'Why are there so many drums playing until dawn?' Exploring the role of Gamba spirits and healers in the post-war recovery period in Gorongosa, Central Mozambique

Sociality and temporality in local experiences of distress and healing: Ethnographic research in northern Rwanda

Prior studies have traced sociality and temporality as significant features of African healing. However, association between the two has not been explicitly investigated. This paper explores how sociality and temporality are associated in local experiences of distress and healing among northern Rwandans. The ethnographic research, including in-depth interviews, focus-group discussions and participant observation, was conducted in 2015-2016, with 43 participants from the Musanze district who have suffered from not only the genocide but also post-genocide massacres. Findings identified common local idioms of distress: ibikomere (wounded feelings), ihungabana (mental disturbances), ihahamuka (trauma), and kurwara mu mutwe (illness of the head, severe mental illness). One stage of distress was perceived to develop into another, slightly more serious than the previous. Social isolation played a significant role in the development as it activated 'remembering' and 'thinking too much' about the past and worsened symptoms. Subsequently, healing was experienced through social reconnection and a shift of time orientation from the past to the future; the healing experience traced a process of leaving the past behind, moving forwards and creating a future through community involvement. The experiences of distress and healing in this population were explained by two axes, i.e. sociality (isolation - reconnection) and temporality (past - future), which are associated with each other. Given the sociality-temporality association in African post-war healing, the study highlights that assistant programmes that facilitate social practice and future creation can be therapeutic and be an alternative for people who cannot benefit from talking-based and trauma-focused approaches.

Ghost Encounters Among Traumatized Cambodian Refugees: Severity, Relationship to PTSD, and Phenomenology

Ghost encounters were found to be a key part of the trauma ontology among Cambodian refugees at a psychiatric clinic, a key idiom of distress. Fifty-four percent of patients had been bothered by ghost encounters in the last month. The severity of being bothered by ghosts in the last month was highly correlated to PTSD severity (r = .8), and among patients bothered by ghosts in the last month, 85.2% had PTSD, versus among those not so bothered, 15.4%, odds ratio of 31.8 (95% confidence level 11.3-89.3), Chi square = 55.0, p < .001. Ghost visitations occurred in multiple experiential modalities that could be classified into three states of consciousness: full sleep (viz., in dream), hypnagogia, that is, upon falling asleep or awakening (viz., in sleep paralysis [SP] and in non-SP hallucinations), and full waking (viz., in hallucinations, visual aura, somatic sensations [chills or goosebumps], and leg cramps). These ghost visitations gave rise to multiple concerns-for example, of being frightened to death or of having the soul called away-as part of an elaborate cosmology. Several heuristic models are presented including a biocultural model of the interaction of trauma and ghost visitation. An extended case illustrates the article's findings.

Differential executive functioning in the topology of Spirit possession or dissociative disorders: an explorative cultural study

BACKGROUND

In Oman, anecdotal and impressionistic observation have helped parse and categorize various manifestations of spirit possession into two broad and distinct categories: intermittent dissociative phenomenon and transitory dissociative phenomenon. The primary aim of the present study was to compare the performance of participants on neuropsychological tests among different grades of possession. Other correlates were also sought.

METHODS

Assessment criteria for the two groups included measures examining executive functioning: controlled oral word association test Verbal Fluency, Wisconsin Card Sorting Test (Perseverative error and the number of categories achieved), Trail Making Test and the Tower of London Test (number of correctly solved problems). Sociodemographic variables and the history of trauma were also sought.

RESULT

Among 84 participants, one third of them presented the intermittent possession type and two thirds, the transitory possession type. Their mean age was 34.17 ± 11.82 and 56% of them were female. Nearly 35% of them endorsed a history of a traumatic experience. Both the multivariate models showed statistical significance (F (5, 78) = 5.57, p < 0.001, R² = 0.22), F (5, 78) = 11.38, p < 0.001, R² = 0.39) with an independent predictor of intermittent dissociative phenomenon (β = - 3.408, p < 0.001), (β = 63.88, p < 0.001) for Verbal Fluency and Trail Making Test, respectively. The history of the traumatic event was also statistically significant with the results of the Trail Making Test (β = - 26.01, p < 0.041. Furthermore, the subtype of Pathogenic Possession turned out to be an independent predictor across all models: Wisconsin Card Sorting Test perseverative error, Wisconsin card sorting test categories achieved and the number of problems solved in the Tower of London Test (OR = 3.70, 95% C.I. 2.97-4.61; p < 0.001), (OR = 0.57, 95% C.I.0.39-0.84; p = 0.004) and (OR = 0.80, 95% C.I. 0.65-0.99; p < 0.037) respectively.

