing
by to convey the meaning of their utterances to the audience.
Practitioners of the ancient Hindu system of medicine, the
Ayurveda, also use the possession states for diagnosis, but speak intelligi-
bly to the client. A patri acts as the medium for a spirit or bhuta. After
drum beating and the burning of incense, the patri goes into a trance, pos-
sessed by his master bhuta. The spirit possessing the client is then asked to
show itself and the client breaks into a weird dance. The spirit speaking
through the healer then engages the spirit possessing the client in a dia-
logue. There is an established hierarchy of spirits, as in neighboring Sri
Lanka, and if the healer's spirit is more powerful it orders the other to leave
the body of the client. If the latter has the ascendancy, the healer's spirit
pleads, asking the other to state its conditions for releasing the client. The
client's spirit declares its conditions, which may be an animal sacrifice, a
ritual feast, or a "house" for its use. After this, both the healer and the client
throw final a fit, foam at the mouth, and pass into unconsciousness.17

Folklore Psychiatry
Levine18 argues that folklore psychiatry - psychiatric ideas,
beliefs and practices maintained by popular culture and tradition and
respected by its patients, apart from and against what the dominant cul-
ture accepts - is neglected by the establishment both in developed and
underdeveloped countries.
Folklore psychiatry is practiced by native healers, who dif-
fer distinctly from academic psychiatrists, medicine men, quacks
and charlatans, and simple domestic popular wisdom. These heal-
ers, working in hundreds of towns and villages, which have never
seen a psychiatrist, are actually the people who deal with the major-
ity of psychiatric cases, and it is neither scientific nor practical to
ignore them.
Kapur19 conducted three studies to examine the patterns of
mental health care in an Indian village. Study One examined the
conceptual frameworks of the various traditional and modern heal-
ers. Study Two was an attitude study inquiring about the type of
healer favored for psychiatric consultation. Study Three was popu-
lation survey in which every person with one or more symptoms
was asked whether he or she had consulted anyone for the relief of
distress. Besides the modern doctors there were three types of tra-
ditional healers: vaids, who practiced an empirical system of
indigenous medicine; mantrawadis, who cured through astrology
and charms; and patris, who acted as mediums for spirits and
demons. It was found that 59 per cent of the residents with symp-
toms had consulted someone. The consultation was determined
more by the severity of illness than by socio-demographic factors.
Modern doctors were more popular, but most people consulted both
traditional and modern healers without regard to the latter's contra-
dictory conceptual framework.
Treatment in Ethnopsychiatry
Situation in Pakistan
Pakistan has a population of about 140 millions and is
inhabitated by various ethnic groups with the predominant religion
being Islam. The Gross National Produce is $430, literacy level
(34%) is very low and the general health scenario is gloomy. The
incidence of mental illness is continually on the rise and the gener-
al awareness about existence and causation of mental illness is
lacking. Recent studies20,21 have shown that people give more
importance to evil eye, possession, magic and Jinnic influence as
being the major causes of mental distress and usually approach a
shaman or a traditional healer for seeking treatment. Mental illness
is recognized by these therapists if one has displayed odd or aggres-
sive behaviour and becomes uninhibited. Usually shamans offer
amulet, holy water, recitations of holy verses and rituals etc.
Research further shows that only 5% of the patients suffering from
mental illness are referred or seen directly by the psychiatrists
mostly in the urban areas of the country which is 28% of the total
population. The vast rural population receive mental health treat-
ment by spiritual healers with the help of traditional medicines, but
reportedly also hazardous methods are used which include exor-
Keeping in view the very low number (300)23 of qualified psy-
chiatrists in Pakistan and the general reluctance towards seeking psychi-
atric help owing to the stigma, high cost, lengthy duration and side
effects of western treatment, the services offered by these alternate prac-
titioners were considered to be worth exploring. Amongst these the
shamans is an important category of healer who by definition is a per-
son claiming to be in direct contact with the spiritual world and who
assumes the responsibility of bringing cure thorough this spiritual con-
nection. Another form of shaman is a 'sufi' who is generally a disciple
of a well known saint. A large number of people have faith in the heal-
ing powers of such practitioners and hence shrines and other holy places
are flocked by the masses, irrespective of educational or ethnic back-
ground, seeking cure especially for mental illness. It is also believed that
'sufi' saints are effective healers and even after deaths have spiritual
influence by virtue of which they can cure or provide relief. Disciples
of such saints are well respected and are approached by people in need
of redressal of problems. One study24 has reported that people do bene-
fit from the treatment given by shamans and sufi's.
The following table gives causes, diagnostic criteria and man-
agement of mental illness according to shamans based on a study pub-
lished in 1998.
