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Purpose: This
study explored the knowledge of mental illness and the concept of mental health
healing among pastors in Mzuzu, with the view of finding possible collaboration
with professional mental health workers.
Methodology: The
study used an exploratory qualitative research method. Purposive sampling
technique was used to recruit participants of the study and data was collected
through FGD's. The study employed thematic data analysis method.
Results: The
findings indicate that participants were able to tell signs and symptoms of a
mentally ill person through changes in behavior, thought and speech. The causes
of mental illness emerged as a determining factor for the pastors on how the
patient should be managed.
Conclusion: The
research study has affirmed that pastors and traditional leaders are key to
decisions and health seeking behavior because many mentally sick people and
their families consult and take their advice. There is need, therefore, to
engage and collaborate with pastors in the healing of mental patients.
Keywords:
Pastors, Mzuzu, Mental illness, Collaboration, Healing, Social cultural
Abbreviations: FGD:
Focus Group Discussion; SJOG: St. John of God; MHS: Mental Health Services
INTRODUCTION AND BACKGROUND
More than 25%
of people at a global level are estimated to experience mental illness at some
point in their life time regardless of the socioeconomic status and age [1].
According to Kauye et al. [2], the prevalence for probable common mental
disorders among primary health care patients in Malawi range between 20-28.8%.
Mental illness presents a major and growing burden worldwide [1,3]. Despite
such alarming statistics, most patients are instructed by the pastors to stop
hospital treatment and solely rely on their faith after they are discharged
from hospital. These patients relapse and seek readmission in the hospital in
worse scenario, while some commit suicide. While religion and health have an
association, literature showed that nothing has been done in Malawi to
understand the concept of healing among pastors yet they have an influence
regarding health seeking behavior of their flock.
The increase in
prevalence rate of mental disorders both in Malawi and globally creates a need
for more mental health professionals. Most of the professionals are always
inadequate to meet the high demand of mental health services [4]. This
inadequacy from mental health professionals has led religious leaders and other
indigenous healers to get involved in the provision of mental health care
services. Studies such as those of Stanford [5], Kruger [6] and Wood et al.
[7] have shown that people with mental health issues will first visit religious
leaders for help before seeing medical professionals. Possible reasons for this
practice might be due cultural and religious beliefs, stigma, and lack of
funding and accessibility of services [8]. Some religious leader’s statements
showed that the term “depression” was associated with having a weak faith and
being viewed as having a negative attitude towards God [5]. The need and reason
for this study is based on the scenario that in as much as
there
is evidence of
traditional and
MAIN OBJECTIVE
The broad objective of this study is to
explore the concept of mental health healing among pastors and possibilities of
collaboration with mental health professionals in Mzuzu.
SPECIFIC OBJECTIVES
1. To
identify pastors’ knowledge regarding causes, signs and symptoms and management
of mental illness.
2. To
find out the pastors’ understanding of the healing concept in mental health.
3. To
identify pastors’ role in mental health and wellness of people with mental
health issues.
4. To
determine the understanding of the management of mental illness.
LITERATURE REVIEW
There are a number
of studies on the relationship between religion and mental health and the
collaboration between the church and the hospital. However, such studies do not
show the understanding of the concept of healing of mentally ill people among
pastors. Shreve-Neiger and Edelstein observed that research on the relationship
between religion and mental health suffers from severe limitation that makes
the data difficult to interpret [9]. Similarly, Park [10] noted that there are
very few studies which are “experimental in nature; almost all of the
researches are conventional or cross-sectional and are contaminated with
confounding factors. For instance, a research done among Arabic speaking
religious leaders in Australia found that spiritual poverty, other than
substance and alcohol abuse, psychosocial factors and biological
predisposition, was mainly the cause of mental illness [11]. This belief and
understanding of the Arabic-speaking religious leaders may influence how
pastors respond to and care for the people with mental illness and may
determine whether they refer their clients to professional mental health
services or not. Hence, it is not surprising to note from the study that most
religious clerics viewed medication as not helpful in the treatment of mental
illness [11]. On the contrary, an Australian study observed that the pastor
attributed drug and alcohol addiction, stressful life events, childhood trauma
and spiritual poverty as the most important causes of mental illness [12]. This
finding was in agreement with what was observed in a Johannesburg community
study. This study explored Muslim faith healers’ perceptions of mental illness
in terms of etiologies and treatment methods. The findings in Johannesburg
suggested that mental illness is caused by a variety of factors including
medical and religious factors [13]. The results also indicated that faith
healers were aware of the distinction between mental and spiritual illness.
