In the Journals

In The Journals- August 2021 Part 1

The highlights of August’s In The Journals (Pt.1) are: a Colloquy in Cultural Anthropology on “L’enfer, c’est les autres”: Proximity as an Ethical Problem during COVID-19″; a “double issue” from the Int’l Journal of Social Psychiatry in which the articles about COVID-19 are open access; and a special issue on African Cultural Psychiatry in Transcultural Psychiatry.

American Ethnologist

Becoming an operating system: Disability, difference, and the ethics of communication in the United States (open access)

Danilyn Rutherford

A remarkable experiment in assistive technology, known as PODD, draws on and challenges mainstream understandings of communication in the US. To engage disabled people in conversation, caregivers turn to PODD books, which are binders of laminated sheets that display icons. As caregivers use these books, they act as “operating systems,” listing directions as they navigate from page to page, then animating the selected utterance in an enthusiastic tone. PODD plays on the language ideology that underlies most communication systems, which are designed to liberate speaking subjects trapped by the limitations of their bodies and minds. But PODD also confronts its users with aspects of communication that set aside the question of meaning. Drawing on interviews and participant observation in trainings with my nonverbal daughter, I show how caregivers struggle to inhabit a community of sign use in which referential meaning is both longed for and beside the point.

Cultural Anthropology (Open Access)

Colloquy: “L’enfer, c’est les autres”: Proximity as an Ethical Problem during COVID-19

“L’enfer, c’est les autres”: Proximity as an Ethical Problem during COVID-19

Thomas Strong, Susanna Trnka, L. L. Wynn

During the COVID-19 emergency, people around the world are debating concepts like physical distancing, lockdown, and sheltering in place. The ethical significance of proximity—that is, closeness or farness as ethical qualities of relations (Strathern 2020)—is thus being newly troubled across a range of habits, practices, and personal relationships. Through five case studies from Australia, Ireland, New Zealand, South Africa, and the United States, contributors to this Colloquy shed light on what the hype of the pandemic often conceals: the forms of ethical reflection, reasoning, and conduct fashioned during the pandemic.

The Pandemic Imaginerie: Infectious Bodies and Military-Police Theater in Australia
L. L. Wynn

When pathogens and their movement between people cannot be seen, we imagine them. That imagined menagerie—imaginerie—of infection then becomes associated with marginal others whose bodies and actions become popularly conflated with disease and its transmission. This essay explores how methods of imagining and managing the COVID-19 pandemic in Australia echoed historical scripts for policing borders and containing the bodies of outsiders deemed threats to the national body.

Necropolitics versus Biopolitics: Spatialization, White Privilege, and Visibility during a Pandemic
Carolyn M. Rouse


Anthropologists have used Michel Foucault’s thesis on biopolitics to critique modern institutions. Yet while useful, biopolitics is often misapplied. The arrests, killings of unarmed Blacks by police, COVID-19 racial health inequities, and the January 6 white nationalist act of sedition made visible fault lines between a biopolitical system set up to care for whites and a necropolitical system that treats Black bodies as expendable. By critiquing the facile overuse of biopolitics and biopower, this article also speaks to what COVID-19 uncovered within the academy.

Be Kind: Negotiating Ethical Proximities in Aotearoa/New Zealand during COVID-19
Susanna Trnka


Citizens do not merely respond to states of emergency; in democratic societies, they help constitute them. This essay analyzes New Zealanders’ engagements in ethical reasoning during the country’s first COVID-19 lockdown. Specifically, I examine how we can understand a variety of public responses to emergency measures—including breaching regulations, threatening rule-breakers, sealing off neighborhoods, and recasting citizen-returnees as “strangers”—as negotiations of ethical proximities focused on keeping appropriately close that which is thought should be near, and keeping distanced that deemed best held afar.