Work done by Altaf H. (1995) and Adnan S. (2002) while
preparing their dissertations have observed among the attenders of the
faith heelers, that 57% were females and 42% were males. Females
were found to be suffering more from depression, dysthymic disorder,
generalized anxiety disorder, and epilepsy. Majority of the patients were
either uneducated or had primary education.
Some adverse Results of Western Treatment
It is important to understand some drawbacks of western medi-
cine in the background of rising popularity for traditional treatment. As
evidenced by the prognosis and side effects profile, the statistics and
personal data give some undesirable outcomes of western-oriented
treatments. Thus antidopaminergic effects have been reported to include
acute dystonia; akathisia; parkinsonism; and tardive dyskinesia. Rarely
a very serious condition in the form of Neuroleptic Malignant Syndrome
results due to super sensitivity of dopamine receptors have fatal out-
come in one fourth of the cases even with intensive care management.
Possible antiadrenergic effects include postural hypertension and inhibi-
tion of ejaculation. Anticholinergic effects may include dry mouth;
reduced sweating; urinary hesitancy and retention; constipation; blurred
vision; and precipitation of glaucoma. Other unwanted effects have
been reported to include cardiac arrhythmias; weight gain; amenor-
rhoea; galactorrhoea; hypothermia; and various hypersensitivity reac-
tions. Similarly, tricyclic antidepressant drugs may give rise to various
autonomic effects including dry mouth; impaired accommodation; dif-
ficulty in micturition; constipation; increased sweating; tachycardia;
hypotension; ECG changes; ventricular arrhythmias; fine tremor; lack
of coordination; headache; muscle twitching; epileptic seizures and
peripheral neuropathy. Other effects noted include skin rashes;
cholestatic jaundice; and agranulocytosis. The benzodiazepines are lib-
erally prescribed which are useful for short term period in cases of anx-
iety and depression but if used for a longer period may lead to depend-

galactorrhoea; hypothermia; and various hypersensitivity reac-
tions. Similarly, tricyclic antidepressant drugs may give rise to various
autonomic effects including dry mouth; impaired accommodation; diffi-
culty in micturition; constipation; increased sweating; tachycardia;
hypotension; ECG changes; ventricular arrhythmias; fine tremor; lack of
coordination; headache; muscle twitching; epileptic seizures and periph-
eral neuropathy. Other effects noted include skin rashes; cholestatic
jaundice; and agranulocytosis. The benzodiazepines are liberally pre-
scribed which are useful for short term period in cases of anxiety and
depression but if used for a longer period may lead to dependence with
disturbing consequences.
Potential for Collaboration
In view of low number of qualified psychiatrists and allied men-
tal health practitioners and large number of alternate practitioners who
act as good counselors, the possibility of collaboration is worth explor-
ing. Razali25 in his paper entitled "Psychiatrists and folk healers in
Malaysia" discusses the Bomohs, who are indigenous Malay medicine
men with important specialization in mental health. People generally
approach them to seek treatment for mental illness. Bomohs especially
see those patients who are affected by supernatural agents like evil spir-
its, witchcraft, black magic and divine anger. The treatment methods
adopted by these practitioners include communication with spirits; recit-
ing special prayers or verses from the Qur'an; examining horoscopes;
use of holy water (sometimes with herbs added); talismans and incanta-
tions. Some Bomohs are thought to be helped by Jinni. They acquire
their treatment skills through years of apprenticeship to an established
practitioner, who believes that though modern methods are good for
physical illnesses, they are powerless against supernatural causes of ill-
ness.
A study25 shows that 73 per cent of Malayan psychiatric patients
in a sample surveyed had consulted a bomoh first, as opposed to only
25 per cent who had used general outpatient services. In addition, most
of the psychiatric patients who had not yet consulted a bomoh said they
would do so if their current treatment failed. Researchers have observed
that mild temporary relief is frequently obtained from bomohs for neu-
rotic disorders; but much less often for psychotic illnesses. Razali sees
the possibility of collaboration between the two systems; and suggests
that Bomohs should recognise their limitations, and that psychiatrists
should learn more about religious and cultural beliefs.
Lashari26 reviewed the possibility of collaboration in his paper
entitled traditional and modern medicine - is a marriage possible?" and
gave the following description. He emphasizes that "... it is the faith of
people in traditional medicine that makes them seek the help of healers.
It is an ancient form of health care, practiced for a long time before the
appearance of scientific medicine, as part of the culture of many people.
It is accessible to people in even the most remote areas; and does not
require sophisticated equipment. The drawbacks and side effects of tra-
ditional medicine go largely unrecorded, because the system does not
include record keeping. Many patients come to hospital when complica-
tions have occurred with traditional treatment. So much time is wasted
that when they approach the hospital they are hopelessly ill; and then the
unfavorable outcome leads to the unpopularity of scientific medicine.
