1
Spi i ual Heale s as a Ba ie o Timely Men al
Heal h Access in Ru al Pakis an: A Mini-Re iew
by
Ahsan Haide Shehzad, MSc Applied Psychology
ahsenhaide [email protected]
Depa men o Psychia y, Di isional Headqua e s & Teaching Hospi al Mi pu AJ&K
Abs ac
Ru al Pakis an in e p e s men al illness in e ms o spi i ual and supe na u al aspec s and no biomedical. Jinn possession,
black magic, o di ine es ing a e usually blamed as a cause o symp oms o dep ession, anxie y, psychosis, and auma,
causing amilies o p e e spi i ual heale s o e men al-heal h p o essionals. This na a i e mini- e iew is an in eg a ion o
c oss-cul u al psychia ic li e a u e, sociological iews, and communi y-speci ic knowledge on he easons why spi i ual
heale s a e he main in e ace o con ac in u al a eas. The e iew uses explana o y model heo y and pa hways- o-ca e
esea ch o explain how cul u al belie s, eligious in e p e a ion, s igma, po e y and less psychoeduca ion led o majo
delays in clinical in e en ion, which is a con ibu o o p olonged Du a ion o Un ea ed Illness (DUI) and un a o able
long- e m ou comes. The e iew also e alua es obs acles in he men al heal h sys em in Pakis an and sugges s cul u ally
conscious and communi y ocused in e en ions including pa ne ing wi h spi i ual heale s ins ead o compe ing agains
hem, ocused psychoeduca ion, ask shi ing h ough Lady Heal h Wo ke s, and he g ow h o mobile and ele-psychia y.
To connec he gap be ween adi ional belie sys ems and e idence based psychia ic ca e, a hyb id model o ca e based
on cul u al espec mus be implemen ed.
Keywo ds: men al heal h in u al Pakis an, c oss cul u al psychia y, impo ance o psychoeduca ion, sociology o men al
diso de s, eligion and s igma o men al heal h in Pakis an
In oduc ion
Psychological dis ess is no e y o en desc ibed as
biomedical when i is obse ed in many pa s o u al
Pakis an. Ra he , i is usually in e p e ed in he spi i ual,
supe na u al o mo al sense ha has a s ong cul u al
backg ound. Whene e ic ims show some o he
ollowing symp oms; cons an sadness, uncon ollable
ea , hallucina ions o uncoo dina ed beha io , amilies
o en e e o he ollowing as being possessed by jinn,
being he ic im o he e il eye (naz ), he ic im o black
magic (jadu), o he ic im o di ine ial. Such meanings
a e no inciden al o ma ginal; hey ep esen es ablished
explana o y pa adigms ha ha e been used by
communi ies o e ex ended pe iod o ime. In his wo ld
ou look, he spi i ual heale s such as pi s, amils, dam-
da uds, and ca e ake s o sh ines a e us ed cul u al
au ho i ies and on line esponde s o emo ional,
beha io al c isis. S uc u al eali ies con inue his pa e n
o help-seeking. Pakis an, wi h u al a eas has acu e
p oblems in e ms o men al-heal h p o essionals,
inadequa e psychia ic acili ies, and high cos s o
ea men . Toge he wi h widesp ead s igma o men al
illness, hese ba ie s make biomedical ca e no only
inaccessible, bu also socially un a o able. Consequen ly,
amilies ha e a endency o seek mo e han one cou se o
spi i ual in e en ion be o e hinking o psychia ic
assessmen despi e he ac ha some condi ions ha e
clinical ea men g ea ly enhancing hei ou comes so a
as one is majo dep ession diso de , psychosis, epilepsy
being con used wi h possession, and se e e anxie y
diso de s. Wi hin he c oss-cul u al psychia ic
unde s anding, hese pa hways ep esen wha Kleinman
e e s o as, he so-called, explana o y models: sys ems
wi hin cul u es ha indi iduals use o make sense o he
symp oms, o p o ide causa ion and o decide on he
p ope ea men . The models a e biased owa ds
supe na u al explana ions, which a e used in u al
2
Pakis ani con ex s no only o shape an indi idual
pe cep ion, bu also o de ine collec i e codes o conduc
in ega ds o wha ac ions can be aken in esponse o
dis ess. This has an an icipa ed and usually haza dous,
delay in e idence-based in e en ion. The mini- e iew
discusses he cul u al, eligious, and socio s uc u al
ci cums ances pe pe ua ing dependence on spi i ual
heale s and cons aining ea ly access o psychia is s and
psychologis s in u al Pakis an. I combines he lessons o
he c oss-cul u al psychia y, medical an h opology and
popula -heal h li e a u e o elucida e he in e sec ion o
misunde s andings o men al illness, limi ed
psychoeduca ion, s igma, and economic cons ain s ha
se e o pe pe ua e he Du a ion o Un ea ed Illness
(DUI). The e iew w aps up by desc ibing cul u ally
sensi i e solu ions o he assimila ion o spi i ual
amewo ks and biomedical ca e o p omo e men al-heal h
access in u al communi ies.