Early religious
communities believed that sin and breaking of God’s law was the cause of any
illness. For example, results of a survey of attitudes toward mental illness in
the Christian Church found that abandonment by the church was the main cause of
mental illness and mental illness was equated with the work of demons
suggesting that the mental disorder was the result of personal sin [5].
Studies, however, conducted among religious leaders and congregants have showed
varied perceptions on the causes of mental illness [6]. Leavey [14] suggested
that mental health problems can have both natural and supernatural causes which
mental health professionals are unaware of and unable to detect. He argued that
Pentecostal ministers believed that psychiatrists would not be able to detect
demonic presence when mental illness has a spiritual origin [14]. Therefore,
the treatment options included use of scripture in order to provide guidance
for good mental and physical health, exorcism and deliverance ceremonies.
However, in the same study, it was discovered that amongst mainstream Christian
pastors such as Anglicans and Roman Catholics, medical care was advised and
religion was viewed mostly as complementary service in the management of mental
illness. The findings also indicated that counseling was a significant activity
in the management plan of mental health problems in the church.
Though many
churches attribute the cause of mental illness to sin or demon possession,
Stetzer [15] argues that pastors and congregants are supposed to be
knowledgeable about the reality of mental illness. Agara et al. [16] observed
that religious leaders had inadequate knowledge about the causes of mental
illness and the treatment options. The study further revealed that religious
leaders had various treatment modalities of mental disorders based on their
knowledge on the cause of mental illness [16].
Lack of knowledge
regarding the causes of mental illness can lead to improper management
techniques. For instance, Young [8] observed that some religious leaders had
misperceptions regarding causes of mental disorders which led to improper
management. The improper management of mental illness perpetuated stress,
anxiety, depression and grief that had clear negative impacts on individuals
and the affected families. A study conducted in Ghana reported that religious
prophets viewed mental illness as a spiritual not a biomedical problem [17]. As
such, the treatment the prophets proposed were hope induction and prophetic
deliverance approach. Further, the prophets confirmed that “a problem
conceptualized supernatural in origin, must ‘logically’ be solved
super-naturally [17]. The participants (pastors) perceived mental illness as
that which can be treated by religious healers and not health care workers. The
conclusion of the study was that the prophetic engagement in mental health care
and treatment can supplement hospital therapies if professional training and
education were to be added [17].
Studies further
suggests that many pastors become involved in helping the mentally ill cope
with their illness. Colling and Culbertson [18] assert that the strategic
position of a pastor in managing the emotionally troubled people is emphasized
in the sense that people with mental illness need spiritual or Pastoral care
more than psychiatric or psychological care. This perception among pastors
often puts them as the first persons to whom the troubled patients or family
members turn for help [19]. This situation gives an opportunity to the
religious pastors to get involved in the recovery process of the clients. In
the United States of America for example, approximately 77% of people attend
church regularly and first seek assistance from the pastor when they have
mental health problems [20]. In support of this observation, Young’s [8] study
also noted that African Americans often seek and obtain significantly fewer
traditional MHS as compared to other groups. Similarly, a Nigerian study
revealed that pastors had stigmatizing attitudes towards people living with
mental illness [21]. This attitude may directly affect the nature of the
treatment and the advice that pastors offer to mentally ill persons.
In yet another
study, Richard Mee [22] noted that networking between religious leaders and
mental health professionals is vital in managing clients with mental health
problems. For effective collaboration, there is need for religious leaders to
have adequate knowledge regarding mental health issues. Osafo [23] noted that
the challenges that hinder possibilities of networking between the two entities
are that the medical professionals disregard religion and culture, while many
religious leaders attend psycho-education seminars on mental health issues
[23]. Osafo further reports that patients had more trust in religious leaders
than they had in health professionals [23].
