Australian and New Zealand Journal of Psychiatry (1976) 10: 39
CONCEPTS OF MENTAL ILLNESS
AMONGST THE RURAL XHOSA PEOPLE
IN SOUTH AFRICA*
by R. W. S. CHEETHAMt and R. J. CHEETHAMS
SYNOPSIS
The rural Xhosa people of South Africa have retained
social cohesion through traditional custom, purity
of language and the dominant role of ancestor
worship, traditional medicine and witchcraft in life-
style, beliefs and ceremonies. Abstract concepts are
limited and ego defence mechanisms include projec-
tion, displacement and rationalization but cognitive
disturbances per se are not regarded as important.
Major attention is paid to severe conative and affec-
tive disturbances, ascribed to object or spirit intru-
sion, witchcraft or sorcery, which necessitate treat.
ment by a traditional “witchdoctor”. Therapy is
community orientated as far as possible unle.cs uncon-
trollable violent behaviour necessitates referral to a
mental hospital.
This paper is a sub-section of a study commenced
in 1960 by a multi-disciplined, multi-ethnic team
amongst the Gcaleka tribe of the Xhosa people, who,
originating from central and north east Africa
migrated southwards to an area now known as the
Transkei. This beautiful region of high mountains,
deep valleys, flowing rivers and a scenic coactline,
approximates Belgium in size (Mertens 1973). It is
populated by about 3 million AmaXhosa, a per-
*Presented at the First Pacific Congress of Psy-
chiatry; Melbourne, May 1975.
?Professor and Head of Department of Psychiatry,
University of Natal, South Africa.
$Part-time Lecturer and Research Assistant, Univer-
sity of Natal, South Africa.
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
centage of whom are still rural people living in
isolated areas who speak only Xhosa and who
continue to retain their centuries-old tribal structure.
Thousands of amaXhosa died of starvation in 1856,
subFequent to mass slaughter of lung-diseased cattle
(the disease attributed to bewitchment by the British
settlers) and destruction of grain in a millenary
movement initiated by a girl ‘Nongquase’ (Elliot
1972). The latter and a prophet ‘Mhlakaza’, the
alleged medium of the mythical but powerful ‘River
People’, said to be half fish and half human with
great powers of magic, promised power, riches and
elimination of the White man provided that this
destruction was carried out as directed with the dire
warning that the sky would fall on the people should
the ‘River People’s’ wishes not be obeyed. The result-
ant migration and depopulation left the Kentani-
Willowvale area the only true Xhosa region and the
Gcaleka the only tribe of all the clans which has
retained the purity of language, culture and social
structure which has been in existence for over 300
years. This tragedy, however, serves to illustrate
the significance and intrinsic belief of the rurol
Xhosa in superstition, magic and witchcraft.
Social Gtmeture of the AmaXbosa.
The basis of social organisation is that of the patri-
lineal clan (Soga 1931), with the extended family
kinship system and a fixed social structure, resistant
to any change in strongly held beliefs, convictions
and patterns of behaviour, which have maintained
individual and social homeostasis through the years.
Cardinal to their existence and to social integration,
is strict adherence to ancestor worship and strongly
40 CONCEPTS OF
held allied beliefs, convictions and patterns of
behaviour. Social cohesion is maintained through
systematised ritual, ceremony and observation of
taboo, which pertain mainly to women but also to
men and children (Soga 1931). Medicine is the focal
point around which all life events, especially illness
and disaster, economy and subsistence devolve, ‘igqira’,
erroneously called a ‘witchdoctor’ by Whites, the
final arbiter and decision maker in these respects
except for legal matters which are the responsibility
of the Chief or Headman and his councillors. It is
important to mention here that the ‘igqira’ is essen-
tially a diagnostician and therapist and the true
‘igqira’ dedicated to the profession of healing and
well-being. The ‘ixhwela’, on the other hand, is
the ‘herbalist’, a brewer of potions and frequently
involved in sorcery.
