Conceptualizing Psychosis in Uganda - The Perspective of Indigenous and Religious Healers - JOANNA TEUTON

06 074976 Teuton 8/3/07 1:19 pm Page 79
transcultural
psychiatry
March
2007
ARTICLE
Conceptualizing Psychosis in Uganda: The

Perspective of Indigenous and Religious Healers
JOANNA TEUTON
Bangladesh
RICHARD BENTALL
University of Manchester
CHRIS DOWRICK
University of Liverpool
Abstract A qualitative study, investigating the representations and

explanatory models of ‘madness’ held by indigenous and religious healers,
was undertaken in urban Uganda. Case vignettes of individuals with a diag-
nosis of a psychotic disorder were discussed by the healers in terms of
phenomenology, causality, intervention and outcome. Indigenous healers
primarily understood ‘madness’ as spiritual or physiological, whereas
religious healers also held psychological models. Healers’ understandings of
‘madness’ are inextricably linked with the historical and sociopolitical
context and may be useful to individuals with psychotic experiences,
however, it is likely that these models are dynamic and continually
changing.
Key words Africa • indigenous healing • psychosis • religious healing •
representations
Vol 44(1): 79–114 DOI: 10.1177/1363461507074976 www.sagepublications.com

Copyright © 2007 McGill University
79
06 074976 Teuton 8/3/07 1:19 pm Page 80
Transcultural Psychiatry 44(1)
In Uganda, as in many other African countries, allopathic approaches to

the treatment of psychological distress exist alongside healing approaches
based on indigenous or religious belief systems. If the needs of people
suffering from psychological distress are to be adequately assessed, and
effective local services delivered, this context needs to be understood. In
this article we report a study of the ways in which indigenous and religious
Baganda healers conceptualized experiences that, within a western psy-
chiatric system, would be characterized as psychosis.
Theoretical Context
Cultural relativism often underpins research examining psychiatric
phenomena from a local perspective (Patel, Musara, Butau, Maramba, &
Fuyane, 1995). This philosophical position suggests that the experiences
of ill health or misfortune are specific to the cultural context in which
they are experienced. There is significant evidence to suggest that indi-
viduals, regardless of their geographical or temporal location, have
psychotic experiences (Ilechukwu, 1991; Jablensky et al., 1992; Kroll &
Bachrach, 1982; Leudar & Thomas, 2000; Westermeyer & Sines, 1979).
However, the ways in which these experiences are interpreted, and the
theories that are developed to make sense of them, are influenced by
sociocultural context (Al-Issa, 1995; Fabrega, 1989a; Leudar & Thomas,
2000; Romme & Escher, 1993). These understandings in turn influence
both the nature of the experience itself, attitudes towards the sufferer
and the action taken by the sufferer and the people or institutions
around them.
Over the last 10 years several clinicians have emphasized the need to
consider the individual’s understanding of their psychotic experiences.
They suggest that nonmedical explanations are often functional in that
they provide meaning for the individual and their families and can have a
significant positive impact on the nature and course of these experiences
(Bracken & Thomas, 2001; Kirmayer & Corin, 1998; Romme & Escher,
1989, 2000). This approach recognizes the importance of biological
perspectives and does not preclude the use of medication, but does not
give biomedical models pre-eminence and views them as being based on
context-specific assumptions (Bracken & Thomas, 2001). One aspect of
the sociocultural context is the healing system. The conceptualizations
presented by practitioners in the healing system are likely to influence the
way in which a sufferer interprets their experiences, and the nature of the
experience itself (Hacking, 1999; Kleinman, 1978, 1980, 1995). Lopez and
Guarnaccia (2000) have argued that culture is a dynamic process influ-
enced by the ever-changing social world. The individual is an active agent
in this process, incorporating, adapting and rejecting different elements of
80
06 074976 Teuton 8/3/07 1:19 pm Page 81
Teuton et al.: Conceptualizing Psychosis in Uganda
these social influences. Healing systems and conceptualizations of suffer-

ing can also be expected to evolve over time.
Healing Context in Uganda

Uganda is a small country in East Africa with a population of 21 million.
Kampala, the capital city of Uganda, is located in Buganda,1 the central
district of Uganda. It has an estimated population of 1.2 million and an
annual urban growth rate of 4.76 % (World Resources Institute, 1996).
A range of social, economic, political and religious factors have signifi-
cantly influenced the healing context in Uganda. Traditionally, the
Baganda2 recognize the influence of the spirit world in many aspects of
their lives. Broadly speaking, there are three types of spirits: the Katonda,
the supreme creator; the balubaale, ancient humans who had special
powers when they were alive and whose spirits now have an influence on
the day-to-day lives of the Baganda; and lesser spirits, including the spirits
of recently deceased ancestors (mizumu) and spirits that are associated
with mountains, rivers and forests (misambwa) (Ssemakula, 2000).
Fortune and misfortune, including sickness, are understood to emanate
from the spiritual world. The Baganda perform rituals to the lesser
spiritual forces as part of their daily lives, in order to ensure good fortune
and prevent misfortune. Each clan has its own medicine-men, Basawo,
who are able to ‘diagnose’ sickness, prescribe medicines, and manage
sickness and misfortune caused by the spirits (Roscoe, 1965).
Christianity and Islam have both had a significant impact on the
spiritual worldview of the Baganda. Islam was introduced into East Africa
in the nineteenth century. It became the predominant religion in Buganda
between the 1840s and 1870s and continues to flourish; approximately
20% of the population of Buganda identify themselves as Muslim
compared with the national figure of 10.5% (Government of Uganda,
1992). Both biomedical and spiritual conceptualizations of sickness and
healing practices have been used in Islamic societies since medieval times.
From a spiritual perspective, sickness is variously seen as a trial or blessing
for the faithful, or as the result of jinn possession. Prayer, divination and
exorcism are practised as a means of dealing with these types of sickness
(Al-Issa, 2000). It is likely that these ideas and practices were introduced
into areas of present-day Uganda by Arab traders during the late nine-
teenth and early twentieth centuries (Reynolds-Whyte, 1991). Christianity
was introduced by missionaries in the nineteenth century and the majority
of the population now identify themselves as Christian. In the 1920s,
African Christians became increasing dissatisfied with the spiritual help of
the mission churches, in particular the racist nature of these institutions
and their failure to deal with sickness, health, fortune and misfortune. This
81
06 074976 Teuton 8/3/07 1:19 pm Page 82
resulted in the rise of the independent churches, which incorporate

elements of indigenous spirituality and Christianity (Haynes, 1996).
Around the same time, fundamentalist Christianity was introduced to
Buganda when a revival, sometimes called Balokole, was introduced
(Parrinder, 1969). During the 1980s the evangelical church was heavily
promoted in Africa (Haynes, 1996), and has become increasingly popular
in Uganda. There are increasing numbers of churches associated with the
Pentecostal and Catholic Renewal movements that have emerged since this
time. These movements are characterized by a belief in experiential faith,
the Holy Spirit, the spiritual gift of glossolalia, faith healing and the
efficacy of miracles (Favazza, 1982; Haynes, 1996).
Since colonization, European powers have introduced the biomedical
approach to health and health care. Over the last 30 years the international
community has increasingly supported government and nongovern-
mental health initiatives based on allopathic medicine. Universities and
colleges graduate a range of medical professionals and, health centres,
health education, immunization programmes and pharmacies are all
commonplace in Uganda. As a result, there is a high level of awareness and
use of allopathic medicine for health problems.
As in many African countries, Uganda has a high level of urban growth.
This is largely attributed to rural–urban migration (Choguil, 1994),
which is driven by perceived and actual economic factors (Hardoy &
Satterthwaite, 1989). As a result, many of the tribal groups in Uganda,
with their varying experiences and cultures, are represented in the urban
areas. Urbanization often results in changes in the social and cultural
structure of families and societies, for example, breakdown of the
extended family. Globalization, advances in information technology and
the mass media in Uganda have led to easier access to international
information and are likely to have resulted in a greater awareness of
alternative worldviews.
A review of the literature from Africa indicates that mental health
problems are variously conceptualized in terms of the models described
above. ‘Abnormal’ behaviour characteristic of mental health problems is
often perceived as indicative of the ancestral spirits being angered by trans-
gressions of social taboos or rituals (e.g., Edgerton, 1966; Good, 1987;
Murphy, 1976; Orley, 1970; Patel, 1995) or caused by witchcraft (e.g., Dale
& Ben Tovim, 1984, Edgerton, 1966; Fosu, 1981; Jacobsson & Merdasa,
1991; Orley, 1970; Patel, 1995). A more limited pool of literature explores
Christian or Islamic conceptualizations, however, there is evidence to
suggest that mental health problems are understood to be caused by Satan
and the devils, and alleviated by the divine power of the Holy Ghost
(Jacobsson & Merdasa, 1991; Sharp, 1994) through prayer, singing, receiv-
ing holy water and the laying on of hands (Ensink & Robertson, 1999;
82
06 074976 Teuton 8/3/07 1:19 pm Page 83
Odejide, Oyewunmi, & Ohaeri, 1989; Sharp, 1994). Physical conceptual-