CONCLUSIONS

This study suggests that typology of spirit possession found in Oman tends to differ on indices of executive function. Those with 'diagnosis' of intermittent possession showed impairment in many indices of executive functioning. Despite its wide prevalence, spirit possession has not been examined in terms of its neuropsychological functioning. We believe that this study will be instrumental in laying the groundwork for a more robust methodology.

Putting the Spirit into Culturally Responsive Public Health: Explaining Mass Fainting in Cambodia

The study explores the cultural and religious meaning behind episodes of mass fainting sweeping through garment factories in Cambodia. An ethnographic study was conducted at 20 garment factories in Kandal, Preah Sihanouk, Kampong Cham, Kampong Speu, Takeo, and Kampong Chhnang provinces. Informants were 50 women who fainted or possessed and their families, factory and clinic staff, and monks. Informants described their views on the causes of the mass fainting. Based on the informants' views, the seeds were sown when factories were built on former Khmer Rouge killing fields, when local guardian spirits were disrespected and when the factories were not inaugurated with the proper rituals. We found that an inauspicious death, a conflict leading to violation of a vow, or culturally inappropriate interventions by management explained what triggered the episodes. The results show that people believe that mass faintings occur in parallel with tensions between the workers and the foreign owners of the factories and tensions between the human and spiritual owners of the land. The study has implications for the development of culturally responsive public health interventions in mass group phenomena.

Unravelling the spirits' message: a study of help-seeking steps and explanatory models among patients suffering from spirit possession in Uganda

As in many cultures, also in Uganda spirit possession is a common idiom of distress associated with traumatic experiences. In the DSM-IV and -5, possession trance disorders can be classified as dissociative disorders. Dissociation in Western countries is associated with complicated, time-consuming and costly therapies. Patients with spirit possession in SW Uganda, however, often report partial or full recovery after treatment by traditional healers.

The aim of this study is to explore how the development of symptoms concomitant help-seeking steps, and explanatory models (EM) eventually contributed to healing of patients with spirit possession in SW Uganda. Illness narratives of 119 patients with spirit possession referred by traditional healers were analysed using a mixed-method approach.

Treatments of two-thirds of the patients were unsuccessful when first seeking help in the medical sector. Their initially physical symptoms subsequently developed into dissociative possession symptoms. After an average of two help-seeking steps, patients reached a healing place where 99% of them found satisfactory EM and effective healing. During healing sessions, possessing agents were summoned to identify themselves and underlying problems were addressed. Often-mentioned explanations were the following: neglect of rituals and of responsibilities towards relatives and inheritance, the call to become a healer, witchcraft, grief, and land conflicts.

The results demonstrate that traditional healing processes of spirit possession can play a role in restoring connections with the supra-, inter-, intra-, and extra-human worlds. It does not always seem necessary to address individual traumatic experiences per se, which is in line with other research in this field. The study leads to additional perspectives on treatment of trauma-related dissociation in Western countries and on developing effective mental health services in low -and middle-income countries.

Are symptoms of spirit possessed patients covered by the DSM-IV or DSM-5 criteria for possession trance disorder? A mixed-method explorative study in Uganda

INTRODUCTION AND AIMS

As in many cultures, spirit possession is a common idiom of distress in Uganda. The DSM-IV contains experimental research criteria for dissociative and possession trance disorder (DTD and PTD), which are under review for the DSM-5. In the current proposed categories of the DSM-5, PTD is subsumed under dissociative identity disorder (DID) and DTD under dissociative disorders not elsewhere classified. Evaluation of these criteria is currently urgently required. This study explores the match between local symptoms of spirit possession in Uganda and experimental research criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5.

METHODS

A mixed-method approach was used combining qualitative and quantitative research methods. Local symptoms were explored of 119 spirit possessed patients, using illness narratives and a cultural dissociative symptoms' checklist. Possible meaningful clusters of symptoms were inventoried through multiple correspondence analysis. Finally, local symptoms were compared with experimental criteria for PTD in the DSM-IV and proposed criteria for DID in the DSM-5.

RESULTS AND CONCLUSION

Illness narratives revealed different phases of spirit possession, with passive-influence experiences preceding the actual possession states. Multiple correspondence analysis of symptoms revealed two dimensions: 'passive' and 'active' symptoms. Local symptoms, such as changes in consciousness, shaking movements, and talking in a voice attributed to spirits, match with DSM-IV-PTD and DSM-5-DID criteria. Passive-influence experiences, such as feeling influenced or held by powers from outside, strange dreams, and hearing voices, deserve to be more explicitly described in the proposed criteria for DID in the DSM-5. The suggested incorporation of PTD in DID in the DSM-5 and the envisioned separation of DTD and PTD in two distinctive categories have disputable aspects.