The End of Intimacy
Thomas Strong


Though comparisons between HIV and SARS-CoV-2 are of limited use, many people experience the epidemics simultaneously. For those of us living with HIV, every comment on COVID-19 becomes a fretful allegory of HIV, and the ethical lessons that COVID-19 teaches will inevitably be brought to bear on how we understand the meaning of the HIV epidemic, especially as it pertains to sexuality. This essay describes some of the ways gay men in Dublin, Ireland, reasoned about the ethics of sex during lockdown.

Proxemics, COVID-19, and the Ethics of Care in South Africa
Susan Levine, Lenore Manderson


In South Africa, lockdown and its excesses have opened up questions on the limits of an ethics of care, whose ethics are privileged, how care is delivered, and what care means. We show how an ethics of proxemics and its operationalization as distance highlight everyday inequalities and limit the provision of care. Constraints on physical distancing in line with public health measures intended to limit the spread of the coronavirus echo the controls enforced under apartheid, showing how inequality is both embodied and legally entrenched.

International Journal of Social Psychiatry

Internalized stigmatization and subjective recovery in individuals with chronic mental illness
Seher Kaşli, Orhan Al, Kerime Bademli

Background:
Individuals with mental illness, as they are stigmatized by society, are also stigmatized themselves, and this process is internalized. This may adversely affect the recovery process.

Results:
In the study it was found that there is a relationship between internalized stigmatization and subjective recovery. Increased levels of internalized stigma patient outcome would decrease the level of recovery.

Depression screening in Surabaya Indonesia: Urgent need for better mental health care for high-risk communities and suicide prevention for men
Margarita M Maramis, Jakobus Gerick Pantouw, Cokorda Bagus Jaya Lesmana

Objectives:
Despite its high prevalence and considerable burden, depression is not handled with the required urgency in Indonesia. Existing data from the government does not specifically note its prevalence and symptoms manifestation. This study screened depression in Surabaya, where the prevalence of mood disorder was reported to be higher than the national prevalence, in order to identify where action is most needed.

Conclusion:
High-risk group with low educational background is in most urgent need of mental health help, and suicide prevention strategy is most needed for men.

Caregivers’ hopes, expectations and concerns surrounding the employment and future of young people with mental health conditions (open access)

Wen Lin Teh et al.

Objective:
Informal caregivers are often placed in a better position to understand and advocate for the vocational needs of young persons with mental health conditions. However, their opinions are largely ignored in the planning of vocational outcomes. This qualitative study had two broad aims: to explore (1) the perceptions of caregivers of young adults with mental health conditions on issues of paid employment and (2) their views and expectations of employment support services.

Conclusions and implications for practice:
Caregivers strongly believed that employment support services should prioritise and advocate for recovery while securing employment. Local mental health employment support services should incorporate the views and expectations of caregivers of young persons with mental health conditions to foster better coordination between stakeholders, and enhance support for successful employment, reintegration into the community, and ultimately recovery for these individuals.

Stigmatising attitude and reflections towards mental illness at community setting, population-based approach, Baghdad City 2020
Maha Sulaiman Younis, Arjan Hidayat Anwer, Hamid Yahay Hussain

Background:
Addressing the social stigma of mental illness is of importance in Iraq where mentally ill patients experience the compounded disadvantages of inadequate health services and illness stigma.

Aims:
To study the prevalence and magnitude of the social stigma towards mental illnesses.

Conclusions:
There were no clear roles of socio-demographic factors in the stigmatic attitude towards mental illnesses. This finding warrants a more in-depth look into the Iraqi community’s cultural, social, and moral contexts

A qualitative study on the use of mobile-based intervention for perinatal depression among perinatal mothers in rural Bihar, India

Uttara Seshu

Background:
Perinatal depression (PND) is one of the most common psychiatric illnesses in women, with a prevalence around 22% in India. Leveraging mobile-based technologies could help in the prevention and treatment of perinatal depression even in remote places. Understanding the experiences and barriers of using such technology interventions by perinatal mothers could help in the better design and in delivery of these interventions. We aimed to study the experiences of the perinatal women using a mobile phone-based intervention, Interactive Voice Response System (IVRS), for the prevention and management of perinatal depression in a rural district of Bihar, India.