Magic, witchcraft and sorcery in these pre-literate
people is closely interwoven into the pattern of living
and includes the belief in spirit and object intrusion
in the form of the “familiars” such as ‘ichanti‘ or
‘mamlambo’, the Mother of the River who is capable
of changing shape but is usually a woman of great
beauty, ‘impundulu’, a bird without bowels mainly
used by women for purposes of bewitchment,
‘inyoka’, a snake of two types, charmed and evil,
used in bewitchment, and ‘tickoloshe’, a short, hairy,
powerful, mischievous male river sprite capable of
walking invisibly through walls and particularly noted
for the size of his penis (Laubscher 1951 and Soga
1931). Magical powers are ascribed to all familiars
who appear to be involved in situations specific to
themselves, for example, ‘ichanti’ and ‘mamlambo’
are usually involved in hallucinatory processes while
‘impundulu’ is associated with persecutory delusions.
This animistic or anthropomorphic attitude, with
specific reference to “mental illness”, inevitably
ascribed to exogenous causes and sorcery, evil spirits,
or familiars, being blamed, provides a material
explanation to the rural Xhosa for abnormal be-
haviour, and action, which otherwise could not be
‘logically’ understood. The ego defence mechanisms
to handle anxiety would appear to be those of
projection, displacement, symbolization and ration-
alization which account for the tendency towards
paranoidal reactions. They serve a purpose, how-
ever, in maintaining social cohesiveness. This
principle is intrinsic to a number of pre-literate
societies in different areas in the world, although the
precise mechanisms vary according to the value
system of the specific tribe or clan. ‘Where limited
cognitive skills do not suffice recourse is made to the
supernatural’ (Lidz, 1973).
Remarkable skills in legalistic argument and
remembering extended kinship systems exist; in
general, however, although the rural Xhosa is
hospitable and helpful in times of need he tends to
lack drive, initiative and tidiness but is cautious, con-
servative and lacking in subtlety. At the first meeting
he is generally not an emotionally expressive person,
but they are usually more expansive amongst them-
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
MENTALILLNESS
selves and on closer acquaintance. As is to be antici-
pated they are extremely suspicious, especially of
change or the introduction of anything which will
disrupt the “natural order of things” (Khoti 1960).
Theirs is a stereotyped form of life for little individu-
ality exists in their similarity of dress, activities and
mode of living without thinking about or questioning
the accepted social organisation or directions of
Headman or ‘igqira’. The rural Xhosa known as
‘Reds’ or ‘Red Blankets’ by virtue of their red
ochre-dyed outer blankets are a colourful people, the
women on ceremonial occasions being ornately
dressed in several garments and young girls fre-
quently garlanded with beadwork. Each family lives
in a collection of huts which surround the cattle
kraal, the sacred place for the propitiation of sacri-
fices to the ancestors. As an example of the animistic
Xhosa concept, during such a sacrifice, it is necessary
for the slaughtered beast to bellow loudly in order
to call the attention of the ancestors to the sacrifice.
Method of Study
A set of questions previously prepared on the basis
of literature pertaining to the AmaXhosa initially
were used but, as shown in Cawte (1972) and
Kiloh’s (1975) studies, structured data cannot be
employed as questions have to be modified con-
stantly according to unexpected answers and circum-
stances. It was frequently necessary to discuss
examples of known psychiatric syndromes in order t o
illustrate a question, and, even more important, was
the use of idiom which abounds in the descriptive
Xhosa language or to use descriptive phrases such as
‘ukupambene’ which means “the mind (or senses)
has been removed” i.e. literally taken away by
familiars or other means, or, “his heart is very sore”
to express depression, a word unknown to them.
Individuals were interviewed singly or in groups, but
as the Xhosa custom is group-counselling by the
Chief, Headman or ‘igqira’, almost invariably the
interviewee, in the fields, in the neighbourhood of his
or her hut, or trading store, or at the sea, was joined
by groups of others, all of whom participated. In
this manner it was possible to elicit information from
a large group. The study also included interviews
from other sources but this paper is confined to
information gathered only from the rural Xhosa
people.
