Beliefs About the Causes of Psychosis Among Persons With Psychosis and Mental Health Professionals: A Scoping Review

OBJECTIVE

The beliefs that people with psychosis hold about causes of their illness (causal beliefs) can affect their choice to adhere to treatment and engage in mental health services. However, less is known about causal beliefs of mental health professionals (MHPs) and their impact on treatment adherence and service engagement. This review explored literature focusing on MHPs' causal beliefs and mapped the degree of concordance between their causal beliefs and those of people with psychosis.

METHODS

A systematic literature search of PubMed, Embase, Scopus, PsycINFO, and Applied Social Sciences Index Abstracts and a gray-literature search of PsyArXiv and MedNar yielded 11,821 eligible references. The first author reviewed all titles and abstracts, and the coauthors reviewed 10% (N=1,200).

RESULTS

Forty-two articles were included. Most articles indicated that MHPs tend to endorse biogenetic beliefs (9 of 15 articles assessing MHPs' beliefs, 60%), whereas people with psychosis tend to endorse psychosocial beliefs (16 of 31 articles, 52%) and other nonbiogenetic beliefs (in 8 of 31 articles, 26%). Most studies did not compare causal beliefs of people with psychosis and their treating MHP. Studies varied in design, setting, and measures.

CONCLUSIONS

MHPs and people with psychosis often hold complex views composed of different types of causal beliefs. However, a gap in causal beliefs between these groups appears to exist, which may affect the therapeutic relationship and pose barriers to treatment adherence. Future studies should address this gap by developing interventions that facilitate open communication about causal beliefs to promote treatment alliance and shared decision making.

The content of delusions in a sample of South African Xhosa people with schizophrenia

BACKGROUND

Although the relationship between cultural beliefs and schizophrenia has received some attention, relatively little work has emerged from African contexts. In this study we draw from a sample of South African Xhosa people with schizophrenia, exploring their cultural beliefs and explanations of illness. The purpose of the article is to examine the relationship between this cultural context and the content of delusions.

METHODS

A sample comprising 200 Xhosa people with schizophrenia participating in a South African schizophrenia genomics study were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Participant delusions were thematically analyzed for recurring themes.

RESULTS

The majority of participants (n = 125 72.5%) believed that others had bewitched them in order to bring about their mental illness, because they were in some way jealous of the participant. This explanation aligns well with the understanding of jealousy-induced witchcraft in Southern African communities and highlights the important role that culture plays in their content of delusions.

CONCLUSIONS

Improved knowledge of these explanatory frameworks highlights the potential value of culturally sensitive assessment tools and stigma interventions in patient recovery. Furthermore such qualitative analyses contribute towards discussion about aspects of delusional thought that may be more universally stable, and those that may be more culturally variable.

'Whom will I give him to? The difficulty is mine' : Psychosocial difficulties experienced by care givers of patients with epilepsy in Cape Town, South Africa

Epilepsy has been reported as one condition that can cause psychological difficulties and distress to care givers of patients suffering from the condition. This study explored psychological difficulties experienced by lay care givers of patients with epilepsy in an urban township in South Africa. Nine individual in-depth interviews were conducted with lay carers who provide care to their relatives, friends and neighbours who have epilepsy. A thematic data analysis method was used. Some fears, social concerns and worries affecting care giving were reported. Community interventions that promote cultural sensitivity in mental health care and empowerment of these carers are needed.

'A thing full of stories': Traditional healers' explanations of epilepsy and perspectives on collaboration with biomedical health care in Cape Town

The experience of epilepsy is profoundly culturally mediated and the meanings attributed to the condition can have a great impact on its social course. This qualitative study used Kleinman's Explanatory Model framework to explore traditional healers' perspectives on epilepsy in an urban township in Cape Town, South Africa. The healers who participated in the study were Xhosa-speaking, had experience caring for patients with epilepsy, and had not received any training on epilepsy. Six individual in-depth interviews and one focus group with nine traditional healers were conducted using a semi-structured interview guide. Traditional healers identified several different names referring to epilepsy. They explained epilepsy as a thing inside the body which is recognized by the way it presents itself during an epileptic seizure. According to these healers, epilepsy is difficult to understand because it is not easily detectable. Their biomedical explanations of the cause of epilepsy included, among others, lack of immunizations, child asphyxia, heredity, traumatic birth injuries and dehydration. These healers believed that epilepsy could be caused by amafufunyana (evil spirits) and that biomedical doctors could not treat the supernatural causes of epilepsy. However, the healers believed that western medicines, as well as traditional medicines, could be effective in treating the epileptic seizures. Traditional healers were supportive of collaboration with western-trained practitioners and highlighted that the strategy must have formal agreements in view of protection of intellectual property, accountability and respect of their indigenous knowledge. The findings suggest a need for interventions that promote cultural literacy among mental health practitioners. Research is urgently needed to assess the impact of such collaborations between biomedical services and traditional healers on epilepsy treatment and care.