izations of mental health problems have also been documented, for
example, Edgerton (1966) found that the Sebei and Potok tribes attributed
‘madness’ to the presence of a worm in the front part of the brain. Drugs
and alcohol have also been implicated in Ethiopia, East Africa and
Zimbabawe (Edgerton, 1966; Kortmann, 1987; Patel, 1995), as has anaemia
in Kenya (Good, 1987), blood impurities in Botswana (Dale & Ben Tovim,
1984) and rapid changes in climate and poor diet in Ghana (Fosu, 1981).
More recent studies in Zimbabwe suggest that people attribute ‘madness’ to
infectious disease, physical trauma to the head and old age (Patel, 1995).
There is less evidence of psychological models of serious mental health
problems, however, Edgerton (1966) found that some African tribes directly
attributed ‘madness’ to psychosocial factors including stress, grief or worry,
and Patel (1995) found that unemployment and marital problems were seen
as causal factors in the development of mental breakdowns in Zimbabwe.
Although a biomedical model of ‘psychosis’ is the sanctioned form of
health care in most African countries, many people (or their families)
continue to access traditional and religious healing services when they
behave in ways considered to be consistent with ‘psychotic’ disorders
(Ensink & Robertson, 1999; Patel, 1993; WHO, 1996, 2001). Furthermore,
the evidence suggests that the prognosis for major mental health problems,
in particular ‘schizophrenia,’ is better in developing than developed
countries (Jablensky et al., 1992). The question arises; do we continue to
impose a western biomedical model of psychosis? Or, do we explore the
possible positive contribution of indigenous and religious healing
practices and promote a more integrative approach to managing mental
health (Ovuga, Boardman, & Oluka, 1999; Patel, 1993; Patel, Mutambirwa,
& Nhiwatiwa, 1995; WHO, 2001)?
One means of pursuing the latter model is to gain a more thorough
understanding of the conceptualizations of ‘psychosis’ held by practitioners
in nonallopathic healing systems and the models of intervention they
advocate to help individuals negatively affected by ‘psychotic’ experiences.
These models and the extent to which they appear in the healing systems
thus become a basis for developing more integrative ‘psychiatric services.’
The current study sought to explore and compare the ways in which
indigenous and religious healers conceptualized experiences that, within a
western psychiatric system, would be characterized as psychosis. The
purpose was to inform service-delivery models.
Design
The research was undertaken among the Baganda living in urban and peri-
urban areas of Kampala and the surrounding towns. In accordance with
83
06 074976 Teuton 8/3/07 1:19 pm Page 84
national regulations in Uganda, ethical approval for this research was

granted from the President’s Office.
In-depth interviews were undertaken with religious and indigenous
healers using one of two case vignettes; one described Patience, a woman
displaying the symptoms of ‘schizophrenia,’ the other Kato, a man exhibit-
ing the symptoms of ‘bipolar disorder’ (see Appendix). The case vignettes
were developed by the first author in conjunction with two Ugandan
psychiatrists and a European psychiatrist working in Uganda. The content
of the case vignettes was based on cases seen by the psychiatrists during
the course of their clinical work. All attempts were made to ensure that
DSM-IV criteria were met, and that symptoms were presented in a way
that reflected common presentations in Uganda. Both case vignettes indi-
cated that the individual was not suffering from fever or other medical
illnesses and was not using alcohol or drugs. This information was
included in order to minimize the possibility of differential diagnoses of
organically related or drug-induced psychoses. The case vignettes were
distributed to a convenience sample of three Ugandan psychiatrists3 and
three British psychiatrists in the UK. Each psychiatrist was asked to give a
provisional diagnosis and differential diagnosis (if appropriate) and to
provide supporting evidence for their decisions. In addition, the psy-
chiatrists were asked to comment on any difficulties they had in reaching
a provisional diagnosis. The feedback was used to refine the case vignettes.
A storyboard depicting the main aspects of the case vignettes was created
as a memory aid to complement the presentation of the case vignettes.
The topic guide for the interviews covered identification and classifi-
cation of the experiences described in the case vignettes, conceptual-
izations of these experiences, interventions and expected change, and the
role of western medicine. The interviews were not confined to the case
vignettes and the healers were encouraged to draw on their own experi-
ences in the discussions. The healers were given the option of conducting
the interviews in Luganda with an English translation,4 or in English. Nine
indigenous healers and one religious healer completed the interview in
Luganda, the remaining interviewees preferred to be interviewed in
English. The interviews were audiotaped and transcribed. Where Luganda
was used, a research assistant acted as an interpreter; the English trans-
lations were transcribed and then the Luganda dialogue was blindly back-
translated and compared with the original English. Interviews lasted
between 1 and 3 hours, over one or two meetings.
A small but diverse group of 20 healers from Kampala and the
surrounding area, who were accessible to individuals in the community,
were recruited for the study. Only Baganda were included in the study for
two reasons. From a theoretical perspective, much research into mental
health in Africa (excluding anthropologically based research) has ignored
84
06 074976 Teuton 8/3/07 1:19 pm Page 85
the fundamental differences across countries and tribal groupings

(e.g., the IPSS and DOSMD). Within Uganda there are approximately 26
different tribal groupings. Although similarities do exist across some of
these tribes, many have different cultural norms, spiritual beliefs and clan
systems. It was not possible to incorporate the great diversity of these
groups within the current study and it was felt that potential differences
between tribal groupings might compromise the study and not allow for
the development of coherent ideas. At a pragmatic level, each of the tribal
groups adopts different vernacular and there were not sufficient resources
within the study to incorporate additional interpreters.
Through informal discussion with local psychiatric staff, a range of
types of healers who provide help for individuals with psychosis were
identified. These fell broadly into two groups: Baganda indigenous healers
who draw on indigenous spiritual paradigms and practices and religious
healers whose practice is based on Christianity and Islam. Ten healers from
each group were recruited using typologies or sampling frames to inform
the purposeful sampling process (Silverman, 2000). Indigenous healers
from peri-urban and urban areas, specialists in madness and non-
specialists were recruited. Religious healers were less specialized and there-
fore denomination and locality were used to define the sampling frame.
The snowball technique was used to access a diverse group of indigenous
healers and a diverse group of religious healers falling into each of these
categories, however, only one female could be recruited to the study.
Minimal additional criteria were applied; the individual should live within
a 30-kilometre radius of the centre of Kampala and consent willingly to
take part in the study. A brief profile of the respondents is given in Table 1.
Transcripts were coded line-by-line and analysed to develop the
explanatory models used by the healers. In the first stage of the analysis
the initial interviews were free-coded by the first author and memos were
written to capture thoughts and ideas in relation to the codes. The remain-
ing transcripts were coded line-by-line using the coding index generated
from this initial analysis, although emerging new themes were identified
and used to further develop the coding index. Throughout this process,
samples from the transcripts were independently coded by the second and
third authors using the coding index. Disagreements were resolved by
consensus and amendments were made to the coding system. The tech-
nique of constant comparison was used by the first author to identify
emerging process codes, these were then used to develop process models
for each of the explanatory models. The models were reviewed and
discussed by the research team and revisions made where data did not fully
support the models. The explanatory and process models were used to
encapsulate the different representations of madness discussed by the
healers and to make comparisons between the two groups of healers.
85
06 074976 Teuton 8/3/07 1:19 pm Page 86
TABLE 1
Profile of indigenous healers (IH) and religious healers (RH)
Code Age Background
IH01 64 A Hajji farming in a peri-urban area using Buganda and Islamic spiritual
medicine to treat health problems, misfortune and bring fortune
IH03 70 Elder in an urban community who strongly advocates Buganda spiritual
healing and works with clients in a shrine near to his home
IH04 45 Muslim who has established an in- and out-patient service for
individuals with mental health problems in a high density urban area. He
utilized Buganda spiritual and herbal approaches
IH05 41 Specialist in eddalu (madness) in a peri-urban community using Buganda
spiritual methods, in particular for curing eddalu caused by witchcraft
IH06 57 Specialist in eddalu and nsimbu (epilepsy) using Buganda spiritual healing
IH07 50 Healer in a peri-urban area treating general problems with Buganda
spiritual healing
IH08 34 Female healer treating general problems with Buganda spiritual healing
IH10 70 Healer in a peri-urban area treating general problems with Buganda
spiritual healing
IH11 47 Farmer and specialist in herbal medicine for witchcraft, but also able to
use Buganda spiritual healing
IH14 56 Muslim living in a urban community using Islamic and Buganda ritual
healing to cure witchcraft
RH03 67 Catholic brother who has a clinic in an urban area where he uses herbal
medicine to treat health problems
RH04 45 Independent Evangelical Christian who asserts that he has the power to
perform miracles in the name of God and uses deliverance and the power
of God to heal health problems
RH05 38 Imam in a peri-urban area who uses the Koran to heal health problems
RH06 45 Pentecostal Christian minister in a peri-urban area using deliverance and
the word of God to heal health problems
RH07 56 Catholic priest in urban area who uses herbal medicines and spiritual
healing
RH08 60 Imam using the Koran to help people with mental problems
RH09 44 Catholic Charismatic priest in a peri-urban area who uses deliverances,
laying on of hands and counselling to manage mental problems
RH10 29 Born again pastor in large urban church who uses spiritual healing and
counselling to deal with health and psychosocial problems
RH11 31 Catholic Charismatic revival priest in large urban church using faith
healing practices to heal the sick
RH12 32 Pentecostal minister in a large urban church using counselling and
spiritual healing to work with youths with health and social problems
Results
All the healers regarded the individuals in the case vignettes as deviating
in some way from ‘normal’ or culturally appropriate behaviour, using a
variety of terms to describe the individual’s condition including: eddalu
86
06 074976 Teuton 8/3/07 1:19 pm Page 87
(madness), akazole and kalogojo (milder forms of madness) and kutabuka

mutwe (disorganized head). The religious healers also utilized western
psychiatric terminology to describe the individuals’ experiences, such as
‘schizophrenia,’ ‘psychosis,’ ‘neurosis,’ ‘mental sickness,’ ‘depressed,’ ‘phobia’
and ‘psychological.’
The healers discussed a range of spiritual, physical and emotional
explanations to account for these experiences. Five spiritual represen-
tations of madness emerged from the interviews. The indigenous healers
represented madness as communication from the family spirits, social
justice, and persecution; whereas the religious healers conceptualized
madness as a manifestation of evil, or as a form of punishment. Both the
indigenous and religious healers held the representation of Kizungu
madness, a physical problem associated with western allopathic medicine,
though they differed in the extent to which they attributed to this to the
physical and spiritual worlds. The religious healers also held a number of
‘psychological’ representations of madness. These included a negative
internal reaction to adversity, a deliberate act of manipulation, and
colluding with false beliefs.
Communication from the family spirits and Kizungu madness were
discussed most commonly by the indigenous healers, whereas negative
internal reaction to adversity, Kizungu madness and manifestation of evil
were discussed by more of the religious healers (Table 2). On the whole,
these explanations did not correspond to the different diagnoses but rather
were associated with different causal pathways. The only exception was the
social justice representation, which was discussed by the indigenous
healers only in relation to the case vignette describing bipolar disorder.
These models are described below.
Spiritual Models of Madness