Much of the study
linking mental health and religion/spirituality has been done in United States
of America. Ghana and Nigeria are among the few African countries that have
conducted some studies related to mental Health and Religion. In Malawi, there
are no published studies that directly reveal religious leaders perception
regarding causes of, and the treatment of people with mental illness. This is despite
the rise in what could be considered the counter variable to mental health; the
rise in the number of prayer houses where people turn to when suffering from
psychological problems.
Research conducted
in Malawi in the area of mental health has just mentioned religion and pastors
in passing. For instance, in a study on health-seeking behavior, it was
reported that the community’s perception on the management of mental disorders
in Malawi was largely based on traditional and religious health systems [9]. In
its findings, mental illness was largely attributed to witchcraft and ancestral
wrath, in which traditional and spiritual healers were consulted respectively
[9]. These findings were supported by those of Kaswaya et al. who reported that
five patients sought help from traditional healers, another five from the
hospital and four from church prayers and counselors [4]. Observations from
these two studies are a testimony that religious leaders in Malawi, just like
traditional healers are equally vital people in the management of people with
mental health problems. A similar study showed that nine percent of the
participants consulted traditional healers while eleven percent sought help
from religious or spiritual advisors where western health care services were
only sought when the indigenous healing systems were unsuccessful [24]. This
health seeking behaviour obviously leads to delays in seeking appropriate care.
Such delays have a potential to contribute to the chronicity and the related
complications of the illness. It is however clear from these studies that
pastors cannot be overlooked when providing effective mental health care to
patients as they too pray an important role in instilling hope to the affected.
However, for their involvement to be effective, there is need for the health
professionals and religious leaders to harmonize their understanding of mental
health healing in order to act and speak in the same language when ministering
to these people. It is against this background that this current study seeks to
explore the concept of mental health healing among pastors in Mzuzu with a view
to propose a working relationship between the pastors and the mental health
workers in order to attain sustainable healing of the mentally ill people.
METHODOLOGY
Study design
This study is an
exploratory qualitative type because it seeks to generate knowledge to
understand the experiences of pastors and knowledge on the ground. Creswell
[25] argues that in a qualitative study, the researcher seeks to listen to participants
and build an understanding based on what they say. The design was chosen
because the research team would like the participants to explain their
knowledge and experiences regarding mental illness care and healing during
prayer activities.
Setting
The study was
conducted in Mzuzu city, in the northern region of Malawi. Mzuzu is the
administrative headquarters of the northern region, characterised by many
people who live in the city for employment and business purposes.
Study population
The study population consists of pastors and
traditional leaders. These pastors were predominantly male with a formal
theological qualification. There were only five females out of twenty pastors
who participated in study. The traditional leaders were from the rural area
called Mpherembe, about 40 km from Mzuzu. All the traditional leaders were male
due to cultural chieftainship of the Ngoni people. Most of these community
leaders were secondary school dropouts.
Sampling and sample
size
The study participants were selected using
purposive sampling technique. The method involved the conscious selection of
certain pastors and traditional leaders to be included in the study. The
research team selected study participants based on personal judgment about who
will be most representative or informative [26]. The study focused on all
pastors who have had mental health education contact with SJOG Services through
psycho-education meetings organized by SJOG, and all pastors who have not had
any contact with SJOG in the catchment area. The traditional leaders were
purposively selected by their traditional authority that was the point of entry
for the research team. The study recruited 30 participants who were divided
into three groups of ten each.
Instrumentation
An instrument with questions was developed in
English and translated into Chichewa by trained mental health workers fluent in
Chichewa. Pre-testing was done among five pastors within Mzuzu city who were
not part of the actual study. The pretesting was done in order to estimate how
much time it would take to administer the entire instrument package and in
order to refine the questions and ensure that appropriate data was collected.
Data collection approaches
The data for this study was generated through
FGD’s. Three FGD’s were conducted. Story telling methods related to how the
pastors conduct their healing ministry in their congregations were adopted. The
major point of departure in the FGD was: what is your understanding of mental
health healing? Based on the responses, follow up questions were administered.
All interviews were audio-recorded with the informed consent of the
participants and written notes were taken to ensure quality of the
transcription and no loss of data.