Concepts of Mind
Difficult as it is to obtain an acceptable definition of
‘mind’ from psychiatrists generally, it is even more
difficult to elicit a concept from the pre-literate
‘Red’. Examples of their concepts are as follows:
“The soul lives in the blood and the heart”, the
latter and other internal organs known as ‘umbilini’,
being regarded as the seat of feeling; however, “blood
is vital and more important than the brain”. They
accepted that the brain might be the seat of the mind
“but mind is rhe person’s health and his actions”.
This phrase is highly significant for it forms their
frame of reference, and, equally significant: “Blood
is more important because you cannot have a mind
 AND R. J. CHEETHAM
R. W. S. CHEETHAM
when there is no blood, but you can have no mind
and still have blood and be alive”.
This concept of mind as the “initiator of action and
required for health”, is important to the AmaXhosa
for the mind, therefore, can be removed in a material
sense, ‘ukupambene’, and it is this physical removal,
or “being affected by bad blood” which differs from
most “sophisticated” concepts of psychological dis-
turbances which include cognitive, affective and cona-
tive processes. Abnormal psychotic behaviour, which
would be regarded in the White as indicative of
mental illness constitutes the same threat to the
AmaXhosa as it does to the White but a major dif-
ference exists in that it is not seen in the same
context as a “mental illness”. Furthermore in Euro-
pean society all three components, particularly a dis-
turbance of cognition, are important whereas to the
‘Red’ it is mainly abnormal behaviour and, to an
extent. abnormal emotion which constitutes this
threat, and generally considered to be caused by
outside sources. It would appear therefore, as if
‘insanity’, per se, is not recognized as such or, is a
concept gradually being conveyed to them by the
White, and to which they refer, but which is not
clearly understood.
Conceph 06 Mental Illness
The Western observer unconsciously, at least, must
tend to be comparative, subjective and open to cnti-
cism in attempting to assess the concepts of mental
illness in a culture completely unlike his own. How-
ever, as the team included an experienced White
Xhosa linguist (W B.C.) and a well educated,
medically trained Xhosa man (M.K.), both living
and working amongst them this review endeavours
to describe the concepts from “within the culture”,
undoubtedly utilizing Western frames of reference,
but with the recognition and acceptance, as uncritic-
ally as is possible, of the vital significance of ancestor
worship, witchcraft, ritual, sorcery, spirit and object
intrusion, limited cognitive skills and the essential
pre-literate anthropomorphic explanation of abnormal
or threatening events.
The schema to be adopted in this paper is to conform
as closely as possible to the relative simplicity of the
tribe’s emphasis upon differentiation according to
behavioural or conative abnormalities, to major
affective or emotional experiences, or a combination
of both, Thus these observations will be limited to
the recognition of abnormality, the manner in which
this presents, the “causes” and appropriate therapy
with occasional mention of psychiatric nosology for
ease of reference.
Reeognilion
As far as could be ascertained abnormalities of
behaviour are relatively easily recognised but only
a limited number of these are regarded as constitu-
tional abnormalities of the brain and mind viz:
( a ) “Those who run around, severely hurt or kill
themselves, or who run into the sea and drown”;
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
41
(b) “those whose brains are later affected after the
falling sickness”, and,
(c) “those whose brains ‘go’ when very old”.
All other categories of abnormal behaviour or
emotion are attributed to ‘ukuthwasa’ which will be
described later, or to exogenous factors which affect
“the person’s health and his actions”. Considerable
variation in the recognition of the type of disturbance
was related to the sex and age of the persons inter-
viewed; the younger age group were more aware of
florid psychotic behaviour, the older people, especi-
ally the women, appreciative of both, including situa-
tions in which, “the heart being very sore”, certain
behavioural changes occurred.