Communication from the Family Spirits
The most common representation of madness, reported by all the in-
digenous healers, is referred to here as communication from the family
spirits. The process model underlying this representation is shown on the
left of Figure 1. These healers indicated that madness is caused by dis-
harmony in the spiritual world, that is, the ancestral spirits become
angered when the family fails to carry out appropriate cultural rituals or
practices (cultural deviancy), or when they are reluctant for a family
member to take on the role of an indigenous healer (cultural calling). The
ancestral spirits bring madness to a family member in order to make the
family aware that they have been neglected or angered. The amelioration
of madness occurs when the individual and/or the family appease the
ancestors (kusamira) either through engaging in cultural rituals or taking
87
06 074976 Teuton
TABLE 2
Numbers and rankings of representations discussed by the healers
Indigenous Healers (N=10) Religious Healers (N=10)
8/3/07
——————————————————————— ———————————————————————–
Representation Schizophrenia Bipolar Rank Representation Schizophrenia Bipolar Rank
Case Disorder Case Case Disorder Case
Vignette Vignette Vignette Vignette
1:19 pm
Spiritual Communication 5 5 1 Manifestation 3 3 3

Representations from the of Evil
Family Spirits
Page 88
Punishment 1 1 6
Persecution 3 3 3
88
Social Justice 0 3 4
Physical Kizungu Madness 5 4 2 Kizungu Madness 5 4 2
Representations
Psychological — — — Negative Internal 5 4 2
Representations Reaction to
Adversity
Deliberate Act of 1 1 6
Manipulation
Colluding with 2 2 4
False Beliefs
06 074976 Teuton
COMMUNICATION FROM THE FAMILY

Representation MECHANISM OF SOCIAL CONTROL
SPIRITS
PERSECUTION SOCIAL JUSTICE

8/3/07
Madness Located in the Madness as a Manifestation of Madness Located between Madness as a

Spiritual Worlds Collective Suffering the Living and Spiritual Manifestation of Individual
Worlds Suffering
1:19 pm
Location & Sent

Experiences Experiences Responsible Causality & Experiences
Nature spiritual manifestation spirits act initiated in
initiated by are a
and created in forces are of madness on behalf the living
manifestation Causally Treatment
the spiritual ancestral/ not specific of living world
of spiritual directly specific to
world forces family spirits to sufferer
Page 89
Causality linked to sufferer

Family
and individual
contribute
Causality and healing Intervention involves the healing behaviour
information
89
known only to the spirits family & represents a family known to about
the spirits causality
Causality
Spiritual Disharmony Social Disharmony
Cultural Cultural Behaviour Immoral

Deviance Calling envied by Behaviour
Legend
REPRESENTATIONS Process Themes Process sub-themes
Figure 1 Process model of indigenous healer’s spiritual representations of madness.

06 074976 Teuton 8/3/07 1:19 pm Page 90
on the role of an indigenous healer. By meeting the demands of the

spiritual forces, the family is in effect re-engaging in cultural practices.
The data suggest that this form of madness is located primarily in the
spiritual world. The onset of the experiences described in the case vignettes
was attributed to ancestral spirits taking control of the individual, rather
than to physiological or psychological factors. Abnormal behaviours were
regarded as the manifestation of spirit possession; the indigenous healers
varied, however, in the way they conceptualized this process. Some
suggested that these behaviours are in fact the spirits’ behaviour (e.g., the
ancestral spirits have no need for clothes and therefore the individual walks
naked). Others indicated that the individual is removed to the world of the
spirits and behaves in relation to the spirit world rather than the human
world. This explains, for example, their ability to perceive things that other
humans cannot; experiences that would be regarded as hallucinations
within a biomedical framework.
Those voices, it is them [spirits] that bring about those voices to her, and
remove her human understanding. It will be them alone operating. They’ve
remove her away from this [world] and they put her into the other [world].
(IH14)
Diagnosis and interventions were equally grounded in the spiritual world.

Indigenous healers regarded much of the information provided in the case
vignettes as irrelevant to understanding the cause of the individual’s
problems and indicated that an explanation could only be elicited from
the ancestral spirits. Similarly, these healers were unable to provide specific
details about interventions, stating that resolution of the problem could
only be determined on an individual basis by the ancestral spirits. They
described their own role as a bridge between the living and spiritual
worlds, facilitating the ancestral spirits to ‘speak’ and inform the living
world of the reasons for the madness and the appropriate healing steps.
Typically, nsimbi enganda (cowrie shells) are thrown by the healer or the
client and the resulting pattern is interpreted by the healer while possessed
by their spirits; misambwa, mizimu or jinn. Other indigenous healers indi-
cated that their ancestral spirits communicate directly with the living
world; speaking through the mouth of the healer, the individual or a family
member. Those indigenous healers who identified themselves as Muslim
Basawo Buganda5 used prayers from the Islamic holy books and herbal
medicines to facilitate communication with the spirit world.
[T]he mizimu or misambwa that is affecting that person and it has possessed
him and I get hold of the nsimbi enganda, which were created by people,
that we could now refer to as a computer, and try to find out what happened
to Kato, that made him suffer from eddalu, to sell his property or to go
90
06 074976 Teuton 8/3/07 1:19 pm Page 91
talking on the way or to wake up. You find it out using the nsimbi enganda
and you tell him about it. (IH06)
The final feature of this representation is that madness is seen as a col-

lective rather than an individual problem. The ancestral spirits responsible
for causing madness are described as an extension of the family of the indi-
vidual. Furthermore, the indigenous healers indicated that the cause of the
problem was not specific to the person, but could be due to any family
member(s) neglecting cultural practice. Within this model, other family
members are equally vulnerable to madness or other forms of misfortune
if the prescribed healing rituals are not adhered to. Conversely, they are
protected from madness or further misfortune if the healing is carried out.
The term okuwongelwa (searching) was used by some indigenous
healers to describe the process of understanding the cause of madness and
identifying the appropriate healing rituals. Although the spirit world and
the indigenous healer play their respective roles, the family are also integral
to this process, as they can communicate directly with their ancestral
spirits. The extended family must gather at the ancestral home in order to
carry out okuwongelwa under the guidance of the indigenous healer. Once
the ancestral spirits have announced the nature of the problem and the
rituals needed to resolve it, the extended family are expected to perform
the rituals. The cost of bringing the family together and buying the cultural
items for the rituals are often considerable, but if the family refuses to
engage in the healing process they risk exacerbating the individual’s
suffering, or bringing further misfortune to the family. Thus helping a
family member suffering from madness represents an important family
investment.
Social Justice and Persecution

Two other spiritual representations emerging from the data were based on
the notion that madness results from disharmony in the social world.
Madness within these models was interpreted by the authors a mechanism
of social control. The processes involved in these representations are
described in the right-hand section of Figure 1.
The first of these representations is referred to as persecution, and was
discussed by six of the indigenous healers. Here, madness represents a
form of harm inflicted on an individual who has been successful, by a
jealous party. For example, if a man is jealous of a successful work
colleague he may consult a ‘witchdoctor’ and ask for the person to be
‘harmed.’ The witchdoctor negotiates with the spirit world on behalf of
their client in order to bring madness to the work colleague, thus destroy-
ing their success.
91
06 074976 Teuton 8/3/07 1:19 pm Page 92
The term persecution is adopted by the authors because of the emphasis

the indigenous healers placed on malevolent features of the explanatory
model underlying this representation. It is important to note that this was
the only context in which the indigenous healers identified witchdoctors as
responsible for creating madness. Furthermore, the healers disassociated
themselves from witchcraft, referring to witchdoctors and their practices in
a negative way and denying detailed knowledge of the bewitching process.
They indicated that this form of madness can only be alleviated when the
spiritual power causing the madness is identified and removed from the
individual by an indigenous healer. This is achieved either physically using
herbs to induce diarrhoea and rashes (representing the expulsion of the
spirits) or with a kiwubilo, a horn-shaped vessel, which is placed on the
body and sucked to remove the physical charm. In the case of the Muslim
indigenous healers, words from the Koran are written on paper, dissolved
in water and smeared on the body or drunk by the ‘victim.’ These processes
are understood to represent the power of the good indigenous healer’s
spiritual forces over the witchdoctors’ evil spiritual forces.
Madness as social justice is used to describe the final spiritual represen-
tation discussed by three of the indigenous healers commenting of the case
vignette depicting bipolar disorder. The explanation underlying this repre-
sentation indicates that madness can develop when an individual engages
in immoral behaviour. One healer explained this in the following way:
Someone could come, for instance up here [indicates his clinic] and says
that they have stolen my car or some property. What we do is to send those
things [spirits], when they get you [the thief], they strike you, fight you, and
do whatever and when they [the thief] consults another indigenous healer
he is told that he stole and if he does not return the stolen property he will
die and if he returns it he recovers. (IH07)
The analysis suggests that the indigenous healers view both these types of
madness as being located between the living and spiritual worlds. As with
the first model, the analysis suggests that the experience of madness is
created by the spiritual world. The witchdoctor or indigenous healer acts
as the intermediary between the human and spiritual worlds that bring
madness, directing the human instigator in rituals or the deployment of
charms they have created, in order to invoke the spirits. The spirits there-
fore create the madness. In these models, however, the spirits responsible
for creating madness are referred to as ‘sent spirits.’ These are distinguished
from ancestral spirits in that they are not associated with the person’s
family and act at the behest of any individual in the living world. Thus,
madness is initiated by the living world.
When an indigenous healer is consulted to heal the madness, the spirit
world is again seen as able to provide information about the source of the
92
06 074976 Teuton 8/3/07 1:19 pm Page 93
problem. In this model, the indigenous healers’ spirit is able to communi-

cate with the sent spirit in order to establish the cause. In contrast to the
first model, however, the family are able to provide information from
the social world that will aid the indigenous healer and their spirit in
identifying the sent spirit and the source of the problem. For example, the
family may suggest who might want to harm their relative and why.
They [spirits] know that graves are in certain places, and Kato and his
relatives will say that we know that person [bewitcher], by the way he’s been
relating to us. They [Kato and family] direct those messengers who are
spirits that you can’t even see. (IH05)
The reliance on the family to provide much of the contextual explanation

for the individual’s suffering further reiterates the interaction between the
social living world and the spiritual world within this model.
In contrast to the first model, communication from family spirits,
madness as social justice and persecution appear to be specific to the
sufferer, rather than a family problem. The precipitants of madness are
directly linked to the way in which the community perceives the social
behaviour of the individual, i.e., immoral behaviour or ‘successful’ be-
haviours. The mechanisms involved in bringing about madness are also
specific to the targeted individual. For example, charms are placed in the
path of the ‘victim’ or directly into the sufferer’s body through ingestion
or cuts. Some of the indigenous healers described a process of making
charms using nails, hair or pieces of clothing belonging to the individual.
Similarly, interventions are specific to the individual. In the social justice
representation, the indigenous healer negotiates a ‘settlement’ with the
sent spirits, which the sufferer has to comply with in order to be ‘cured.’
In the persecution model, the indigenous healers seek to remove the source
of the spiritual power, the charm, from the individual, either physically or
spiritually.
Manifestation of Evil and Punishment