Non-suicidal self-injury in developing countries: A review
Srinagesh Mannekote Thippaiah et al.

Background:
Non-suicidal self-injury (NSSI) may be understood as a physical and behavioral expression of emotional distress. Over the past 70 years, it has been variably formulated as a type of emotional reaction to various stressors. NSSI has complex goals, sometimes implicit, but overall it serves as a transient psychological relief. Many believe that NSSI is a maladaptive behavior and is not related to suicide, with the primary differentiating factor between suicide and NSSI being the ‘intention’ to die. NSSI is an important mental health problem in current modern societies, and it is part of a trend in current psychiatric and mental health practice to medicalize maladaptive behaviors or psychological distress.

Complicated grief: A systematic review of the last 20 years
Rosa De Stefano et al.

Background:
Grief is a common reaction to the feeling of loss and it is considered a physiological and instinctive response. The ‘normal’ grief evolves into an ‘integrated’ phase within 1 year from death, and it is a non-pathological condition, that do not require specific therapeutic interventions. When this ‘integrated phase’ does not occur, the subject could reach pathological manifestations related to the grief. The Persistent Complex Bereavement Disorder (PCBD) is a new DSM5 clinical category characterized by symptoms related to the detachment and to the post-traumatic distress and it differs from normal and uncomplicated grief, for the disability caused by these reactions and their persistence and pervasiveness.

Psychological torture: Characteristics and impact on mental health
Joseph El-Khoury, Riwa Haidar, Andres Barkil-Oteo

Torture has been illegal in most of Europe and the United States for over a century but persisted in other parts of the world. The changing geopolitical landscape has led to its resurgence in recent years. The public rejection of traditional forms of torture that rely on the infliction of physical pain has paradoxically increased the reliance on psychological methods of torture. This critical commentary aims to define and characterize psychological torture (PT) while exploring practical, legal, ethical and therapeutic implications relevant to clinicians and policymakers. Psychological torture comes in a range of forms. It is being increasingly justified and adopted by legitimate authorities in the name of national security. The emphasis on the avoidance of physical pain leads to the assumption that PT does not produce the levels of suffering and harm that are associated with physically violent forms of torture. This same assumption has allowed for the implication of mental health professionals in theorizing and providing legitimacy for the actions of perpetrators. Psychological torture is still poorly defined with limited understanding of its long-term psychiatric impact on those who are subjected to it. The role of mental health professionals in preventing or addressing psychological torture remains ambiguous and needs to be reinforced.

The mindfulness trajectories of addressing suicidal behaviour: A systematic review
Saurabh Raj et al.

Background and objectives:
Suicidal behaviour has been a persistent concern in medical as well as general settings. Many psychotherapeutic approaches have tried to address suicidal behaviour in different ways. Mindfulness-based interventions (MBIs) have garnered much attention in the last decade because of their treatment efficacy. This systematic review aimed to examine evidence-based research regarding the effectiveness of MBIs as a psychotherapy intervention on suicidality and to deliver suggestions that might help future research.

International Journal of Social Psychiatry: COVID-19 (Open Access)

Mental health of frontline healthcare workers exposed to COVID-19 in Egypt: A call for action
Hussien Elkholy

Background:
World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19) as a pandemic in March 2020. Such widespread outbreaks are associated with adverse mental health consequences.

Conclusion:
Ensuring proper mental health support for HCW is an important component of public health measures for addressing the COVID-19 epidemic and safeguarding the continuity of appropriate medical service.

Coping styles and mental health in response to societal changes during the COVID-19 pandemic
Caroline Gurvich et al.

Aims:
The aim of this study was to gain an understanding of psychosocial responses to the COVID-19 pandemic, including depression, anxiety and distress, as well as effective coping styles in an Australian sample.

Results:
47% of the respondents were experiencing some degree of psychological distress. Females experienced higher levels of depression, anxiety and stress than males. Coping strategies associated with better mental health were positive reframing, acceptance and humour. Conversely, self-blame, venting, behavioural disengagement and self-distraction were associated with poorer mental health.