DATA ANALYSIS
Data generated from FGD was analysed using
thematic data analysis method. Recorded data was transcribed then translated
from vernacular Chichewa (languages spoken by the research team and the
participants) to English after each FGD. It is from this data that themes were
generated.
ETHICAL
CONSIDERATION
Prior to carrying out the study the researchers
sought ethical approval from St. John of God Research and Ethics committee in
Ireland (ID 701); National Health Sciences Research Committee (NHSRC) in Malawi
(Protocol # 18/5/2035), further permission was sought from Mzuzu City Assembly.
Participation in the study was voluntary. The data collected was
non-pseudonymised because participants in the FGD knew what the others were
saying.
RESULTS
There was clear disproportion in
representativeness between female and male participants. This was probably due
to the methodology chosen to select participants. This was acknowledged as a
weakness in the method. Pastors agreed a deviation from ones cultural behaviors
is the main indicator that someone is getting mentally ill. These changes can
be summarized as physical, psychological and sociocultural changes as shown in
the Table 1.
Physiological expressions
Male pastor
(MP1) indicated that ‘biblically, when a person is possessed with demons or
evil spirits also called ziwanda will portray a change in
behavior. This behavioral change such as walking naked, aggressive behavior,
talkativeness, poor self-care for example dressing in rugs. Demons are acquired
if the behavior of the person is not in harmony with the community’s norms.
These evil spirits leads a to person smoke chamba (Cannabis sativa), drinking too much alcohol and strange behavior.
When
participants were discussing on what causes mental illness, it was clear that
they all believed that the way one tells what is wrong with the patient will be
dependent on what is causing the symptoms. Therefore, they all believed that
the bio-psycho-social element is the main way of determining whether someone is
mentally sick and what has caused the mental illness.
Causes
MP4 argued that a person possessed with evil
spirits would start exhibiting strange behavior for example walking naked,
talking to self, wandering around, dressing in rugs, picking in rubbish bins.
Female Pastor (FP11) on the other hand said that “sin can lead to having
a person possessed by demons. For example a person who gets involved in
promiscuous behavior; if one goes for another person’s wife, this will lead to
anger to the owner of the wife who will start even thinking to be-witch the
other person.” In agreement, MP2 said that “biblically someone behaving in a
strange way is said to be possessed with evil spirits,” locally known as ziwanda.
Physical cause or biological causes
Participants had similar concepts for the
cause and how they identified mental illness. As such causes of mental illness
were categorized as physical causes, psychological causes, social-cultural as
summarized in the Table 3.
Cause of mental illness
Psycho-social causes: MP9
indicated that life challenges such as loss of relatives or property, conflict
between two individuals may lead to depressive thoughts. These thoughts may
result to stress which will lead to development of some psychiatric problems.
Physical/biological
causes: FP3 explained that inheritance could be a cause of mental illness:
“…sometimes this disease runs in families. One can easily track an illness in
the family tree. Drug abuse like alcohol can also cause mental illness if used
excessively, smoking marijuana and cocaine use.” MP5 noted that “diseases that affect the
brain directly, e.g. cerebral malaria, meningitis and other diseases that may affect the
brain indirectly.”
Social-cultural causes: FP6
noted that bewitchment due to anger, curses can cause mental illness. For her,
“a man may start going along with another man’s wife (chigololo), then out of anger another man may start thinking of
hurting the other person through witchcraft, or curse to punish the other man
through magic.”
Spiritual causes: Possession by evil
spirits commonly termed as ziwanda is
one of the popular causes of mental illness that was pointed out by many (N=17)
in this culture during the discussions. It is associated with a person who
breaks cultural norms, and may be affected by evils spirits as a punishment or
a curse. These types of beliefs are important to discipline people to strictly
adhere their cultural norms.
Management of mental
illness
It was evident
that treatment was influenced by what was believed to be the cause of the
mental illness. If the illness was believed to be due to physical or biological
causes, all pastors unanimously agreed that the person should be sent to
hospital for determination of the severity of the illness and establishment of
the treatment. However pastors believed that there are two types of healing:
physical healing and spiritual healing (kuchirisindwa kwa thupi ndi kwa
mzimu). Pastors believed that it is only God who can heal all types of
illnesses both spiritually and physically. The challenge with this approach was
when it came to determining where the patient should go first [27]. Pastors
believe that the hospitals are a creation of God and therefore prayers should
come first when someone is mentally ill. Hospitals and doctors are a creation
of God and so they cannot take precedence over God.