Differences in the degree of presenting sympto-
matology also existed, for example, a severe emo-
tional disturbance and frequently a pre-psychotic or
psychotic and mediumistic hallucinatory experience
was accepted by the tribe as a single entity whereas
to the ‘igqira’ this could fall into the category of
severe emotional disturbance or a psychotic experi-
ence. Nevertheless, it provided a means of descrip-
tion for everyone. Similarly a syndrome ‘isifo
esimhlophe’ or ‘the white disease’ which will be
described later is generally accepted to be indicative
of the person “being called to be an ‘igqira’ ”.
The ‘igqira’, however, recognises additional cate-
gories of abnormal behaviour which are attributable
to “the brain being removed by the ‘familiars’ ”, or
“because of bad blood and getting out of gear with
the whole body”; “where hair has been removed
from the person and hidden in the river by the person
bewitching that person” or “disappearance of the
mind as a result of jerkings in the case of falling
sickness”. These differences in recognition by the
‘igqira’ may be significant in terms of their later
explanation, therapy and prognosis.
Mental retardation is recognised in the term ‘azili-
langa’ - unlike the cockerel at sunrise, “he has not
crowed”, or by the phrase ‘ingquonda infutshala’, ‘the
brain is short’. A sacrifice is undertaken but if
unsuccessful the subnormality accepted as such and
not regarded as a mental abnormality. If the
retardation is not too severe circumcision is under-
taken, in due course, and the father even provides
cattle for ‘lobola’ (bride price) at a later stage. It is
important to note here that the only tribe t o practice
the rite of circumcision of their ‘amakweta’ (adoles-
cents) is “essentially an ‘Abe-Nguni’ (Xhosa)” (Soga
1931).
SYMPTOMATOLOGY
Conetive and Affective Abnormalities
In general the rural Xhosa divided abnormalities of
behaviour and affect into three main categories
according to the presenting symptoms t o which a
possible specific Western orientated diagnosis could
be postulated. In preference to this, however, and in
order to illustrate abnormal behaviour as perceived
42 CONCEPTS
06 MENTALILLNESS
by the ‘Red’ the following are verbatim reports taken
from group accounts of the “illnesses”.
1 . “He is the one who runs about, throws his clothes
away, eats very little, one may eat too much; he
does not sleep, or just for a while and then wakes
up. One is very fond of thrashing other people and
in this one his actions and his language and what
he says does not meet with anybody. In some
instances these are people who may d o one thing
suddenly and after that he sits quietly and is very
inactive at his work, he might also shout and swear
and talk nonsense, or there is another who is like
that because there is nothing he can feel deeply, he
feels like a child and you cannot be able to say
whether the person has got any ‘mood’ because his
mind is dead. He places the fault on other people
but the fault is with him because he ‘bought a
familiar’. Or there are others who soil themselves
and may rush around”.
These symptoms conceivably fall into the categories
of mania, schizophrenia, epileptic confusional or
acute brain syndromes. It was difficult to determine
whether schizophrenia, as a separate syndrome, was
recognised by virtue of the characteristic inertia,
untidiness and limited ambition of the rural Xhosa
(Khoti 1960) and as cognitive abnormalities play a
relatively minor role in their assessment. Incongruity
of affect, however, had been observed but could “not
be caught” (understood).
2. “There are those who did not run and do not
eat. This particular one does not behave like before
and has to be. urged to do some work, she does not
work only because she is lazy because ever since
she was born she was not like that. She may cry
because her heart is very sore and she may become
very thin. Because she is married she should behave
as she did before but it is possible that her mind has
been removed”.
This, conceivably, could be a unipolar manifestation
of a manic depressive illness, an involutional melan-
cholia or even a catatonic state but it is singularly
noticeable that little reference is made to any cogni-
tive disabilities.