The religious healers also provided elaborate spiritual explanations of
madness: madness as a manifestation of evil was discussed by six of the
healers and madness as punishment discussed by two of the healers. In
both of these representations, evil spirits create madness in response to the
individual’s behaviour and emotions (see Figure 2).
The religious healers indicated that certain indigenous rituals and
practices, immoral behaviour such as swearing, idolatry and lascivious-
ness, and, emotions such as fear, anger, bitterness and depression are
congruent with evil spirits. When individuals engage in these behaviours
or experience these emotions, they provided an opportunity for the evil
93
MANIFESTATION OF EVIL PUNISHMENT
Representation
06 074976 Teuton
8/3/07
Madness Located in the Madness Represents

Spiritual World Supremacy of Evil
1:19 pm
Experiences Causality Evil spiritual Madness is a

initiated and and healing forces means of
created by known only overcome bringing a
evil spirits to the spirits good spiritual person to the
forces Devil
Location & Nature
Page 94
Madness and healing

determined by own spiritual
94
Window of Opportunity for
Spiritual Disloyalty
evil spirits
Engaging
Negative Immoral Not engaging in cultural rituals

Causality in cultural emotions behaviour
rituals
Legend
Figure 2 Process model of religious healer’s spiritual representations of madness.

06 074976 Teuton 8/3/07 1:19 pm Page 95
spirits to ‘enter’ them and create a ‘bad’ person. Madness represents the
manifestation of this evil. The individual’s state can only be ameliorated
when they denounce the evil forces and take on the beliefs and practices
of ‘goodness,’ which are synonymous with Christianity or Islam.
Alternatively, madness can result from not engaging in indigenous
practices. In this context, not carrying out indigenous rituals is construed
as a sign of disloyalty to Satan and as an indication of an alliance to
God/Allah. In this model, madness represents a punishment from Satan
and accounts for the experience of madness among individuals who
practise Christianity or Islam rather than the indigenous spirituality.
As with the indigenous healers, the religious healers viewed these form
of madness as being located primarily in the spiritual world. In contrast
to the indigenous healers, however, this spiritual world was presented as
inhabited by the evil spirits. These spirits create madness and control the
behaviour of the individual in a similar way to the ancestral spirits. For
example, one religious healer cited the example of the madman of Nadara
(described in Mark chapter 5) to illustrate this process, whilst another
suggested that the individual has handed over their free will to the evil
forces. These religious healers, like the indigenous healers, explained
hallucinations in terms of the possessed individual coming into contact
with an alternative spiritual world.
Spiritual forces were also regarded as integral to understanding and
healing madness. The religious healers indicated that they act on behalf of
the good spiritual forces, using the spiritual powers that have been
bestowed on them, in order to understand and heal people suffering from
madness. For example, one religious healer described being visited by Jesus
and instructed to perform miracles. Another explained that through his
ministry he was learning to ‘perceive the word of God’ and therefore to
know a person’s problems and address the evil forces in the name of God.
In contrast to the indigenous healers, the religious healers overtly
emphasized the importance of the individual’s spiritual belief system in
the causality and healing of madness. They indicated that, as part of the
healing process, the individual should renounce their allegiance to
indigenous practices, which were seen as evil and demonic, and should live
by the word of God, for example, attending church and fellowship groups,
praying and reading the scriptures. By engaging with God, the individual
would be protected from the demonic spirits. These approaches effectively
re-conceptualize the meaning of indigenous behaviours, beliefs and
culturally significant objects within a Christian worldview and thus elim-
inate the power of the ancestral spirits.
The second process central to these representations is that the spiritual
world is regarded as dichotomous, comprising benevolent and malevolent
spiritual forces. Conflict between these forces is central to this concept of
95
06 074976 Teuton 8/3/07 1:19 pm Page 96
madness. Two mechanisms emerge from the data to explain how the evil
forces create madness. Evil forces constantly battle with good spiritual
forces in order to destroy the positive and godly images created by God.
Madness is seen as the outcome of the conflict, in which evil forces prevail.
This process can be passive (an individual engaging in certain types of
behaviour is sufficient to allow demons to exert an influence on the indi-
vidual) or active (evil spiritual forces physically enter the person through
actual openings in the body).
And when they talk to the witchdoctors, the witchdoctor says, maybe your
problem could be answered by being cut and then you’ll be blessed, they
will chase away everything but actually the cuts on the body, is an opening
for diabolical spirits to attack that person. (RH11)
Alternatively, madness is seen as a means by which the evil spirits manipu-

late an individual into making an allegiance with them. Here the relation-
ship between cultural practices and madness is inverted. Madness becomes
a mechanism used by the evil force to induce the individual and/or their
family to consult an indigenous healer. For example, a Muslim religious
healer suggested that the jinn are motivated to create madness in order to
ensure the individual engages in traditional practices.
From the perspective of the religious healers, healing occurs when the
evil forces are eradicated by good forces. They commonly advocated de-
liverance, the use of prayer, the ‘word of God’ and, healing practices that
physically connect the individual to the spiritual source.
I’d also pray what we call a prayer of deliverance, a prayer of deliverance is
a prayer to break the bondage, to break the power of the evil one, so I’d say
‘In the name of Jesus Christ, in the name of Jesus who is risen, I take all
authority of God and I command all evil presences to depart, I bind you
evil one, I command you to leave and to go to the foot of the cross’. (RH09)
During these rituals the good power of God is transmitted to the in-
dividual in order to remove or nullify the evil force. A similar process is
described by the Imams who use the holy words of the Prophet to expel
the jinn. For example, one Imam explained that it is common practice for
Imams to recite the words of the Koran while placing their fingers in water,
thus allowing the power of Allah to be transfer to the water. The water is
subsequently drunk by the sufferer, or used for bathing in order to repel
the jinn.
Kizungu Madness
Nine indigenous and nine religious healers recognized a form of madness
which they associated with the physical self and a western medical
paradigm of health. A variety of terms are used to distinguish this form of
96
06 074976 Teuton 8/3/07 1:19 pm Page 97
madness from spiritual forms of madness, including: ‘real illness’;

bulwadde buzungu, (white men’s sickness); and ‘kizungu madness’ (white
man’s madness).
The indigenous healers suggested that fever, HIV/AIDS and, to a lesser
extent, syphilis cause kizungu madness. The term fever is often used in
Uganda to refer to malaria and/or symptoms of fever that may result from
a variety of infectious diseases. Some of the indigenous healers suggested
that these infectious diseases were due to viruses, poor sanitation and poor
hygiene. Other precipitants of madness discussed by these healers included
substance misuse and poor feeding. They gave little indication, however,
of how these diseases or behaviours might lead to madness. There was
some evidence from the interviews that the indigenous healers associated
madness with the brain (mind or head).6 For example, a number of them
suggested that madness results from fever of the brain, whereas others
referred to problems with the misuwa (a term used to convey both blood
vessels and nerves) in the brain. Beyond this, they found it difficult to
discuss the process by which these factors cause madness.
Most of the indigenous healers agreed that kizungu madness could not
be treated by traditional medicine, indicating that, if they diagnosed this
type of madness they would refer the individual to muzungu (western)
doctors and hospitals. It was generally thought that these doctors would
prescribe medication (particularly injections), carry out blood tests for
HIV/AIDS and examine the brain and musuwa; however, they were unable
to elaborate further.
As with the indigenous healers, the religious healers suggested that
infectious disease such as HIV/AIDS, malaria and syphilis, physiological
problems with the brain, and, substance misuse could cause madness. In
addition, some of the religious healers also implicated physical trauma to
the head and psychiatric illness. They consistently stated that these
conditions affected the physical body and resulted in the unusual be-
haviours described in the case vignettes. A number of the religious healers
also suggested that madness could be inherited and their discussions
suggested that they understood inheritance as a biomedical construct
rather than a spiritual one. For example, one Imam used the term ‘science’
when explaining the transmission of disease across generations, while
other religious healers referred to madness passing down the family line
through the blood or through sexual intercourse.
In contrast to the indigenous healers, the religious healers were less
consistent in delineating this type of madness in terms of the
spiritual–nonspiritual dimension. A number of the religious healers high-
lighted the need for the client to be referred to a western medical insti-
tution for biomedically orientated interventions. As with the indigenous
healers, they suggested that this would involve medication and blood tests.
97
06 074976 Teuton 8/3/07 1:19 pm Page 98
Some also referred to the national psychiatric hospital, which suggests that
they distinguished between physical and mental health problems. Others
integrated biomedical healing into their own practice. For example, one
evangelical Christian minister employed a retired psychiatric nurse who
prescribed medication (such as diazepam) for his clients, while he treated
their spiritual needs. The discourse suggested, however, that the religious
healers did not regard treatment of kizungu madness as being exclusively
within the domain of western medicine. A number of them suggested that
God is responsible for creating everything including disease and therefore
is central in the development and healing of madness. In some instances,
western medicine was seen as a ‘short cut’ to healing, wheras in others it
was stated that spiritual healing alone could resolve kizungu madness,
particularly where biomedical treatment is either inadequate or not
available.
Psychological Models of Madness

The final groups of explanations can be broadly termed psychological and
emerged from discussions with nine of the religious healers. The processes
underlying these representations are described in Figure 3.
Negative Internal Reaction to Adversity