Interventions for children affected by war: an ecological perspective on psychosocial support and mental health care

BACKGROUND

Children and adolescents exposed to armed conflict are at high risk of developing mental health problems. To date, a range of psychosocial approaches and clinical/psychiatric interventions has been used to address mental health needs in these groups.

AIMS

To provide an overview of peer-reviewed psychosocial and mental health interventions designed to address mental health needs of conflict-affected children, and to highlight areas in which policy and research need strengthening.

METHODS

We used standard review methodology to identify interventions aimed at improving or treating mental health problems in conflict-affected youth. An ecological lens was used to organize studies according to the individual, family, peer/school, and community factors targeted by each intervention. Interventions were also evaluated for their orientation toward prevention, treatment, or maintenance, and for the strength of the scientific evidence of reported effects.

RESULTS

Of 2305 studies returned from online searches of the literature and 21 sources identified through bibliography mining, 58 qualified for full review, with 40 peer-reviewed studies included in the final narrative synthesis. Overall, the peer-reviewed literature focused largely on school-based interventions. Very few family and community-based interventions have been empirically evaluated. Only two studies assessed multilevel or stepped-care packages.

CONCLUSIONS

The evidence base on effective and efficacious interventions for conflict-affected youth requires strengthening. Postconflict development agendas must be retooled to target the vulnerabilities characterizing conflict-affected youth, and these approaches must be collaborative across bodies responsible for the care of youth and families.

Traditional healers and laypeople: a qualitative and quantitative approach to local knowledge on medicinal plants in Muda (Mozambique)

ETHNOPHARMACOLOGICAL RELEVANCE

Through this study, relevant information was gathered on the knowledge about medicinal remedies in some rural communities of Muda (central Mozambique). The use of 198 different medicinal plants has been recorded and a significant number of medicinal species and uses new for Africa and particularly for Mozambique has been detected. Our investigation appears to be the first comparing knowledge about medicinal plants between laypeople and traditional healers and also between the two kinds of healers (curandeiros and profetas).

MATERIALS AND METHODS

Ethnobotanical data were gathered through semi-structured interviews with 67 informants: 9 curandeiros (traditional healers believed to be guided by spirits), 12 profetas (independent Pentecostal churches "prophets" healing both souls and bodies) and 46 untrained lay villagers. Data were entered in a data base and processed, also by means of suitable quantitative indexes.

RESULTS

A total of 546 citations were recorded for 198 different ethnospecies (i.e. basic ethno-taxonomical units). The species with the highest cultural value (estimated with Cultural Importance index) resulted to be Ximenia caffra (CI=0.224), Zanha golungensis (CI=0.194) Vernonia colorata (CI=0.149) and Ozoroa reticulata and Holarrhena pubescens (both with CI=0.134). Eight out of the 162 identified plants mentioned by the informants were not previously recorded as medicinal plants in Africa: Cissus bathyrhakodes, Clematis viridiflora, Combretum goetzei, Dioscorea cochleari-apiculata, Grewia pachycalyx, Indigofera antunesiana, Ipomoea consimilis, Tricliceras longipedunculatum. More than half of the species reported by our informants and already known as medicinal in Africa resulted to be newly documented for Mozambique. Comparing the mean number of species known by each informant group, statistically significant differences were observed both between curandeiros and laypeople and between profetas and laypeople. No significant differences emerged instead between curandeiros and profetas. Yet, even laypeople proved to hold quite a good knowledge about medicinal remedies; women in particular use several different plants to heal common diseases of the whole family, mostly for children and female health problems.

CONCLUSIONS

The high number of plants and uses recorded demonstrates that in the study area ethnobotanical knowledge is still quite rich and alive. The finding of many medicinal plants and uses new for Mozambique or even Africa shows the importance of recording this knowledge before it vanishes, also as a basis for further investigations on possible pharmacological properties of local plants. The lack of health infrastructures in Muda results in the need for lay villagers of acquiring and developing a rather high degree of knowledge about plants remedies; in a different interaction between healers and lay villagers, compared to urban areas; ultimately, in a different distribution and wider spread of traditional knowledge on medicinal plants.