Conclusion:
Rates of psychological symptoms amongst the Australian population are similar to those reported in other countries. Findings add to the growing literature demonstrating a gender disparity in the mental health impacts of COVID-19. Positive emotion focused coping strategies may be effective for reducing psychological symptoms. Understanding psychosocial responses including beneficial coping strategies are crucial to manage the current COVID-19 situation optimally, as well as to develop mental health response plans for future pandemics.

Severely increased generalized anxiety, but not COVID-19-related fear in individuals with mental illnesses: A population based cross-sectional study in Germany
Eva-Maria Skoda et al.

The COVID-19 pandemic affected individuals, governments, and health care centers all around the globe. Social isolation obligation, restricted working shifts, and curfews posed unprecedented challenges for the population. Social isolation, boredom, and financial problems have been shown to stress peoples’ mental health in previous comparable pandemics and even in regular situations. Individuals with a mental illness may particularly be at risk due to an already instable mental health status. While research mainly focused on the pandemic’s impact on somatic health care and risk group patients, psychological obstacles caused by legal restrictions and their impact on already mentally affected individuals have been discussed, but so far only scarcely been investigated in a large sample. For this study, 12,028 people completed an online-survey during that time in Germany, when the COVID-19 outbreak gained momentum with a surge in cases and death rates as well as a lockdown of the public life. Generalized anxiety (GAD-7), depression (PHQ-2), distress (distress thermometer) and COVID-19-specific items, especially COVID-19-related fear, were assessed in healthy individuals, patients suffering from mental illnesses, and in patients with chronic somatic diseases, known to be at risk for an unfavorable course of COVID-19. Results show that the COVID-19-pandemic significantly worsens psychometric scores throughout the population – individuals with already heightened levels, like people with mental illnesses now reach concerning levels. Surprisingly, even though generalized anxiety, depressive symptoms, and perceived distress are elevated in individuals with mental illness, these individuals seem to be less affected by explicit COVID-19-related fear, than the general population or individuals with chronic somatic diseases. This study thus objectively quantifies the psychological impact of COVID-19 in a large sample and provides evidence for not only the public, but also critically affected individuals with a mental illness.

Lived experiences of Indian Youth amid COVID-19 crisis: An interpretative phenomenological analysis
Alina Suhail, Naved Iqbal, Jonathan Smith

Aim:
The aim of the present study was to get an in-depth analysis of the lived experiences of Indian youth amid COVID-19 crisis and its impact on their mental health.

Conclusion:
The study draws attention to the mental health concerns of Indian youth amid the current crisis. The findings also highlight the positive outcomes of the crisis as well as the different ways of coping adopted by young individuals in India.

Early indicators and risk factors associated with mental health problems during COVID-19 quarantine: Is there a relationship with the number of confirmed cases and deaths?
Héctor Badellino et al.

Background:
On March 20 2020, the Argentine Ministry of Health enforced a mandatory quarantine throughout the country in response to the COVID-19 pandemic.

Aims:
The object of this study is to determine the initial impact on mental health of Argentine population, by measuring the prevalence of anxiety, depression, insomnia, and self-perceived stress and by determining the associated risk factors, and to analyze that impact in relation to the number of confirmed cases and deaths.

Conclusion:
Despite the low number of COVID-19 confirmed cases and deaths at that time, a strong impact on mental health indicators was revealed. The authors of this study recommend the monitoring of the population at risk over time and early interventions in order to avoid long-lasting mental health problems.

Mental health implications of COVID-19 pandemic and its response in India
Adrija Roy et al.

Objectives:
In this study, we attempt to review the prevailing mental health issues during the COVID-19 pandemic through global experiences, and reactive strategies established in mental health care with special reference to the Indian context. By performing a rapid synthesis of available evidence, we aim to propose a conceptual and recommendation framework for mental health issues during the COVID-19 pandemic.