Most commonly, madness was seen as a negative internal reaction to
adversity; an involuntary coping mechanism to deal with difficult personal
and social problems. The adverse social context incorporates three types
of social and personal hardships which the religious healers identified as
potential precipitants of madness: Economic insecurity refers to poverty,
insecurity of income and insecurity of employment (e.g., the healers
discussed lack of access to basics amenities such as food and water and
difficulties meeting payments when income is low and erratic); adverse
personal experiences included suspecting or knowing that you or a family
member has HIV/AIDS, childhood experiences such as neglect, loss of
parents, and abuse, or war ‘trauma’; finally, conflicts within the family were
cited by most of the religious healers as a potential cause of madness (e.g.,
infidelity and the oppression of wives by the husband’s family).
The explanatory models underlying this representation suggest that the
religious healers locate madness in the internal world of the individual.
Three mechanisms are used to explain the process by which people become
mad in the face of social adversity. All of these mechanisms are presented
as involuntary in the sense that the individual does not deliberately set out
to create the mechanisms described. The articulation of these particular
mechanisms suggests that the religious healers perceived the internal world
as comprising of both psychological and physiological elements.
98
Representation DELIBERATE ACT OF NEGATIVE INTERNAL REACTION TO COLLUSION WITH
WILL
06 074976 Teuton
ADVERSITY FALSE BELIEFS

8/3/07
Location & Nature Madness Located in the

Internal World
1:19 pm
Emotional Avoidance
reaction mechanism
Causality Physical reaction

Page 99
99
Adverse Social Context False Beliefs
Economic Family
insecurity conflict Self-
Imposed generated
beliefs belief
systems systems
Adverse personal
experience
Legend
Figure 3 Process model of psychological representations of madness presented by the religious healers.
06 074976 Teuton 8/3/07 1:19 pm Page 100
First, and most frequently, the religious healers suggested that the indi-
vidual responds emotionally to the adverse social situation; for example,
becoming anxious, feeling hopeless or a failure. The experiences described
in the case vignettes are seen as the manifestations of these psychological
reactions to adversity.
[F]ear of the future, fear of the past, fear of the ancestors, fear of death, fear
of death is very strong, fear of sickness, people are very, very afraid, and
there’s no security, there’s poverty . . . the fear of AIDS here, the fear of
poverty . . . (RH09)
Interventions that enabled the individual to express the problems under-

lying their reaction and develop better ways of dealing with them were felt
to be appropriate for these individuals. The term ‘counselling’ was often
used to explain this process; however, the religious healers’ concepts of
counselling varied. Some emphasized the need to question the individual
and to explore the underlying problems, whereas others referred to
changing the way the individual thinks about their situation and encour-
aging them to recognize that their situation is not as bad as it appears.
Counselling also included providing practical advice and guidance on how
to deal with the problem, promoting reconciliation or forgiveness,
changing the person’s expectations and encouraging the individual to
submit to their social situation. A central aspect of this type of inter-
vention appears to be engendering hope or optimism. The religious
healers described the importance of conveying to the client that they are
able and willing to help, and that they had previous experience helping
people with similar problems.
Avoidance was the second mechanism discussed by the religious healers.
They indicated that individuals develop avoidance strategies in order not
to have to face the difficulties in their lives and the associated emotions
and thoughts. Within this model, the experiences described in the case
vignette were seen as the manifestation of this avoidance. For example, one
minister suggested that Kato’s claims about meeting the President were
part of a fantasy self which he had created as a means of coping with
vocational disappointments in life (see case vignette in Appendix). An
alternative model put forward, was of individuals suppressing their
thoughts and feelings associated with difficult experiences. Although some
of the healers found it difficult to explain how this might result in
madness, one Christian minister drew on the metaphor of a boil to
explain this process. He suggested that suppressed feelings build up and
eventually erupt; madness represents this eruption. Some of the religious
healers suggested that other members of the community often did not
understand or talk to the individual about their problems and felt that this
further reinforced avoidance strategies. The religious healers emphasized
100
06 074976 Teuton 8/3/07 1:19 pm Page 101
the need to encourage individuals to confront the experiences, thoughts

and emotions that were being avoided. Once this is done, more practical
support, such as financial support and opportunities for employment and
income generation, could be offered.
A number of the religious healers also indicated that cognitive and
emotional reactions to the adverse social context can result in somatic or
physiological processes which in turn caused madness. For example, one
explained that when people worry they do not sleep and this can cause the
brain to deteriorate. Another stated ‘when you think too much, the blood
can start not doing too much in your head.’ The religious healers gave little
indication of the types of healing necessary to deal with the physiological
problems, with the exception of a Catholic priest who administered a
range of herbal medicines to rectify physiological dysfunctions.
Collusion with False Beliefs

The second psychological representation of madness, discussed by four of
the healers, is referred to as collusion with false beliefs. The explanatory
model underlying this representation is limited but suggests that madness
emanates from beliefs (e.g., witchcraft) which are instilled in the sufferer
by others in the community, but which are contrary to the beliefs of the
religious healer. The relationship between holding these beliefs and the
manifestation of madness is not clear; however, the religious healers
seemed to be suggesting that the emotional and behavioural consequences
of these beliefs cause madness. There is some evidence to suggest that the
religious healers regard witchdoctors as knowingly perpetuating beliefs
about witchcraft in order to create anxiety and thus continue to earn an
income from resolving witchcraft. It is interesting to note, however, that
another religious healer identifies strong religious beliefs as a cause of
madness.
Sometimes if there is no proper guidance it’s possible [that religion causes
madness]. A person may begin to jump into the picture, the scene that has
been taught at the pulpit and get absorbed in there so much that they
believe that they have demons. And in the end they get that psychological
illness. (RH04)
The religious healers make little reference to resolving this type of

madness, however, they indicated that they encourage individuals to re-
linquish these beliefs and the practices associated with them. For example,
one religious healer indicated that he would destroy any charms or amulets
given to the individual by the witchdoctor, and another indicated that he
would convince the individual that their religious beliefs are untrue and
encourage him to leave that particular church.
101
06 074976 Teuton 8/3/07 1:19 pm Page 102
There was also a suggestion that madness was caused by the individual
believing too much in their own dreams and fantasies. In contrast to
madness as a negative internal reaction to adversity, these fantasies are not
functional; rather they are presented as apparently arbitrary and in this
sense similar to the psychiatric concept of a delusion. One religious healer
drew on an example from the national press to illustrate this. A woman
dreamt that the soil in her garden could cure AIDS. On waking she took
this dream as a message from the indigenous spirits and began to spread
the word about the healing properties of her soil. As a consequence many
people flocked to her homestead to take the soil in the hope of a cure. This
story is congruent with indigenous belief system and may be accepted by
many Ugandan people. The religious healer, however, viewed this woman
as being mad, explaining that her madness resulted from her ‘believing too
much’ in her own dreams.
Deliberate Act of Manipulation

A less common representation referred to madness as a deliberate act of
manipulation. This was drawn from the interviews of two religious healers
and there is limited data from which to develop an explanatory model.
The data suggest that these healers attributed the experiences described in
the case vignette to a conscious pattern of behaviour engaged in by the
individual to turn a difficult situation to their advantage. For example, one
religious healer suggested that the person in the case vignette may be
pretending to be rich in order to develop links and contacts to increase his
own prosperity. Within this model, healing was not discussed, as the
experience was not perceived as being a problem for the individual.
Discussion
The data indicate that there is a range of explanatory models of madness
within the nonallopathic healing system in urban Uganda. These models
draw on different paradigms, reflecting the diversity of the cultural context
of urban Uganda. As has been found by previous investigators, the healers
were able to hold a number of models simultaneously (Fosu, 1981; Good,
1987; Ovuga et al., 1999; Patel, Musara et al., 1995). The explanatory
models discussed by the healers were not differentially applied to the two
vignettes designed to reflect syndromes recognized by western medicine,
schizophrenia and bipolar disorder, with the exception of the social justice
model, which was only referred to by indigenous healers discussing the
case vignette depicting bipolar disorder.
Spiritual and physical explanatory models emerged as predominant;
however, the spiritual models were more fully elaborated by the
102
06 074976 Teuton 8/3/07 1:19 pm Page 103
indigenous healers. This is consistent with previous research in Africa, as

outlined earlier, and suggests a degree of commonality in themes under-
pinning conceptualizations of ‘madness’ across the continent.
In their spiritual models, both the indigenous and religious healers
attributed madness to transgressions of social and moral rules and, in the
case of the religious healers, negative emotions. Responsibility for madness
was to some extent located in the sufferer and/or their family. The
exception to this appeared to be the representation of madness as per-
secution, in which another’s jealousy was seen as being responsible for
creating madness. The agent of change common to these models was an
external spiritual force rather than an internal physiological or psychologi-
cal mechanism. The spiritual world was presented as real and exerting an
influence in the living world. Different spiritual forces were implicated,
reflecting the specific worldviews drawn on by the different healers. The
indigenous healers made a within-worldview differentiation between
ancestral and sent spirits. In contrast, the religious healers attributed
madness to bad spirits, which were equated with the indigenous spiritual
world, whereas the good spirits associated with Christianity and Islam (God
or Allah) were seen as the healing force. In this sense, the religious healers
acknowledged the indigenous spiritual worldview but re-conceptualized it
negatively within a Christian/Islamic framework.
Shweder and Bourne (1982) suggest that, within many cultures,
concepts of self, which they refer to as sociocentric organic, integrate the
individual with the social, natural and supernatural worlds. It was clear
that both the religious and indigenous healers interviewed for this study
understand the self to be inextricably linked with spiritual forces. The
models underlying the indigenous healers’ spiritual representations of
madness additionally reflected their understanding of some forms of
madness as collective experiences, and indicated that they saw the self as
also being integrated with the social world. This emerged most strongly in
the representation of madness as a communication from the family spirits,
in which madness is seen as the manifestation of inappropriate family
behaviour. Similarly, the process of healing engages the whole family, with
adherence having a positive impact on the family and nonadherence being
associated with negative consequences. Collectivism is not immediately
evident in the representations of madness as social justice and per-
secution, as causality and interventions are specific to the individual.
However, even in these cases the experience of madness is created out of
the triad of the individual, the spirit world and a member of the
community. This contrasts with the religious healers’ representations, in
which individual immoral behaviour or emotional reactions are directly
responded to by the spiritual world and where interventions focus specifi-
cally on the individual rather than the family.
103
06 074976 Teuton 8/3/07 1:19 pm Page 104
Most of the indigenous and religious healers utilized explanatory models