Signs and symptoms
The symptom of a
person who has a mental illness is basically seen by change in observing ones
cultural norms. As discussed earlier, these include: walking naked, undressing
in public, aggressive behavior, isolating oneself from other members of the
community, dressing in rugs, picking food from dust bins and any other behavior
that deviates from the norms of other members of the community.
Collaboration
It was clear that
both the hospital and pastors are needed in the treatment of mental illness.
However, the idea of collaborating was very controversial. Pastors believed
that there is no trust between doctors and pastors. The pastors were suspicious
that doctors believe that pastors cannot understand the pathophysiology of
illnesses and believed that doctors have no or very little faith in the power
of God. In relation to this, one pastor (MP11) proclaimed the following:
“health professionals and pastors do not trust each other hence it is very
difficult to work together and refer patients to each other for more holistic
care. Otherwise, treatment requires that both of us doctors and pastors should
work together and refer patients to each other.”
DISCUSSION
In this study, the majority of participants
were men (N=25). The Traditional leaders were included in the research because
they are custodians of cultural values and are very influential in the health
seeking behavior of people suffering from mental illness. All the pastors who
participated in the research were from Pentecostal denominations. The age range
of all participants was from 30 to 60, with only seven participants aged above
fifty. Most participants (28) were married. Only four participants had a
bachelor’s degree as their highest qualification and many (16) had diplomas
while remaining (10) were secondary school dropouts. The pastors who had no
contact with SJOG seemed to have some awareness about mental health, probably
from the media publicity of SJOG programs or influence through their own
pastors meeting.
This study
reveals that there is mistrust between healthcare workers and pastors. Pastors
believe that healthcare workers have very little faith in God while healthcare
workers believe that pastors do not understand the pathophysiology of illness.
This perception also acts as a barrier to the provision of mental health
services as noted in a study conducted in Ghana [28]. This therefore means that
any efforts for collaboration may be difficult between the two groups without
any form of psycho-education on both. In agreement with a study done by Gyekye,
mental illness was perceived by both groups of pastors to be caused by
supernatural entities and therefore should be treated by supernatural means
[29]. Pastors claimed that doctors did not have nor had very little faith in
God. Following this line of thought, sending patients to doctors was like
putting doctors first over God which is not acceptable in their belief.
All groups
relied on deviation of behavior from the culturally accepted to something that
does not conform to the person’s cultural background to describe and identify
mental illness. As regards to causes of mental illness, there were agreements
in the assertion of bio-psycho-socio-cultural and spiritual causes. MP7 said
that “biblically the person is possessed with evil spirits or demons (ziwanda).
These will lead to change in behavior e.g. walking naked, over talkativeness,
talking to self and poor self-care. Demons or evil spirits are acquired if a
person’s behavior does not conform to cultural norms as a punishment. These
spirits will make a person engage in abnormal behaviors e.g. smoking chamba,
drinking alcohol excess fully.”
The research
has affirmed the findings of Ssengooba et al. [19] that pastors are key to
decisions and health seeking behavior because many people seek their advice
when they are mentally sick. They further argued that there are illnesses which
are natural and healing can be done through biomedical treatment, while some
illnesses are supernatural which cannot be healed by the hospital but through
prayers. The majority of pastors and traditional leaders in this research
contend that mental illness has a supernatural cause hence patients can be
healed through faith healing prayers and traditional medicine. There was no
major difference between the data collected from pastors who had a contact with
SJOG and those who did not have contact. The research team attributed this
similarity to the fact that all the pastors were from Mzuzu and that they might
have heard of SJOG through the weekly radio program hosted by SJOG on mental
health related issues.
In most cases,
there appeared to be a competition between the pastors and the healthcare
professionals. As the results indicate, most pastors believe in faith healing
prayers to heal mental illness, while the healthcare professionals encourage
the use of medicine an observation also made in a study by Asamoah-Gyadu [30].