3. The third category is that of ‘isifo esimhlophe’
referred to originally as an indication that the person
was being “called” to be an ‘igqira’. This syndrome
appears to be heralded in by ‘mbilini’ which are
sensations of palpitation, throbbing, discomfort or
subjective feelings of pain in the epigastric region
(similar to autonomic nervous system overaction).
‘Mbilini’ is associated with increased sensitivity and
emotional instability related to increased excitement
or depression. This emotional state, usually accom-
panied by abnormal behaviour, sometimes in a state
of clear consciousness, is generally known to the
‘Red’ as ‘ukuthwasa’. It is often accompanied by
psychotic behaviour and, in the “natural” ‘ukuth-
wasa’, invariably with hallucinatory experiences which
inevitably involve the ancestors as the ‘igqira’ must
have the guidance of the accompanying ancestral
spirit for the rest of his or her life to assist in their
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
mediumistic powers. The other type of ‘ukuthwasa’,
regarded as due to bewitchment, often consists of
‘mbilini’ with psychotic behaviour but without hal-
lucinatory experiences. These variations are prob-
ably recognised by the ‘amagqira’ for although all
‘amagqira’ allegedly have been subjected t o ‘mbilini‘
and “natural” ‘ukuthwasa’ in all the ‘igqira’ inter-
viewed during this study little evidence of psychotic
thinking or behaviour was observed in these intel-
ligent, highly perceptive individuals. As also observed
by Laubscher (1951) it is likely that the ‘mbilini’ and
‘ukuthwasa’ in their instance varied in intensity and
degree and was probably some highly emotionally
disturbing, but not psychotic state. On the other
hand, they may conceivably fall into the category
of spirit possession described by Yap (1969). One
very helpful, informative ‘igqiri’ (“S”) stated that
she experienced ‘mbilini’ at the age of 18, and on
close questioning, it was evident that she had been
suffering from a severe depressive episode, possibly
endogenous in origin, as she became very fat “after
treatment”. On the other hand two novitiates who
were interviewed, and obviously under surveillance
and treatment, were undoubtedly mildly psychotic.
It would be unwise to speculate as to their ultimate
success in their profession as both were obviously
schizoid.
Despite the epidemiological literature that depression
is infrequent amongst Africans not only was this often
described (and personally observed) but the ‘Reds’
were well aware of the high incidence of the heart
being very sore. Suicide, however, is uncommon. the
highest incidence occurring in the male between 23-30
and often the result of being scolded or reprimanded
(which they find difficulty in tolerating) or in the
woman aged about 35 with 4-5 children. It was
thought not to be related to any form of mental
illness but to worry or to the heart being very sore
as in one person, prior to hanging himself, repeatedly
saying: “My heart is very, very sore; why am I
being tortured like this?”. Another who drowned in
the river “had been called by the ‘River People’”
and appears t o have been schizophrenic. Neverthe-
less, although depression is not regarded as a mental
illness, and suicide never discussed, those who are
obviously depressed are kept under constant surveil-
lance.
Cognitive Changes
Obsessions and compulsions were seldom observed,
as measured in terms of Western standards of dilig-
ence, meticulousness, punctuality, etc. It is our thesis,
however, that obsessional attitudes d o exist in many
instances but that these can only be determined
according to the rural Xhosa value system, in their
strict adherence to ritual, custom and taboo and the
extreme anxiety which arises when propitiation rites
are not observed, although this is frequently sup-
pressed. This appears indicative of super-ego develop-
ment but directed in a manner foreign to the West
which certainly would not accept certain aspects of
their behaviour as being super-ego directed.