Results:
The major mental health issues reported were stress, anxiety, depression, insomnia, denial, anger and fear. Children and older people, frontline workers, people with existing mental health illnesses were among the vulnerable in this context. COVID-19 related suicides have also been increasingly common. Globally, measures have been taken to address mental health issues through the use of guidelines and intervention strategies. The role of social media has also been immense in this context. State-specific intervention strategies, telepsychiatry consultations, toll free number specific for psychological and behavioral issues have been issued by the Government of India.

Conclusion:
Keeping a positive approach, developing vulnerable-group-specific need-based interventions with proper risk communication strategies and keeping at par with the evolving epidemiology of COVID-19 would be instrumental in guiding the planning and prioritization of mental health care resources to serve the most vulnerable.

Mental health in biological disasters: From SARS to COVID-19
Kuan-Ying Hsieh et al.

Background:
The outbreak of coronavirus disease 2019 (COVID-19), like severe acute respiratory syndrome (SARS), provokes fear, anxiety and depression in the public, which further affects mental health issues. Taiwan has used their experience of the SARS epidemic for the management of foreseeable problems in COVID-19 endemic.

Aim/Objective:
This review summarizes issues concerning mental health problems related to infectious diseases from current literatures.

Results:
In suspected cases under quarantine, confirmed cases in isolation and their families, health care professionals, and the general population and related effective strategies to reduce these mental health issues, such as helping to identify stressors and normalizing their impact at all levels of response as well as public information and communication messages by electronic devices. The importance of community resilience was also addressed. Psychological first aid, psychological debriefing, mental health intervention and psychoeducation were also discussed. Issues concerning cultures and religions are also emphasized in the management plans.

Conclusion:
Biological disaster like SARS and COVID-19 not only has strong impact on mental health in those being infected and their family, friends, and coworkers, but also affect wellbeing in general public. There are evidenced that clear and timely psychoeducation, psychological first aid and psychological debriefing could ameliorate negative impact of disaster, thus might also be helpful amid COVID-19 pandemic.

Transcultural Psychiatry

Special Issue: African Cultural Psychiatry

Sociocultural contexts of mental illness experience among Africans (open access)
Akin Ojagbemi, Oye Gureje

Even though mental disorders can be found in every culture globally, the lived experience, expression of associated distress, and interpretation as evidence of deviance from acceptable norms are influenced by social and cultural context (Kirmayer, 2001). Hence, the context of mental illness experience should be a key consideration in the provision of culturally appropriate interventions. Historically, scant attention was paid to the unique sociocultural elements of mental disorders in Africa. In particular, early documentation of mental illness experience, predominantly by colonial psychiatrists, demonstrated little grasp of the social and cultural norms of the people. There were reports suggesting limited understanding of the local languages and modes of expression of distress, as well as failure to properly communicate directly with patients (Lucas & Barrett, 1995). Inferences about the experience of mental illness in Africans were thus made based on this lack of appreciation of diversity (Tooth, 1950). The studies in this issue of Transcultural Psychiatry reflect a growing body of work that is informed by the diversity and lived reality of contemporary African contexts.

A pioneer of psy: The first Ugandan psychiatric nurse and her (different) tale of psychiatry in Uganda
Julia Vorhölter

In Africa, the emergence of a “modern” mental health regime centered on psychiatry is often portrayed as a unidirectional intervention by “the West.” Analyses ranging from medical histories of colonial psychiatry to more recent studies of Global Mental Health focus mostly on the role of external actors and the ways their actions impact(ed) on local populations. Uncritical studies simply reduce the complexity of African therapeutic landscapes to a “treatment gap” and see the introduction of “science-based” mental health approaches as necessary “civilizing” missions. Critical studies emphasize the harms of psychiatric interventions and celebrate local healing practices instead. Both approaches are problematic: they ignore the many interconnections between highly dynamic treatment regimes that cannot be neatly designated as African or western, portray local populations as largely passive, and neglect the multiple ways in which psychiatry has been embraced, adapted, and disrupted by Africans themselves. This article challenges simplistic depictions of “western” psychiatry in Africa by providing a portrait of Rwashana Selina, the first Ugandan psychiatric nurse who—after being sent to the UK in the 1950s for training—became a central figure in Ugandan psychiatry. Based on interview material, I recount her life story and discuss her formative role in the development of psychiatric care in the colonial and postcolonial era. Rwashana’s tale of Ugandan psychiatry emphasizes co-operation, mutual acknowledgments and pluralistic leadership and thus breaks with typical images of and dichotomies between white doctors and supposedly inferior African medical staff.