that draw heavily on dominant concepts of physical health promoted in
Uganda – primarily those associated with infectious diseases, HIV/AIDS,
malaria and fever. This is consistent with research in Zimbabwe which
found that AIDS and chronic physical illness were identified as causes of
mental illness among care providers, community workers and traditional
and faith healers (Patel, Musara, et al., 1995). These infectious diseases are
(or have been) highly prevalent in Uganda and have received considerable
investment in terms of health education and treatment (Government of
Uganda, 2000). Furthermore all these infectious diseases can result in
bizarre and socially unacceptable behaviour, delusions and hallucinations
(Aghanwa & Morakinyo, 2001; Rausch & Stover, 2001; Slade & Bentall,
1988). It is likely that the prevalence and general awareness of these
conditions in Uganda, in conjunction with effective reduction in
symptomatology following biomedical intervention, has resulted in the
development of these models. The religious healers, however, draw on a
much broader range of concepts associated with biomedicine than the
indigenous healers. Significantly, they utilized a range of psychiatric terms
suggesting greater exposure to a biomedical concept of mental health.
With the exception of hygiene practices, little reference is made by the
indigenous healers to the aetiology or transmission of disease. Reynolds-
Whyte (1982) suggests that in many African societies, illnesses are treated
symptomatically but, when this treatment fails, the aetiology of the
misfortune is sought in terms of the social and spiritual world. Thus,
physiological explanations of madness may not be very relevant to these
healers. In their discussions of madness, however, both the indigenous and
religious healers included reference to problems located in the head, due
to diseases affecting the brain or problems with the misuwa. This obser-
vation suggests that they do have a concept of a physical self in which the
head and nerves/blood vessels can mediate behaviours and perceptual
experiences.
From the interviews with the indigenous healers it was apparent that
kizungu madness was distinct from madness that results from spiritual
sources; the former being associated with biomedicine in terms of diag-
nosis, medication and injections. Historically, non-kiganda or kizungu
illnesses are thought to have been brought to Buganda by the Arabs and
Europeans and are therefore believed to be outside the remit of indigenous
medicine. A similar delineation did not clearly emerge in the transcripts of
the religious healers. Although at one level these healers discuss the appro-
priateness of referral and treatment in hospitals in the same way as the
indigenous healers, they link the development of madness and effective
treatment to the higher power of God, implying that they do not accept the
paradigm of biomedicine to the same degree as the indigenous healers.
104
06 074976 Teuton 8/3/07 1:19 pm Page 105
In marked contrast to the indigenous healers, most of the religious

healers provided elaborate psychological models of madness that are more
consistent with a western psychological explanation of distress. Within
these models, madness is viewed as being precipitated by experiences in
the social world; in particular, economic insecurity, personal experience
and social conflict. These social problems are experienced by many
Ugandans. Uganda is a very poor country and there are limited oppor-
tunities for secure employment for the urban poor. The country has a
significant HIV/AIDS problem that, among other things, has resulted in
large number of children being orphaned. Recent and ongoing internal
conflicts have resulted in significant loss of life, child abduction and abuse
(Barton & Mutiti, 1998). These are all high profile issues in the develop-
ment discourse in Uganda and the donor community has invested signifi-
cant resources in an attempt to address them.
It is interesting, however, that these issues have not been incorporated
into the explanatory models of the indigenous healers and a number of
hypotheses can be put forward here to account for this. First, it has
been suggested that the religious and indigenous healers differ in their
understandings of these social experiences. Haynes (1996) argues that
Christian fundamentalists emphasize a materialistic ‘gospel of prosperity’
that encourages economic success as a sign of God’s favour. Wealth in
these terms relates to financial capital, unlike the historical natural-
resource-based concept of wealth held by the Baganda. A further related
factor concerns the populations encountered by the different healers.
Historically, indigenous healers were consulted by members of their clan
(Roscoe, 1965), and it is likely that the indigenous Baganda rather than
the migrant population continue to consult Baganda indigenous healers.
The Baganda have greater access to land in Kampala, thus the concept of
financial security may be less significant in the indigenous healers’ con-
ceptualization of their lives. In contrast, the religious healers do not have
an affinity to any particular clan or tribe and seek to provide support for
members of the community who reject the indigenous systems (Haynes,
1996). In this respect, it is possible that they see greater numbers of urban
migrants, and that economic insecurity is a more prominently expressed
problem within this community.
Second, indigenous conceptualizations of the relationship between the
individual and the social and natural world may also be important in
explaining the lack of emphasis placed on the psychological impact of
personal experiences. Anthropological research in Uganda suggests that
social and natural trauma or misfortune are often attributed to spiritual
forces (Reynolds-Whyte, 1991). Although the practical implications of
these disasters may be attended to, reference back to the spiritual world is
common practice in order to prevent further disaster and to encourage
105
06 074976 Teuton 8/3/07 1:19 pm Page 106
good fortune. For example, spiritual practices such as ritual cleansing are
conducted in order to rid the individual of harmful spirits, thank the
spirits for the safe return of individuals from war, and prevent further
misfortune (Barton & Mutiti, 1998). It would appear that less emphasis is
placed on examining the impact of the experience on the individual self
than would be expected from a western psychological perspective.
The third reason why contemporary issues may not have been in-
corporated into the models of the indigenous healers concerns the premise
that individuals react ‘psychologically’ to these social experiences. In order
to act in relation to a situation, there is a need to have some concept of
self as autonomous and independent. This notion of the self is relatively
modern and emerged during the Enlightenment in Europe. During this
period, science and reason dominated over religion and the spiritual, and
autonomy and freedom became important societal values (Bracken, 1998).
Societies which have adopted this model of self have been referred to as
egocentric-contractual in that they focus more on the intrapsychic and
advocate self-reflection on desires and cognitions (Shweder & Bourne,
1982). Taylor (1997) suggests that key features of modern concepts of self
are the individual self as distinguished from the natural and social worlds,
the ability of the individual to initiate change, and individuals acting for
themselves in a purposeful way. This view of self in part gave rise to the
need to develop ‘theories of the self and behaviour that would explain
human action and so allow for technical interventions to be made’
(Bracken, 1998: 43). For example, psychoanalysis and cognitivism suggest
that meanings are individualistic and generated in the mind, and these
meanings need to be attended to through introspection in order that the
person’s concept of reality is realigned. The social anthropological litera-
ture suggests that the model of self as independent and autonomous is not
shared by all cultures and societies (Bracken, 1998; Fabrega, 1989b;
Shweder & Bourne, 1982).
It can be hypothesized that the religious healers have a greater affinity
with this model of self because of their exposure to European and North
American culture during their training and interactions with American
and European representatives of the church. Thus they are able to draw on
this concept of self in order to provide healing that is based on the notion
that the individual is free to change thoughts or behaviour in order to
alleviate suffering. As a consequence of globalization and development,
these egocentric-contractual concepts of self have been widely promoted
in relation to mental health in regions such as Africa. For this reason, until
very recently there would be little reason for the indigenous healers to
develop more psychologically orientated models of madness. Where these
models do exist, they are less developed than models based on the socio-
centric organic self.
106
06 074976 Teuton 8/3/07 1:19 pm Page 107
Implications for Service Development

The presence of multiple and complex explanatory models of ‘madness’ in
conjunction with the fact that nonallopathic healing systems are utilized
to a much greater extent than allopathic medicine for ‘mental health’
problems in Uganda (F. Baingana, personal communication, 18 January
1998) leads to a number of policy and research issues in relation to service
delivery.
It is likely that the spiritual explanations of psychotic experiences offered
by these healers are congruent with the worldviews of the individuals and
family members who consult them. By containing their experiences within
a familiar and authoritative explanatory framework, the individual is able
to frame them in a meaningful way. The sociocentric models of self and
healing promoted by the indigenous healers place a greater emphasis on
managing experiences within the social context and promote greater social
relatedness. This may reduce the negative social consequences associated
with madness and facilitate reintegration following a psychotic episode
resulting in a better prognosis (Kirmayer & Corin, 1998). In contrast, by
promoting a psychiatric model as the ‘truth,’ the client’s experience and
understanding of their experiences is ignored and the indigenous or
religious belief system upon which it is based is undermined (Bracken,
1998). Furthermore, it has been suggested that the egocentric concept of
self, which is characteristic of developed societies and implicit in psychi-
atric models of ‘psychosis,’ can interfere with recovery from ‘schizophrenic
conditions’ (Kirmayer & Corin, 1998; Lin & Kleinman, 1988). By imposing
a psychiatric explanatory model and system of intervention there is a
danger of disrupting the sociocentric model of healing currently engaged
in within the community.
The kizungu model suggests that there is a cultural construct of self that
is biologically determined and influences behaviour and experiences. This
construct may be consistent with a psychiatric model so that the use of
psychotropic medication by doctors is likely to be consistent (in part) with
the expectations of the patient. Kizungu ‘madness,’ however, is more closely
aligned with models of infectious disease, and it is likely that individuals
will expect medication to be short-term and curative, rather than longer
term and prophylactic. This expectation, combined with the significant
side effects of neuroleptics, which are sometimes equally or more de-
bilitating than the original psychotic experiences (British Psychological
Society Division of Clinical Psychology, 2000), may result in non-
compliance with treatment.
The descriptions of psychological models of, and interventions for,
madness given by the religious healers are particularly important. There is
a tendency to assume that religious healers utilize purely spiritual forms
107
06 074976 Teuton 8/3/07 1:19 pm Page 108
of healing; however, this research suggests that they also use psychological
interventions. Bracken and his colleagues (Bracken, 1998; Bracken, Giller,
& Summerfield, 1995) have been critical of exporting western psychologi-
cal models of distress and interventions. They suggest that these
approaches are based on an individualistic approach to human life and
egocentric-contractual concepts of the self, assumptions that are not valid
in many nonwestern countries. The theoretical basis of the models
described by the religious healers is, however, unclear and appears to stem
from idiosyncratic understandings of western psychological medicine.
Although some religious leaders may receive training in psychological
ideas and counselling to aid their pastoral care role, the extent of their
knowledgebase in relation to helping people with ‘psychotic’ experiences
is questionable.
Conclusions
The extent to which these diverse accounts of madness are embraced and
promulgated by the healers clearly reflects the extent to which they have
been influenced by the Baganda, Christian–Islamic and western scientific
traditions which have come together to constitute the present cultural
environment of urban Uganda. It is important that this healing context
and its role in relation to the management of psychotic experiences is
acknowledged and understood, not only to help allopathic practitioners
gain a greater understanding their client’s experiences, but also as a means
of exploring and developing more integrated approaches to the manage-
ment of individuals distressed by psychotic experiences.
It is suggested that service provision in Uganda adopt a more flexible
approach to the management of people with psychotic experiences and
liaise to a greater degree with indigenous and religious healers. While not
denying the importance of medication for some people, this approach may
allow psychiatric services to focus on aspects of the clients’ experiences for
which they have the appropriate skills and resources while allowing
indigenous and religious healers to provide services that enable clients to
understand and manage their ‘psychotic’ experiences within a meaningful
worldview. This approach would also enable a more individuated response
to client experiences and understandings. Those clients who opt for a more
medical understanding of their experiences may not choose to consult with
indigenous and religious healers, whereas others may gain significantly
from being able to access these types of healers in an atmosphere of
collaboration rather than ambivalence or antagonism. This is consistent
with the view taken by Halliburton (2004) who suggests that the avail-
ability of diverse healing systems may facilitate recovery from mental
108
06 074976 Teuton 8/3/07 1:19 pm Page 109
disorders because different services are perceived as helpful by different