 R. W. S. CHEETHAM
AND R. J. CHEETHAM
Illusions and pai ticularly visual and auditory hal-
lucinations are an essential component of the rural
Xhosa value system, especially the hypnagogic variety
occurring in the twilight state early in the morning,
many of which may be dream states, and representa-
tive of wish-fulfilment or an expression of uncon-
scious guilt. Auditory and visual hallucinations
appear to have “status value” particularly as the
content is usually that of an ancestor and related to
propitiation or other ceremonies obviously referable
to the significance of their beliefs and the previously
mentioned essential role of the ancestor in the
‘igqira’s’ activities. When hallucinations are expressed
in states of clear consciousness they are accepted as
expressed as, for example, paranoid auditory hallu-
cinations which may be regarded as a warning from
the ancestors. Even when these are associated with
florid psychotic phenomena the behavioural and affec-
tive disturbances are of far greater significance as
abnormalities in need of therapy. One example given
was “we do see people who talk alone to themselves
or to others who are not there. These may be talking
to the ancestors or it is because they have worries
and talk to themselves about it. These we do not
take to the ‘igqira’”.
In this brief reference to cognitive disturbances, such
as delusional states, it is apparent that mention only
is possible of aspects such as circumstantiality, very
common to the Xhosa even in normal conversation,
perseveration and thought blocking, either as a
conscious or unconscious form of denial or due to
their particular stage of cognitive development. In
keeping with the social system over-valued ideas,
ideas of inference and reference, and passivity feelings
are common, not necessarily indicative of psychotic
thought processes but constructed around their belief
patterns and serve as a means of alleviating anxiety.
Delusional patterns, both systematised and unsys-
tematised were evident, again as an emotional defence
mechanism, and delusions of sin and guilt were
described associated mainly with obvious depressive
episodes. Of considerable importance and signific-
ance to this paper, however, is that, almost invari-
ably, expressed delusions were regarded as exagger-
ated statements or taken at their “face value”
particularly in the absence of florid abnormal
behaviour or major affective disturbance and in a
state of relatively clear consciousness. For instance,
an individual making obviously delusional and
extravagant claims to “many, many cattle” (their
symbol of wealth) was regarded as an entertainer
or liar, whilst nihilistic delusions were considered to
be “their own fault for having bought a familiar”.
In a mildly delirious patient we heard complaining
of “being on fire” the attitude was “let her suffer,
she is burning because of her wrong doings”.
Another rural woman was punished subsequent to
“confessing” to having bewitched and causing the
death of three children in the area yet on enquiry
it was obvious they had died of gastro-enteritis.
Close questioning elicited that she was suffering
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
43
from involutional melancholia and her “confessions”
delusional in content.
Aetiology
Apart from the three “constitutional” types and
‘ukuthwasa’ mentioned earlier, all “mental illness” has
an extraneous cause relating to:
failure to propitiate the ancestors with the
necessary sacrifices or rituals;
non-observance of taboos and the consequent
ancestral displeasure;
bewitchment in which the mind has been
removed through a sorcerer who has obtained
a potion or evil influence from an ‘ixhwela’;
object intrusion-in which removal of the
mind has occurred through the actions of one
of the familiars such as ‘tickoloshe’ making
incisions under the hair line;
spirit intrusion - evil spirits sent by sorcerers;
bad blood and the foam reaching the brain;
excessive worry over matters which “have been
kept to himself”.
Hereditary aspects were ‘observed’ but obviously not
recognised as such in a genetic context. Case histories
were given of patients or relatives whose children had
suffered similar behavioural or affective abnormalities
but, in those described to us, an extraneous factor
was inevitably regarded as the cause despite the
coincidences. This applies in many instances where
individuals are “called” as in one obvious paranoid
schizophrenic who was suffering from persecutory
delusions and auditory hallucinations (from the
ancestors warning him of a plot to kill him). His
wife confidentially informed us that “he was being
called” as his mother was “just like him” and had
been an ‘igqira’. Also “coincidental” were the
number of ‘amagqira’ of whom a parent or grand-
parent had also suffered from ‘isifo esimhlophe’.