As Owoahene-Acheampong et al. [31] indicated in their study, the findings of
this research suggests that health workers should engage pastors in
psycho-education and establish a working collaboration [31].
All the
participants (30) were able to tell signs and symptoms of a mentally ill person
through changes in behavior, thought forms and speech patterns. They agreed
that most of the people suffering from mental illness deviate from their normal
way of living. Again, all the participants recognised the causes of mental
illness on a biopsychosocial-spiritual and cultural understanding. These
included biological, psychological, social cultural and spiritual. Pastors who
had contact with SJOG had better understanding of causes of mental illness than
those who did not have contact with SJOG. Social cultural causes were more
prominent in pastors who had no contact with SJOG. However, they were not rigid
with these social cultural causes possibly because they were influenced in an
informal circumstance within the area of study. It was noted through analysis
that pastors who had contact with SJOG were more flexible to refer patients to
the hospital for confirmation while the other group of pastors relied heavily
on deliverance and faith healing prayers. Referral to a mental hospital was
only seen as an option as pastors who no contact with SJOG had believed that
hospital, doctors and medicine were all a product of God’s own intelligence
[28]. This is against a background that many people with mental illness use
traditional and complementary medicine.
The two groups of Pastors (20) had a problem
in collaborating with healthcare workers. The majority of pastors think that
they are undermined by health workers. This viewpoint agrees with the findings
of Asamoah et al. [28]. As such, they can only send the patients to the
hospital if the health workers also send patients to them. This understanding
portrays a clear evidence of conflict between pastors and healthcare
workers in the community which needs to be addressed.
This study further reveals that there is mistrust
between professional health care workers and pastors. Similar to findings of a
study in Ghana [23], pastors in this study believe that health workers have
very little faith in God and health workers believe that pastors do not
understand the pathophysiology of illness. This therefore means that any
efforts for collaboration will be very difficult without training of pastors.
The causes of mental illness was a
determining factor by all (30) participants on how the patient should be
managed. This is the area where many pastors and traditional leaders thought
the hospital would help in excluding biological causes.
STUDY LIMITATION
Data collection
was only done through FDG’s in this study. Issues of faith and gifts of healing
that pastors operate upon are so personal and private. In fear of being laughed
at, the pastors may not be comfortable to discuss such issues in public.
Therefore, there is need for triangulated methods in future studies. The study
only sampled pastors from an urban setting, it would be important to conduct a
similar study with a rural-based population. The majority of pastors had a
theological training; it may be significant to sample pastors who run their
ministries without training in a theological school. The study was only based
with few study participants; hence the findings cannot be statistically
extrapolated. Nonetheless, this study is consistent with other studies
conducted in Africa and adds another useful dimension to the holistic care of
people suffering from mental illness.
CONCLUSION
The study notes
that pastors have a different understanding of healing of a mentally ill
person. The causes of mental illness are determinant factors in the management
and treatment of people with mental illness. Further, there is a clear evidence
of conflict between pastors and healthcare workers in the community which needs
to be addressed. Pastors and traditional leaders are very crucial to the choice
of treatment modalities and therefore present as potential collaborators in
promotive, preventive and curative treatment intervention.
RECOMMENDATION
Based on the findings of this study, there is
a need to develop an approach where orthodox healthcare systems collaborate
with pastors and traditional leaders in order to complement healing of a mentally ill person.
This complementarity approach may provide the most efficient, appropriate and
cost-effective way to meet the huge need for mental health care and to reduce
relapse of patients. Like studies in the past done on the African continent, we
further recommend integration or collaboration of the two systems through
psycho-education of all stakeholders for both referral and appropriate decision
making. More research is needed on how western biomedical care can collaborate
with indigenous Malawian healing systems in mental health.
ACKNOWLEDGEMENT
This research
project was funded by SJOG Research Grant Scheme in Stillorgan, Dublin –
Ireland.
AUTHOR CONTRIBUTIONS
Conceptualization, funding acquisition, investigation,
project administration, writing – original draft:
Chrispine Nthezemu Kamanga.
Formal analysis, methodology, writing, review and
editing: Chrispine Nthezemu Kamanga, Harris Kaswaya
Chilale, Charles Maloya and Zione Louise Mugala.
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