Lashari26 comments: "Some 'genetic counseling' may be needed
to ensure a healthy offspring from a marriage of two systems, to avoid
hostility and misunderstanding between the partners'. He suggests that
He recommends that traditional healers should undergo
training in the basic principles of scientific medicine for at least
eighteen to twenty-four months before they can join the health
team; and that they should then be helped to adhere to a proper
code of ethics.
In Pakistan, like in any other developing country, the faith
healers flourish and have reportedly caused harm in a number of
cases, therefore it is important to monitor their activities with
appropriate law enforcement.
Conclusion
This review paper is an attempt to gain insight into different
cross-cultural issues in terms of aetiology, causation and manage-
ment, to understand the diverse mental health especially in the
ethnopsychiatric perspective.
References
1. Kleinman AM, Lin T. Normal and abnormal behaviour in Chinese culture. Holland:
Dordrecht: Riedel 1996, pp. 1-42.
2. Race RP. Culture and mental illness. Bristol: Arrow Smith 1998, pp. 1-19.
3. Shweder RA, Bourne EJ. Does the concept of person vary cross-culturally? In: Marsella
AJ, White GM, (ed). Cultural conceptions of mental health and therapy. Holland:
Dordrecht: Reidel 1992, pp. 10-21.
4. Littlewood R, Lipsedge M. Aliens and alienists: normal and abnormal. London:
Routledge 1993, pp. 189-217
5. Muhammad AA. Uses and limitations of ethnopsychiatry, (unpublished doctoral thesis
1997).
6. Simons RC. "Culture experience and the startle reflex." New York: Oxford University
Press, 1996, pp. 24-26.
7. Pfeiffer WM. Transkulturelle psychiatrie, 2nd ed. Stuttgart, Thieme, 1994, pp. 101-5.
8. Jilek WG. Modified states of consciousness: their role in ethnopsychiatry. Transcult
Psychiatry Newslett, 2001, WPA, 12:5-8.
9. Marano L. Windigo-psychosis: the anatomy of an emic-etic confusion. Curr Anthropol
2002;23:385-412
10. Gaines AD. Ethnopsychiatry: the cultural construction of psychiatries. In: Gaines AD
(ed) Ethnopsychiatry, Albany State University of New York Press, 1992, pp. 3-49.
11. Jilek WG, Jillek-Aall, L.The mental health relevance of traditional medicine and
shamanism in refugee camps of Northern Thailand., Curare 1990;13:217-24.
12. Harding T. Psychosis in a rural west African community. Soc Psychiatr 1973;8:198-203.
13 Suwanlert S, Phii Pob. Spirit possession in rural Thailand. In: Lebra WP (ed). Culture
bound syndromes, ethnopsychiatry and alternative therapies. University Press of
Hawaii, Honolulu: 1976.
14. Prince R. Amok then and now. Transcult Psychiatr Res Rev 1991;28:219-29.
15. Hollweg MG. Main culture bound syndromes in Bolivia. Curare 1997;20:23-8.
16. Gelfand M., Psychiatric disorders as recognized by the Shona. Cent Afr J Med
1967;13:39-46.
17. Leff J. Possession and divination: psychiatry around the globe. New York: Marcel
Dekker 1971, pp. 115-24.
18. Levine RE, Gaw AC. Culture-bound syndromes. Psychiatr Clin North Am 1995;18:523-
36.
19. Kapur RL. The role of traditional healers in mental health care in rural India. Soc Sci
Med 1975;13:27-31.
20. Gadit AA. Treatment approaches by traditional healers: presented in international con-
ference on cultural psychiatry, Lahore 1995.
21 Gadit AA. Shamanic concept and treatment of mental illness in Pakistan. J Coll Phys
Surg Pak 1998;8:33-5.
22 Gadit AA. Scope of ethnopsychiatry in Pakistan (ed). J Pak Med Assoc 1996;46:119.
23. Gadit AA, Khalid N. State of mental health in Pakistan - education, service and research,
Karachi: 1st ed. Corporate Printers, 2002, pp. 34-42.
24. Jilek WG. Traditional medicine relevant to psychiatry. In: Sartorius N, DeGivolamo G,
et al. (eds).Treatment of mental disorders. Washington: WHO/American Psychiatric
Press, 2001, pp. 341-90.
25. Razali MS. Psychiatrists and folk healers in Malaysia. World Health Forum 1995;16:56-
8.
26. Lashari MS. Traditional and modern medicine: is a marriage possible? World Health
Forum 1984;5:175-7.