Methods of Treatment
These have been “community orientated” for cen-
turies and immediately an abnormality is observed
the patient inevitably taken to the ‘igqira’ who insti-
tutes his or her own ritual of ‘telling’ the patient the
symptoms of the illness, to the accompaniment of
chants and the response ‘siyavuma’ (we agree) from
the relatives. The response varies in intensity and
the ‘igqira’, being extremely perceptive to the
responses of patient and relatives to the direct state-
ments, is able to ascertain which of his comments
are accurate or not and to concentrate on those
which create the more positive reactions. In the
subsequent ritual of passing of the hands over the
head, face, neck, thorax, abdomen and extremities,
deformities can be determined. Subsequent therapy
is highly elaborate with the introduction, inter alia,
of emetics or purgatives, or application of ‘muti’
(herbal medicines) to external orifices causing
sneezing, coughing, etc., depending upon the ‘igqira’s’
diagnosis and the need or otherwise to expel evi1
44 CONCEPTS
06 MENTALILLNESS
influences or counteract the actions of familiars in
many cases. Another method used is t o prick the
skin of a patient with a needle attached t o a cow’s
horn containing ‘special muti’ possessed of magical
powers. Not infrequently an injunction to perform
some ritual sacrifice either to request assistance from
the ancestors or to placate them for a rite forgotten,
or not undertaken, is advised.
Should ‘isifo esimhlophe’ be diagnosed the individual
is treated with extensive ‘muti’ and ritual treatment
is advocated for the state of ‘ukuthwasa’. The patient
then spends four t o five years with the ‘igqira’ in
treatment and subsequently in training. In severe
emotional or psychotic conditions which the ‘igqira’
decides to treat, the patient is constantly under sur-
veillance, treated and then trained; herbs used
obviously possess a powerful sedating effect on a
number of patients
Should a patient refuse to undergo the ritual treat-
ment deterioration in symptomatology occurs. The
‘igqira’ on the other hand may state that he or she
is unable to treat the patient who is then usually
taken to another ‘igqira’ and frequently given the
same opinion probably as a severe illness beyond
the scope of their own treatment is recognisd. These
categories of patients are then referred to the magis-
trate or European doctor for admission to the nearby
mental hospital. In addition uncontrollably violent
patients are also referred to the mental hospital but
referral to the institution is deferred as far as
possible and attempts are invariably made to retain
and treat the patient within the community unless
the violence is so uncontrolled as to constitute a
serious threat to person or property. Even those in
a state of mania or catatonic excitement are adroitly
restrained with the minimum of local injury by
means of soft thongs applied to the wrists and
ankles. They are “kept out of sight of sorcerers’’ in
the maize fields by day and huts by night and pro-
vided with the necessary food and water. The influ-
ence of superstition is such, however, that ex-mental
hospital patients are regarded with suspicion, as
occurs in “developed” societies, but for an entirely
different reason.
COMMENTS
I t would be interesting to study the psychodynamics
and psychopathology involved, suffice to say in this
paper that probably the essential ego defence
mechanisms appear to be those of repression, regres-
sion, rationalization, substitution and particularly by
virtue of the social system and belief in witchcraft,
sorcery and suspicion, displacement and projection.
This observation, however, has more serious connota-
tions. Although the Western psychiatrist may be
aware of all these aspects the application of
Western analytic or dynamically orientated therapy
is virtually impossible by virtue of the fixed,
deeply-rooted, ingrained value systems. Even in the
townships witchcraft abounds or is replaced by the
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
syncretic Zionist religious movement described in
principle as a combination of a primitive Christian
religious belief with baptism by total immersion, and
indigenous ancestor worship and belief in witchcraft
and sorcery; even their bibles are kept bidden t o
prevent a sorcerer removing a page with evil intent.