African psychology and the Africentric paradigm to clinical diagnosis and treatment

The notion of clinical or psychological diagnosis in African psychology is used, at times, to refer to the redressive action that is taken to determine the source of a difficult/abnormal illness. The need for such an interventive action arises in the face of a sudden or ‘strange’ illness that befalls a family member and refuses to abate after all medicines (including Western psychiatric hospitalization) have been administered. Under such a situation, the tendency within the Africentric paradigm to mental health and illness is to see such a challenging illness as an extraordinary or abnormal illness that carries a hidden message that must first be decoded before a decisive solution to achieving a cure can be found. Consequently, recognizing certain illnesses as ‘symbolic illnesses’ or ones with a hidden meaning, indigenous African peoples routinely persuade themselves that they must go beyond the ‘information given’ (Bruner, 1986) to determine ‘who’ is speaking through such an illness and what they are expected to do to effect a cure. In this way, they try to set their eyes not only on what is happening to the sick one (the observable manifestations of the illness) but also on the question of identifying the agent behind its onset and escalation in their approach for questioning the misfortune. This article draws attention to the missing link in the Western paradigm to psychopathology and treatment that makes it unable to deal decisively with certain illness presentations of the Black African client.

The potential consequences of informal interpreting practices for assessment of patients in a South African psychiatric hospital

In South Africa health care practitioners are commonly professionals who speak only one, or at most two, of the languages spoken by their patients. This provides for language provision challenges, since many patients are not proficient in English or Afrikaans and ad hoc and haphazard arrangements are made for interpreting by untrained personnel. As part of a larger study (conducted in 2010) in a public psychiatric hospital, we report here on the potential consequences for diagnostic assessments of 13 psychiatric evaluations mediated by ad hoc interpreters who were employed as health care workers and household aides. The psychiatric evaluations were recorded and transcribed verbatim. The first author checked for accuracy of transcription and translations, and the two members of the author team who are both senior African language academics rechecked transcription and translation. We used the typology developed by Vasquez and Javier (1991) to study interpreter errors (i.e. omissions, additions and substitutions). All errors were independently rated by a senior psychiatrist and a senior clinical psychologist to determine whether the errors were likely to have a bearing on clinical decisions concerning the patient and to rate whether errors deemed clinically significant contributed to making the patient appear more ill psychiatrically, or less ill. Of the 57 errors recorded, 46% were rated as likely to have an impact on the goal of the clinical session. Raters concurred that the clinically significant errors contributed towards potentially making the patient look more psychiatrically ill. Detailed analyses of evaluations demonstrate the complexity of informal interpreter positioning regarding issues of diagnosis and cultural factors in illness. Evaluations conducted where clinicians and interpreters are not trained in language and interpreting issues may create a distorted picture of the patients' mental health conditions.

Psychology Training Directors' Reflections on Evidence-Based Practice in South Africa

Despite its importance in the international arena, the evidence-based movement appears to have had little impact among South African clinical and counseling psychologists. We interviewed 13 of the 18 directors of psychology training programmes to understand the extent to which these programmes were rooted in an evidence-based approach to psychological practice; how important directors thought it was to emphasise an evidence-based approach in psychology training; and how students were taught to use research to inform their ongoing practice as clinical or counselling psychologists. Directors expressed a range of positions including opposition to evidence-based practice (EBP), support for EBP, and equivocality about EBP. Those who were opposed to EBP based their opposition on a “critical” approach to evidence, epistemological and ontological differences with the notion of EBP, and the conflation of theoretical orientation with EBP. Concerns were also raised in relation to areas of psychological need that lacked a research base, cultural factors that did not fit well with EBP, and different viewpoints on what constituted evidence. However, among several training directors, EBP was considered essential, particularly in light of the need to offer cost-effective services in an under-resourced setting like South Africa. These results are discussed in the context of the international evidence-based movement in mental health. Three recommendations flow from our research, namely, that the Health Professions Council of South Africa engage formally and vigorously with EBP for psychological interventions; that the Psychological Society of South Africa (PSYSSA) place the matter of EBP squarely on the organisational agenda; and that a standardised accreditation of clinical and counselling psychology training programmes be developed according to locally developed criteria for assessing EBP.