clients and their families. It is important, however, not to romanticize
healers as they have significant power, particularly in the context of vulner-
able individuals and families who are seeking help for something which is
potentially distressing, which can be abused and as yet, there is little
research on the efficacy of spiritual models of healing (Swartz, 1998).7 A
model of integration would, however, provide a more positive environ-
ment within which to share western biomedical models and modes of
treatment for both organic and functional ‘psychoses’ with indigenous and
religious healers and develop training, cross referral and research
initiatives.
In pursuing such a model there continues to be a need for further
research concerning indigenous means of helping people who are
troubled by psychotic experiences. Studies examining pathways to care
among people with ‘psychotic’ experiences and the conceptual models
held by these individuals and their caretakers, would complement the
current findings and produce a clear picture of the extent to which
indigenous and religious healing practices are consulted in relation to
‘psychosis.’ In addition, there is a need to ascertain the efficacy of the
healing systems described in this study. It is important, however, that
efficacy is defined in terms relevant to clients in the African context and
not solely based on western diagnostic symptoms, as these may not repre-
sent problematic or culturally relevant experiences. More collaborative
research projects integrating indigenous and religious healers in the
design and implementation of these studies would potentially result in
better quality research and allow an opportunity for these healers to inte-
grate more appropriately in the development of services for people with
‘psychotic’ experiences.
Notes
1. Prior to colonization, Buganda was a kingdom in East Africa bordering Kenya
and Lake Victoria. It is now a district of modern-day Uganda.
2. The indigenous people of Buganda.
3. At the time of the study, only six Ugandan psychiatrists were practising in the
country.
4. Luganda is the vernacular language of the Baganda.
5. Muslim Buganda doctors or Muslim indigenous healers.
6. The concepts of the brain, head and mind were not easily differentiated in
Luganda.
7. It should also be noted that human rights abuses have been reported in the
context of psychiatric services in Africa (e.g., Alem, 2000).
109
06 074976 Teuton 8/3/07 1:19 pm Page 110
References
Aghanwa, H. S., & Morakinyo, O. (2001). Correlates of psychiatric morbidity in
typhoid fever in a Nigerian general hospital setting. General Hospital
Psychiatry, 23, 158–162.
Alem, A. (2000). Human rights and psychiatric care in Africa with particular
reference to the Ethiopian situation. Acta Psychiatrica Scandinavica, 101,
93–96.
Al-Issa, I. (1995). The illusion of reality or the reality of illusion: Hallucinations
and culture. British Journal of Psychiatry, 166, 368–373.
Al-Issa, I. (2000). Al-Junun: Mental illness in the Islamic world. Madison, CT: Inter-
national Universities Press.
Barton, T., & Mutiti, A. (1998). NUPSNA: Northern Uganda psycho-social needs
assessment report. Kampala, Uganda: UNICEF.
Bracken, P. J. (1998). Hidden agendas: Deconstructing post traumatic stress
disorder. In P. J. Bracken & C. Petty (Eds.), Rethinking the trauma of war.
London: Free Association Books.
Bracken, P. J., Giller, J., & Summerfield, D. (1995). Psychological responses to war
and atrocity: The limitations of current concepts. Social Science & Medicine,
40(8), 1073–1082.
Bracken, P. J., & Thomas, P. (2001). Postpsychiatry: A new direction for mental
health. British Medical Journal, 322, 724–730.
British Psychological Society Division of Clinical Psychology. (2000). Recent
advances in understanding mental illness and psychotic experiences. Leicester,
UK: British Psychological Society.
Choguil, C. L. (1994). Crisis, chaos, crunch? Planning for urban growth in the
developing world. Urban Studies, 31, 935–945.
Dale, J. R., & Ben Tovim, D. I. (1984). Modern or traditional? A study of treatment
preference for neuropsychiatric disorders in Botswana. British Journal of
Psychiatry, 145, 187–192.
Edgerton, R. B. (1966). Conceptions of psychosis in four East African societies.
American Anthropologist, 68, 408–425.
Ensink, K., & Robertson, B. (1999). Patient and family experiences of psychiatric
services and African indigenous healers. Transcultural Psychiatry, 36, 23–43.
Fabrega, H. (1989a). On the significance of an anthropological approach to
schizophrenia. Psychiatry, 52, 45–65.
Fabrega, H. (1989b). Cultural relativism and psychiatric illness. Journal of Nervous
and Mental Disease, 177(7), 415–425.
Favazza, A. R. (1982). Modern Christian healing of mental illness. American
Journal of Psychiatry, 139, 728–735.
Fosu, G. B. (1981). Disease classification in rural Ghana: Framework and impli-
cations for health behaviour. Social Science & Medicine, 15B, 471–482.
Good, C. M. (1987). Ethnomedical systems in Africa: Patterns of traditional
medicine in rural and urban Kenya. London: Guildford Press.
Government of Uganda. (1992). Population and housing census 1991. Entebbe,
Uganda: Government of Uganda.
110
06 074976 Teuton 8/3/07 1:19 pm Page 111
Government of Uganda. (2000). Health sector strategic plan 2000/01–2004/5.

Entebbe, Uganda: Government of Uganda.
Hacking, I. (1999). The social construction of what? Cambridge, MA: Harvard
University Press.
Halliburton, M. (2004). Finding a fit: Psychiatric pluralism in South India and its
implications for WHO studies on mental disorder. Transcultural Psychiatry,
41, 80–98.
Hardoy, J. E., & Satterthwaite, D. (1989). Squatter citizen: Life in the urban third
world. London: Earthscan.
Haynes, J. (1996). Religion and politics in Africa. London: Zed Books.
Ilechukwu, S. T. C. (1991). Psychiatry in Africa: Special problems and unique
features. Transcultural Psychiatric Research Review, 28(3), 169–203.
Jablensky, A., Sartorius, N. Ernberg, G., Anker, M., Korten, A., Cooper, J. E. et al.
(1992). Schizophrenia manifestations, incidence and course in different
cultures. A World Health Organization ten-country study. Psychological
Medicine Supplement, 20, 97.
Jacobsson, L., & Merdasa, F. (1991) Traditional perceptions and treatment of
mental disorders in western Ethiopia before the 1974 revolution. Acta Psychi-
atric Scandinavica, 84, 475–481.
Kirmayer, L. J., & Corin, E. (1998). Inside knowledge: Cultural constructions of
insight in psychosis. In X. F. Amador & A. S. David (Eds.), Insight and
psychosis (pp. 193–220). London: Oxford University Press.
Kleinman, A. (1978). Concepts and a model for the comparison of medical
systems as cultural systems. Social Science & Medicine, 12, 85–93.
Kleinman, A. (1980). Patients and healers in the cultural context. Berkeley:
University of California Press.
Kleinman, A. (1995). Writing at the margin: Discourse between anthropology and
medicine. Berkeley: University of California Press.
Kortmann, F. (1987). Popular, traditional, and professional mental health care in
Ethiopia. Transcultural Psychiatric Research Review, 24(4), 255–274.
Kroll, J., & Bachrach, B. (1982). Visions and psychopathology in the Middle Ages.
The Journal of Nervous and Mental Disease, 170, 41–49.
Leudar, I., & Thomas, P. (2000). Voices of reason, voices of insanity: Studies of verbal
hallucinations. Florence, KY: Taylor and Francis/Routledge.
Lin, K.-M., & Kleinman, A. M. (1988). Psychopathology and clinical course of
schizophrenia: A cross cultural perspective. Schizophrenia Bulletin, 14, 555–567.
Lopez, S. R., & Guarnaccia, P. J. J. (2000). Cultural psychopathology: Uncovering
the social world of mental illness. Annual Review of Psychology, 51, 571–598.
Murphy, J. (1976). Psychiatric labelling in cross-cultural perspective. Science, 191,
1019–1028.
Odejide, A. O., Oyewunmi, L. K., & Ohaeri, J. U. (1989). Psychiatry in Africa: An
overview. American Journal of Psychiatry, 146, 708–716.
Orley, J. H. (1970). Culture and mental illness: A study from Uganda. Nairobi,
Kenya: East African Publishing House.
Ovuga, E., Boardman, J., & Oluka, E. G. A. (1999). Traditional healers and mental
illness in Uganda. Psychiatric Bulletin, 23, 276–279.
111
06 074976 Teuton 8/3/07 1:19 pm Page 112
Parrinder, G. (1969). Religion in Africa. Harmondsworth, UK: Penguin.