Ancestral calling, traditional health practitioner training and mental illness: An ethnographic study from rural KwaZulu-Natal, South Africa
Martine van der Zeijst

This qualitative ethnographic study complements an epidemiological study on first episode psychosis in Vulindlela, a rural area in KwaZulu-Natal, South Africa. It focuses on two themes that emerged from our data: (1) the calling of the ancestors to become a traditional health practitioner and (2) ukuthwasa, the training to become a traditional health practitioner. The purpose of this study is to describe the ancestral calling, and to explore whether ukuthwasa may help with the management of mental disturbances, including unusual perceptual experiences. We also provide a discussion of the changing sociopolitical context of healing in KwaZulu-Natal, as a background to our study. In-depth interviews were conducted with 20 (apprentice) traditional health practitioners, formal health practitioners, patients and relatives recruited through local traditional health practitioners and a health care clinic. Our results show that the ancestral calling might announce itself with symptoms of mental illness including unusual perceptual experiences, for which some participants consider ukuthwasa as the only effective cure. We found indications that in some individuals successful completion of ukuthwasa might promote recovery from their illness and lead to a profession in which the unusual perceptual experiences become a legitimate and positively valued aspect. We suggest that – in this particular community today, which has been subject to several sociopolitical changes – ukuthwasa may be a culturally sanctioned healing process which moderates experiences that a Western psychiatric system might characterize as psychotic symptoms, providing some individuals with a lucrative and respected role in society.

Psychopathology among apprentice traditional health practitioners: A quantitative study from rural KwaZulu-Natal, South Africa
Martine C.E. van der Zeijst et al.

Sociocultural context seems to influence the epidemiology, phenotype, treatment, and course of psychosis. However, data from low- and middle-income countries is sparse. This research is part of a multidisciplinary and multimethod study on possible mental disturbances, including hallucinations, among (apprentice) traditional health practitioners (THPs) who have experienced the “ancestral calling to become a THP” in rural KwaZulu-Natal, South Africa. The aim of the current article is to examine whether the calling-related experiences can be assessed according to a psychiatric taxonomy. We included individuals who were identified with the calling and who were undergoing training to become a THP (ukuthwasa). IsiZulu-speaking formal mental health practitioners conducted thorough psychiatric interviews that measured psychological experiences with and without distress using the Community Assessment of Psychic Experiences, and psychiatric symptoms and disorders using the Schedule for Clinical Assessment in Neuropsychiatry. Of the 48 individuals who participated, 92% had psychotic experiences (PE), causing distress in 75%; and 23% met DSM-5 criteria for an unspecified psychotic disorder (15%) or mood disorder (8%). In conclusion, in rural KwaZulu-Natal, the ancestral calling may resemble phenomena that psychiatry would understand in the context of psychosis, ranging from subclinical PE to clinical psychotic disorder. Ukuthwasa might have a beneficial influence on the course of psychotic symptoms in some individuals, potentially because it reduces stigma and promotes recovery. Further multidisciplinary research is needed to investigate the psychopathology of the apprentice THPs and the underlying processes of ukuthwasa.