Obstacles to the Utilisation of Psychological Resources in a South African Township Community

Attitudes and beliefs regarding the utilisation of psychological resources were explored among a group of black Africans of 18 years and older. Both males and females participated in focus groups that were conducted at Itsoseng Clinic on the Mamelodi Campus of the University of Pretoria. Discussion questions addressed participants' perceptions of psychologists and psychotherapy, barriers to seeking treatment and recommendations for improved service delivery. The focus group responses indicated that reasons for seeking treatment included HIV&AIDS, problems related to the participants' socioeconomic situation, relationship issues and educational problems (learning problems, career guidance and educational stress among tertiary learners). Key barriers to service utilisation included the stigma of mental illness, lack of knowledge, affordability of treatment, lack of trust, impersonal service and lack of cultural sensitivity. Participants discussed the issue of the psychologist's race, as they felt that many white psychologists lack sensitivity toward and knowledge of black communities. Participants further stated that black psychologists were not much better due to the acculturation that occurs during the training of black psychologists. Recommendations for more culturally sensitive services are suggested. The implications of these findings for the practice and profession of psychology are also examined.

The Psychology of Bewitchment (Part II): A Psychoanalytic Model for Conceptualising and Working with Bewitchment Experiences

This article extends the phenomenological description of bewitchment experience outlined in Part I, arguing for a viable psychological explanation of what is claimed to be a supernatural phenomenon. Any adequate explanation must satisfactorily account for the four characteristic features of bewitchment experience; that is, a paranoid state of mind, the presence of a precipitating interpersonal context of hostility and envy, a dichotomous moral and religious belief structure, and the subjective experience of having one's body infiltrated by poisonous substances or destructive alien entities. Beginning with Freud's claim that all supernatural belief systems unconsciously express and simultaneously defend adherents against universal instinctual impulses and anxieties, Klein's object relations psychoanalytic model is proposed as a useful interpretive framework to understand the four interrelated aspects of bewitchment. Bewitchment, it is argued, is a culturally sanctioned supernatural belief system used defensively by individuals to protect themselves against acknowledging and experiencing a range of painful and anxiety-provoking feelings, typically involving hostility, envy, and loss. Bewitchment arises when individuals split off and project problematic self aspects elicited by adverse or stressful experiences, locating these in hated or envied others, who are then believed to use witchcraft to magically attack and harm the victims. This theoretical model is supported and illustrated by means of a case study of the psychodynamic treatment of a ‘bewitched’ patient. This case is used to demonstrate some of the psychotherapeutic challenges of treating patients who attribute their psychological difficulties to magical influences.

How healers manage the pluralistic healing context: The perspective of indigenous, religious and allopathic healers in relation to psychosis in Uganda

This paper examines the relationships between service providers involved in caring for people with 'psychosis' in Uganda. Data from qualitative research investigating conceptualisations of 'madness' held by indigenous, religious and allopathic healers in urban Uganda are used to explore the attitudes of these different service providers towards each other. Case-vignettes of individuals with a diagnosis of a psychotic disorder were discussed by the healers and real cases were discussed by allopathic doctors, and their discourse was analysed. The healers varied in their attitudes towards other parts of the healing context. The indigenous and religious healers were tolerant of allopathic medicine, although the religious healers were inclined to explain its success in terms of a Christian or Islamic framework. In contrast, the allopathic healers made little reference to religious healers and were ambivalent towards indigenous healers. Finally, the relationship between the religious and indigenous healers emerged as one of conflict. The religious healers negated the beliefs and methods of the indigenous healers, whilst the indigenous healers regarded indigenous spirituality and evangelical Christianity as incompatible. Historical and social psychological perspectives are used to understand these differences. There appear to be opportunities for greater dialogue between indigenous and religious healers and allopathic doctors and this could contribute to a more integrative model of care for individuals with psychotic experiences in Uganda.

Trends and Redress in Community Psychology during 10 Years of Democracy (1994–2003): A Journal-Based Perspective

Drawing on a content analysis of selected articles from the South African Journal of Psychology (SAJP) and Psychology in Society (PINS), the authors reflect on the extent to which South African community psychology's early vision resonates in publications in post-1994 South African psychology. Concerned about the Euro-American, patriarchal, classist, and individualised orientation in clinical, counselling, and social psychology, community psychology's vision arose as a response to this crisis of ‘relevance’ in the 1980s in South Africa. It placed the accent on accessible psychosocial services, re-defining the roles of psychologists, democratising psychological practice, prevention, competencies, empowerment of under-represented groups, collaboration, and inclusive modes of knowledge production. Our content analysis suggests that South African community psychology tends to operate within a porous disciplinary boundary, sharing academic concerns with a larger group of critical psychologists. Authorship characteristics show that for the 1994 to 2003 period male and females were more or less equally represented as authors, the majority of whom were affiliated to academic institutions. In contrast, co-authorship as an expression of collaboration did not feature strongly and the community voice was unrepresented at authorship level. Most of the articles tended to assume an empirical or theoretical slant and examined themes consistent with community psychology's early vision and focus. Similarly, research in community psychology seemed to have attended to selected priority psychosocial issues and drawn on historically neglected groups, including black adolescents and adults, to serve as participants. By way of conclusion, we surmise that community psychology, albeit an under-represented branch of psychology, may be one of many areas of engagement for those aligned to the quest for emancipatory psychological practice and theory in South Africa.