Patel, V. (1993). Traditional medicine has much to offer [letter]. British Medical
Journal, 307, 387.
Patel, V. (1995). Explanatory models of mental illness in Sub-Saharan Africa.
Social Science & Medicine, 40, 1291–1298.
Patel, V., Musara, T., Butau,T., Maramba, P., & Fuyane, S. (1995). Concepts of mental
illness and medical pluralism in Harare. Psychological Medicine, 25, 485–493.
Patel, V., Mutambirwa, J., & Nhiwatiwa, S. (1995). Stressed, depressed, or
bewitched? Development in Practice, 5, 216–224.
Rausch, D. M., & Stover, E. S. (2001). Neuroscience research in AIDS. Progress in
Neuro-Psychopharmacology and Biological Psychiatry, 25, 231–257.
Reynolds-Whyte, S. R. (1982). Penicillin, battery acid and sacrifice: Cures and
causes in Nyole medicine. Social Science & Medicine, 16, 2055–2064.
Reynolds-Whyte, S. R. (1991). Knowledge and power in Nyole divination. In P. M.
Peek (Ed.), African divination in systems: Ways of knowing (African systems of
thought series) (pp. 153–172). Bloomington: Indiana University Press.
Romme, M., & Escher, S. (2000). Making sense of voices. London: Mind.
Romme, M. A., & Escher, A. D. (1989). Hearing voices. Schizophrenia Bulletin, 15,
209–216.
Romme, M. A. J., & Escher, A. D. M. A. C. (1993). Accepting voices. London: Mind.
Roscoe, J. R. (1965). The Baganda: An account of their native customs and beliefs
(2nd ed.). London: Frank Cass.
Sharp, L. A. (1994). Exorcists, psychiatrist, and the problems of possession in
northwest Madagascar. Social Science & Medicine, 38, 525–542.
Shweder, A. R., & Bourne, E. J. (1982). Does the concept of the person vary cross-
culturally? In A. J. Marsella & G. M. White (Eds.), Cultural conceptions of
mental health and therapy (pp. 97–137). Dorderecht, Germany: Reidal.
Silverman, D. (2000). Doing qualitative research: A practical handbook. London:
SAGE.
Slade, P. D., & Bentall, R. P. (1988). Sensory deception: A scientific analysis of
hallucinations. London: Croom Helm.
Ssemakula. (2000). The Buganda home page: Indigenous religion of Buganda.
Available: www.buganda.com.eddiini.htm.
Swartz, L. (1998). Culture and mental health: A southern African view. Cape Town,
South Africa: Oxford University Press.
Taylor, C. (1997). Philosophical arguments. Cambridge, MA: Harvard University
Press.
Westermeyer, J., & Sines, L. (1979). Reliability of cross-cultural psychiatric
diagnosis with an assessment of two rating context. Journal of Psychiatric
Research, 15, 199–213.
World Health Organization. (1996). Investing in health research and development:
Report of the ad hoc committee on health research relating to future inter-
vention options. Geneva, Switzerland: WHO.
World Health Organization. (2001). World health report. mental health: New
understanding, new hope. Geneva, Switzerland: WHO.
World Resources Institute. (1996). World resources: A guide to the global environ-
ment: The urban environment. New York: Oxford University Press.
112
06 074976 Teuton 8/3/07 1:19 pm Page 113
Appendix
Box 1 Case vignette depicting a woman who may be diagnosed with schizophrenia using
DSM-IV criteria (English version)
Mr Kalyango comes to you with his wife, Patience, who is 21 years old. He tells you
the following story about his wife.
Before she started to change about 12 months ago she was normal and was a good
mother and wife. For the last year, Patience has been acting differently. She has been
telling me that she hears voices of unseen people and that these voices are talking
about her. She tells me they are planning to come and kill her and everyone in our
family. But this is not true. She also won’t take food unless she prepares it herself as
she thinks people are tying to poison her. But no one is trying to poison her and we
all eat from the same bowl. Two weeks ago, Patience wandered off into the bush. We
spent two days trying to find her. When we found her she said that a big machine in
Kampala is controlling her and it made her go to the bush. But there is no machine
in Kampala that makes people do such things.
Sometimes when Patience talks, her ideas are not connected and she talks nonsense.
Sometimes she says that people know what she is thinking before she says it. Patience
can argue and sometimes abuses and fights people, even her father-in-law. This is
causing the family problems.
Gradually over the year, she has started neglecting her body hygiene and now she is
not bathing regularly. Sometimes she is walking around half naked in front of the
neighbours. At other times it seems like she is in a world of her own (she is like she
does not know, hear, nor care about what is around her). She has started to neglect
her duties in the house.
Patience has never taken alcohol or any drugs and is not on treatment. She has no
medical illness or high fever in the last few years.
Box 2 Case vignette depicting a man who may be diagnosed with bipolar disorder using
DSM-IV criteria (English version)
Mrs Kato comes to you with her husband, Kato. She tells you the following story
about him.
Kato used to be a normal, hardworking man who brought home money for the
family. Last month, my husband, he started to become very restless and irritable and
he just stays awake all night. He had no fever and has not been drinking or taking
drugs. He is over talkative and when he talks people cannot understand him very well
because he talks too fast and he talks about so many different ideas and plans. He is
too happy and when he talks he says he is very important and powerful. He has been
telling people he has a cure for AIDS and that he is writing a book about it and that
he is going to see the president about it. But this is not true. He also says he has lots
of land and hundreds of cows, but we have only a small plot of land and two cows.
He has also started moving up and down the village and is spending money that we
have not got.
Before he started acting this way, he had for some time not been so interested in his
work and was not sleeping. He was also thinking too much about things and was a
bit sad. But that only happened for a short time. He was normal before that.
113
06 074976 Teuton 8/3/07 1:19 pm Page 114
Joanna Teuton, PhD, is a freelance research psychologist currently working in

Bangladesh. She also holds an honorary position at Nottinghamshire Healthcare
Trust, UK, where she is involved with the mental health in refugee research
network. She received her Masters in Clinical Psychology in 1991 from the
University of Newcastle-Upon-Tyne, UK and her PhD in Cross Cultural Clinical
Psychology in 2003 from the University of Manchester, UK. Her primary research
interests are cultural expressions of distress, mental health service delivery in
developing countries and psychosocial distress and interventions for refugee
populations. [E-mail: joanna@teuton.wanadoo.co.uk]
Richard Bentall, PhD, is Professor of Experimental Psychology at the University

of Manchester, UK. His main research interests concern the role of psychological
processes in symptoms of psychosis (hallucinations, delusions, thought disorder
and mania), and the development of novel psychological treatments for people
suffering from or at risk of suffering from these disorders. He is the author of
Madness explained: Psychosis and human nature (London: Penguin Books, 2004).
Address: School of Psychological Sciences, University of Manchester, Oxford Road,
Manchester M13 9PL, UK. [E-mail: richard.p.bentall@manchester.ac.uk]
Christopher Dowrick, MD, is Professor of Primary Medical Care and Head of

the School of Population, Community and Behavioural Sciences at the University
of Liverpool, UK. He is the editor of Chronic Illness and author of Beyond
Depression. He is also a member of the UK Department of Mental Health Task
Force. His research interests include depression in primary care and community
settings, critical perspectives on diagnosis and management, the role of primary
care and the impact of psychosocial interventions. He is a practicing GP in North
Liverpool. Address: School of Population, Community and Behavioural Sciences,
2nd Floor, Whelan Building, University of Liverpool, Liverpool L69 3GB, UK.
[E-mail: Cfd@liverpool.ac.uk]
114

Conceptualizing Psychosis in Uganda - The Perspective of Indigenous and Religious Healers - JOANNA TEUTON

Uploaded by

Copyright:

Available Formats

You might also like

Conceptualizing Psychosis in Uganda - The Perspective of Indigenous and Religious Healers - JOANNA TEUTON

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Conceptualizing Psychosis in Uganda - The Perspective of Indigenous and Religious Healers - JOANNA TEUTON

Uploaded by

Copyright:

Available Formats

06 074976 Teuton 8/3/07 1:19 pm Page 79

Conceptualizing Psychosis in Uganda: The

Abstract A qualitative study, investigating the representations and

Vol 44(1): 79–114 DOI: 10.1177/1363461507074976 www.sagepublications.com

Transcultural Psychiatry 44(1)

In Uganda, as in many other African countries, allopathic approaches to

Teuton et al.: Conceptualizing Psychosis in Uganda

these social influences. Healing systems and conceptualizations of suffer-

Healing Context in Uganda

Transcultural Psychiatry 44(1)

resulted in the rise of the independent churches, which incorporate

Teuton et al.: Conceptualizing Psychosis in Uganda

Odejide, Oyewunmi, & Ohaeri, 1989; Sharp, 1994). Physical conceptual-

Transcultural Psychiatry 44(1)

national regulations in Uganda, ethical approval for this research was

Teuton et al.: Conceptualizing Psychosis in Uganda

the fundamental differences across countries and tribal groupings

Transcultural Psychiatry 44(1)

Teuton et al.: Conceptualizing Psychosis in Uganda

(madness), akazole and kalogojo (milder forms of madness) and kutabuka

Spiritual Models of Madness

Spiritual Communication 5 5 1 Manifestation 3 3 3

COMMUNICATION FROM THE FAMILY

PERSECUTION SOCIAL JUSTICE

Madness Located in the Madness as a Manifestation of Madness Located between Madness as a

Location & Sent

Causality linked to sufferer

Cultural Cultural Behaviour Immoral

Figure 1 Process model of indigenous healer’s spiritual representations of madness.

Transcultural Psychiatry 44(1)

on the role of an indigenous healer. By meeting the demands of the

Diagnosis and interventions were equally grounded in the spiritual world.

Teuton et al.: Conceptualizing Psychosis in Uganda

The final feature of this representation is that madness is seen as a col-

Social Justice and Persecution

Transcultural Psychiatry 44(1)

The term persecution is adopted by the authors because of the emphasis

Teuton et al.: Conceptualizing Psychosis in Uganda

problem. In this model, the indigenous healers’ spirit is able to communi-

The reliance on the family to provide much of the contextual explanation

Manifestation of Evil and Punishment

Madness Located in the Madness Represents

Experiences Causality Evil spiritual Madness is a

Madness and healing

Negative Immoral Not engaging in cultural rituals

Figure 2 Process model of religious healer’s spiritual representations of madness.

Teuton et al.: Conceptualizing Psychosis in Uganda

Transcultural Psychiatry 44(1)

Alternatively, madness is seen as a means by which the evil spirits manipu-

Teuton et al.: Conceptualizing Psychosis in Uganda

madness from spiritual forms of madness, including: ‘real illness’;

Transcultural Psychiatry 44(1)

Psychological Models of Madness

Negative Internal Reaction to Adversity

ADVERSITY FALSE BELIEFS

Location & Nature Madness Located in the

Causality Physical reaction

Transcultural Psychiatry 44(1)

Interventions that enabled the individual to express the problems under-