Complementing standard western measures of depression with locally co-developed instruments: A cross-cultural study on the experience of depression among the Luo in Kenya
Tom L. Osborn, Arthur Kleinman, John R. Weisz

Our present understanding of depression relies on a Western nosology that might not be generalizable across diverse cultures around the world. As a consequence, current clinical research and practice may not capture culturally salient features of depression. Expanded cross-cultural research that uses ethnographic methods and local instruments may yield information of clinical utility to enhance culturally sensitive research and practice. In this mixed methods study, we used ethno-semantic interview procedures based on the DSM-5’s cultural formulation process to elicit a broad range of depression features reported by the Luo people of western Kenya. We identified how the Luo conceptualize depression, including idioms of depressive distress, moods associated with persistent negative affect, and other features including context, stressors and support systems. This information informed the co-development of a Luo Depression Questionnaire (LDQ-17). We used the LDQ-17 in a cross-sectional community survey (N = 116) to investigate its association with a standard Western instrument (Patient Health Questionnaire-9; PHQ-9). Factor analysis revealed a one-factor model for the PHQ-9 but not the LDQ-17 for which exploratory factor analysis suggested a three-factor model including cognitive, affective, and physical symptoms. Psychological, environmental/social, and even supernatural causes (i.e., ancestors, God and devil) of these symptoms were identified, as were support systems. Finally, visualizations through multidimensional scaling approaches showed some overlap between the LDQ-17 and the PHQ-9, but the local LDQ-17 identified salient features the Luo associated with depression that the PHQ-9 missed. Our findings illustrate how simple ethnographic procedures may guide the development of local instruments to complement current standardized instruments, potentially enhancing cultural relevance.

Mental health literacy in Ghana: Implications for religiosity, education and stigmatization
Peter Adu, Tomas Jurcik, Grigoryev Dmitry

Research on Mental Health Literacy (MHL) has been growing internationally. However, the beliefs and knowledge of Ghanaians about specific mental disorders have yet to be explored. This vignette study was conducted to explore the relationships between religiosity, education, stigmatization and MHL among Ghanaians using a sample of laypeople (N = 409). The adapted questionnaire presented two vignettes (depression and schizophrenia) about a hypothetical person. The results revealed that more participants were able to recognize depression (47.4%) than schizophrenia (15.9%). Religiosity was not significantly associated with recognition of mental disorders but was positively associated with both social and personal stigma for depression, and negatively associated with personal and perceived stigma for schizophrenia. Moreover, education was found to be positively associated with disorder recognition, and negatively with perceived stigma. Finally, perceived stigma was positively associated with disorder recognition, whereas personal stigma for schizophrenia related negatively to recognition of mental disorders. In conclusion, education but not religiosity predicted identification accuracy, but both predictors were associated with various forms of stigma. Findings from this study have implications for MHL and anti-stigma campaigns in Ghana and other developing countries in the region.

Contextualized understanding of depression: A vignette study among the !Xun and Khwe of South Africa (open access)
Thijs N den Hertog et al.

Colonial misconceptions about the absence of depression and the lack of a psychologization of distress among Africans have long been refuted. However, cultural variation in depression in terms of symptomatic expression, conceptualization, explanatory models, and social responses is widely acknowledged. Insight into the cultural variation of depression is useful for providing appropriate care; however, few studies have explored cultural understandings of depression in African settings. In a depression vignette study of two displaced and marginalized San communities in South Africa, we conducted 20 semistructured interviews to explore causal interpretations and strategies for coping. Causal interpretations consisted of several dimensions, including life struggles and physical, psychological, and spiritual interpretations. Respondents primarily focused on life struggles in terms of socioeconomic and interpersonal problems. They described coping strategies as primarily addressing negative emotional and psychological affect through social support for relief, comfort, distraction, or advice on coping with the situation and emotions. In addition, religious coping and professional support from a social worker, psychologist, support group, or medications were mentioned. Findings illustrate that depression should be understood beyond individual suffering and be situated in its immediate social environment and larger sociopolitical setting. Interventions for depression therefore may benefit from a multilevel approach that addresses socioeconomic conditions, strengthens local resources, and fosters collaboration among locally appropriate informal and formal support structures.

Sociality and temporality in local experiences of distress and healing: Ethnographic research in northern Rwanda (open access)
Yuko Otake, Teisi Tamming

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.