The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique

In this article we assess the prevalence rates of harmful spirit possession, different features of the spirits and of their hosts, the correlates of the spirit possession experience, health patterns and the sources of health care consulted by possessed individuals in a population sample of 941 adults (255 men, 686 women) in post-civil war Mozambique in 2003-2004. A combined quantitative-qualitative research design was used for data collection. A major study outcome is that the prevalence rates vary according to the severity of the possession as measured by the number of harmful spirits involved in the affliction. The prevalence rate of participants suffering from at least one spirit was 18.6 percent; among those individuals, 5.6 percent were suffering from possession by two or more spirits. A comparison between possessed and non-possessed individuals shows that certain types of spirit possession are a major cause of health impairment. We propose that knowledge of both local understandings of harmful spirit possession and the community prevalence of this kind of possession is a precondition for designing public health interventions that sensitively respond to the health needs of people afflicted by spirits.

Dissociative symptoms and reported trauma among patients with spirit possession and matched healthy controls in Uganda

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Orthostatic Panic as a Key Vietnamese Reaction to Traumatic Events: The Case of September 11, 2001

This article discusses a culturally specific response to traumatic events: orthostatic panic attacks among Vietnamese refugees. We compared the rate and severity of orthostatic panic as well as the rates and severity of associated flashbacks a month before and a month after September 11, 2001. After that date, the rate and severity of orthostatic panic greatly increased, as did the rate and severity of associated flashbacks. The central role of orthostatic panic as a response to traumatic events is illustrated through a patient's vignette. An explanation of why September 11 so profoundly influenced this population is adduced, including an explanation of why it resulted in considerable worsening of orthostatic panic.

When the war was over, little changed: women's posttraumatic suffering after the war in Mozambique

This article explores the psychosocial effects of women's prolonged exposure to civil war in the center of Mozambique. Using a combination of quantitative and qualitative methods, 91 women were assessed for posttraumatic stress symptoms and psychosocial indicators of ill health. The results indicate that for the majority of the women in this study, traumatic experiences are sequential processes. Their ill health ranges from symptoms of posttraumatic stress to episodes of spirit possession (gamba), affecting women's capacities to conceive and raise children, and marginalizing their social position. A careful analysis of the specific problems and needs of women in postwar contexts is recommended, along with a systematic examination of the effectiveness of the available resources that may play a role in boosting trauma recovery in this group of women.

Mental and social health in disasters: Relating qualitative social science research and the Sphere standard

Increasingly, social scientists interested in mental and social health conduct qualitative research to chronicle the experiences of and humanitarian responses to disaster We reviewed the qualitative social science research literature in relation to a significant policy document, the Sphere Handbook, which includes a minimum standard in disaster response addressing "mental and social aspects of health", involving 12 interventions indicators. The reviewed literature in general supports the relevance of the Sphere social health intervention indicators. However, social scientists' chronicles of the diversity and complexity of communities and responses to disaster illustrate that these social interventions cannot be assumed helpful in all settings and times. With respect to Sphere mental health intervention indicators, the research largely ignores the existence and well-being of persons with pre-existing, severe mental disorders in disasters, whose well-being is addressed by the relevant Sphere standard. Instead, many social scientists focus on and question the relevance of posttraumatic stress disorder-focused interventions, which are common after some disasters and which are not specifically covered by the Sphere standard. Overall, social scientists appear to call for a social response that more actively engages the political, social, and economic causes of suffering, and that recognizes the social complexities and flux that accompany disaster. By relating social science research to the Sphere standard for mental and social health, this review informs and illustrates the standard and identifies areas of needed research.

Testimony method to ameliorate post-traumatic stress symptoms. Community-based intervention study with Mozambican civil war survivors

BACKGROUND

The effectiveness of the testimony method has not been established in rural communities with survivors of prolonged civil war.

AIMS

To examine the effectiveness and feasibility of a testimony method to ameliorate post-traumatic stress symptoms.

METHOD

Participants (n=206) belonged to former war zones in Mozambique. They were divided into a case (n=137) and a non-case group (n=69). The case group was randomly divided into an intervention (n=66) and a control group (n=71). Symptoms were measured during baseline assessment, post-intervention and at an 11-month follow-up.

RESULTS

Post-intervention measurements demonstrated significant symptom reduction in both the intervention and the control group. No significant differences were found between the intervention and the control group. Follow-up measurements showed sustained lower levels of symptoms in both groups, and some indications of a positive intervention effect in women.

CONCLUSIONS

A remarkable drop in symptoms could not be linked directly to the intervention. Feasibility of the intervention was good, but controlling the intervention in a small rural community appeared to be a difficult task to accomplish.