CONCLU6ION
Social integration, the whole social system related to
ancestor worship, ritual and belief has provided
security to its members for generations. It is to
be anticipated therefore that individuals nurtured in
a society such as this which is strongly resistant to
change must either be emotionally disturbed or view
with grave suspicion circumstances, events or any
threat to their accepted value system. Thus doctors,
and particularly psychiatrists, attempting to apply
Western orientated procedures inevitably must be
confronted with the problem of establishing a posi-
tive doctor-patient relationship which is so essential
especially as they d o not represent the traditional
authority figure and furthermore have not “been
called” in the accepted cultural manner. From per-
sonal experience major difficulties frequently arise in
arriving at a satisfactory diagnostic evaluation. Even
more problematical and difficult is the institution
of effective therapeutic techniques in the treatment
of the ever increasing number of rural Africans
suffering from an increasing incidence of psychiatric
illness and psychosomatic disorder. There is thus.
as exemplified by Galdston (1971), not only the
urgency but also “clearly and widely” the need for
in-depth comprehensive research in these aspects by
anthropology and psychiatry. Both disciplines face
a challenge in respect of the health of the rural
African admitted to general hospitals in the city and
a pre-requisite should be the active participation
in this research and in these studies by registered
African medical practitioners.
Finally, if the observation in this paper that obses-
sional attitudes do exist amongst the rural Xhosa
as determined according to their value system and
not assessed through Western standards and frames
of reference, this principle must apply to many and
diverse cultures, their members hitherto not regarded
as being obsessional and is a pointer to the re-
evaluation of many “primitive” people where projec-
tion and paranoidal attitudes exist resultant upon
an underlying obsessive compulsive attitude towards
ancestor worship, propitiation, ritual and sacrifice.
ACKNOWLEDGEMENTS
Sincere appreciation is expressed to the South
African Medical Research Council for the interest
displayed and the award of a grant to assist in
compiling our research results and to the Department
of Health for financial assistance to present this
paper. In particular our deep gratitude to the late
Mr. W. B. Caley, Mr. M. Khoti and Miss C.
Goosen for their invaluable teamwork, interpretation
and contribution to this study.
 R. W. S. CHEETHAM
AND R. J. CHEETHAM
REFERENCES
Broster, J. A. (1967). Red Blanket Valley. H . Keart-
tand, Johannesburg.
Cawte, J. A. (1972). Cruel, Poor and Brutal Nations.
Honolulu University Press, Hawaii.
Cheetham, R. W. S., Sibisi, H., and Cheetham, R. J.
( 1974). Psychiatric problems encountered in urban
Zulu adolescents with specific reference to changes
in sex education. Australian and New Zealand
Journal of Psychiotry, 8: 41.
Elliot, A, (1972). The Magic World of the Xhosa.
Collins, London.
Galdston, I. ( 197 1 ). The Interface Between Psy-
chiafry and Anthropelogy. Brunner/Mazel, New
York.
Graves, G. D., Krupinski, J., Stoller, A., and Har-
court, A. (1971). A survey of community atti-
tudes towards mental illness, part 1. Australian
and New Zealand Journal of Psychiatry, 5: 18.
Khoti, M. B. (1960). Personal communications.
Professor R. W. S. Cheetham
Department of Psychiatry, Faculty of Medicine
University of Natal
P.O. Box 17039, Congella 4013
South Africa
Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on June 29, 2015
45
Kiloh, L. G. (1975). Psychiatry amongst the Aus-
tralian Aborigines. British Journal of Psychiatry,
126: 1.
Laubscher, B. J. E. (1951). Sex, Custonr and Psy-
chopathology. Routledge and Kegan Paul Ltd.,
London.
Lidz, R. W., Lidz, T., and Burton-Bradley, G.
(1973). Culture, personality and social structure:
cargo cultism. Journal of Nervous and Mental
Diseases, 15% 370.
Mertens, A., and Broster, J. A. (1973). African
Elegance, Purnell, Cape Town.
Soga, J. H. (1931). The Ama-Xhosa: Life and
Customs. Lovedale Press, Lovedale, South Africa
and Kegan Paul, Trench & Trubner & Co. Ltd.,
London.
Yap, P. (1969). The culture-bound reaction syn-
dromes, in Mental Health Research in Asia and
the Pacific. (eds. Candiall, W., and Lin, T. Y.)
East-West Centre Press, Honolulu, Hawaii.