“An automatic Bible in the brain”: Trauma and prayer among Acholi Pentecostals in northern Uganda
Lars H. Williams

This article examines the role of prayers for traumatized survivors of war within a Pentecostal-charismatic community in post-conflict northern Uganda. It argues that becoming part of a church group and learning certain regimes of prayer can work toward symptom relief and recovery for people suffering from traumatic experiences. The study builds on 13 months of ethnographic fieldwork in rural northern Uganda, with extensive participant observation of religious practices and interviews with rural church congregants. The article attempts to show, through a single case narrative, how individual prayer practices are trained and learned and to identify features of prayer that may alter the individual experience of distress. Analytically, the article builds on Tanya Luhrmann’s scholarship on prayer and applies this conceptual framework to a post-conflict context. The study expands on Luhrmann’s concepts of prayer as an emotional technology in order to understand how psychiatric symptoms are managed within a Pentecostal-charismatic community. The article further argues that a conceptual focus on training of skills can contribute to debates on the universal versus particular characteristics of psychiatric expression and concepts of mind. This argument contributes to current debates on non-clinical ways of managing traumatic experiences and to debates about models of mind in different cultural settings.

Self-identification, mode of diagnosis and treatment, and perceptions of relationships with medical providers of South African Xhosa-speaking traditional healers
A. S. J. van der Watt et al.

There is widespread use of traditional medicine in treating common mental disorders in South Africa. We aimed to (i) explore the self-identification of traditional healers (THs; how they refer to themselves, e.g., as healer, spiritualist, sangoma, etc.); (ii) determine if different types of THs treat different conditions (physical/psychological) or use different modes of diagnosis and treatment; (iii) identify factors that influence the willingness of THs to refer patients to biomedical hospitals; and (iv) compare TH practices between two provinces. Participants included Xhosa-speaking THs (mean age = 54.10, SD = 13.57 years) from the Western (n = 50) and Eastern (n = 68) Cape provinces. Participants completed a questionnaire regarding self-identification, mode of diagnosis/treatment, relationship with biomedical hospitals, type of condition(s) treated, and a Patient Health Questionnaire. There were significant associations between the type of TH (as self-identified) and (i) mode of diagnosis, (ii) mode of treatment, and (iii) type of condition(s) treated. Spiritualists, male THs, and THs who had previously been hospitalised for a mental disorder were more likely to treat mental disorders. THs who had previously been hospitalised for mental disorders were more likely to report a willingness to refer patients to biomedical hospitals. Findings highlight the complex practices of Xhosa-speaking THs. Collaboration between THs and mental health care professionals could be facilitated by focusing on male THs, spiritualists, and THs who have previously been hospitalised for mental illness. Future research should provide clearer operational definitions of the type of TH included.

“Medical treatments are also part of God’s gift”: Holy water attendants’ perspectives on a collaboration between spiritual and psychiatric treatment for mental illness in Ethiopia
Laura Asher et al.

In Ethiopia, traditional and spiritual treatments, such as holy water, are used by people with mental disorders instead of, or alongside, psychiatric services. Collaborations between traditional and psychiatric providers may increase access to evidence-based treatments and address human rights abuses. This study aimed to explore the perspectives of holy water attendants on a novel collaboration between holy water and psychiatric care, at St Mary’s Clinic, Entoto, Ethiopia, and to characterize the users of this service. Semi-structured interviews were conducted with 14 holy water attendants, who run group houses for holy water residents and are paid by family members. A thematic analysis was conducted. Socio-demographic and clinical data were extracted from the records of all service users who had attended the clinic. A total of 174 individuals have attended the clinic in the three years since it opened. The majority were diagnosed with schizophrenia. Holy water attendants provide a partial gatekeeping role to psychiatric care, selecting which of their clients they think will benefit and, for these individuals, facilitating attendance to the clinic and antipsychotic medication adherence. Psychiatric care was felt to be compatible with holy water by some, but not all, attendants. However, family members often had the “final say” in individuals attending the clinic, in some cases putting up strong resistance to using psychiatric care. A novel collaboration is acceptable to some holy water attendants and may increase access to psychiatric care amongst people with mental illness living at a holy water site in Ethiopia.


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