Why Ru al (and Many U ban) Communi ies in
Pakis an Do No Belie e in Men al Diso de s
To comp ehend his, i is necessa y o explo e some o he
in e connec ed issues, namely cul u al s o ies, eligion,
educa ion, and social sys ems. In mos Pakis ani amilies,
men al illness was ne e b ough in as a alid heal h
concep . Ra he , dis ess is concep ualized by:
• jinn in luence
• naz (e il eye)
• black magic
• mo al-spi i ual weakness
• di ine es ing
• in luence o impu e spaces o abandoned
places
These in e p e a ions a e clea , simple and com o ing o
he emo ions. They a e cong uen wi h na a i es ha
people ha e been old since hei childhood by olde
pe sons, neighbo s and by eligious na a o s. I would
ake a long ba le o change cen u ies o wo ld iew o
explain men al illness as a medical condi ion. Such a
ansi ion is g adual and usually opposed. The eachings in
Islamic eligion conce ning he jinn, e il eye, and
a lic ion by spi i s a e qui e common in Pakis an. Bu
schola ly in e p e a ions a e usually o e shadowed by
cul u al ones. The people in he illage o en assume ha :
• audi o y hallucina ions (hea ing oices) = jinn
whispe ing
• dissocia i e episodes pe cei ed as “body
con ol by a spi i ”
• dep ession = lack o p aye o weak iman
• panic a acks labelled as “jinn in luence”
• odd beha io = possession
Because hese in e p e a ions hold social legi imacy,
amilies p e e heale s who p omise spi i ual p o ec ion,
Qu anic eci a ions, o exo cisms ( uqya), a he han
psychia is s who diagnose using wes e n echniques.
Since such in e p e a ions a e socially alid, he amilies
will choose heale s who will gua an ee hem o spi i ual
p o ec ion, Qu anic eci a ions, o exo cism ( uqya), as
opposed o psychia is s who will diagnose using wes e n
me hods and p esc ibe medica ion o some hing ha is
no isible.
Islam does no ejec medical ea men , hough local
in e p e a ions o i combine eligion and olklo e. This
pu s he subjec o spi i ual healing as some hing no only
an op ion, bu also a eligious du y. A pi o an amil is
ega ded as a pe son who has God as his means. A
psychia is is pe cei ed as a pe son who ope a es using
wes e n de ices. To a la ge numbe o u al ci izens, he
decision is mo ally in ui i e. They also eel ha he e is no
sickness ha canno be seen and so i is no in eali y.
Whe e educa ion is es ic ed, concep s in biomedicine
such as: neu o ansmi e s, anxie y diso de s, psychosis,
auma esponses, mood dys egula ion, a e unknown. In
he absence o psychoeduca ion, illage s a e de eloping
explana ions ha ely on wha hey ha e hea d in s o ies,
spi i ual sys ems and sha ed belie s. Men al illness is no
usually isible, objec i e and miscons ued.
Village s ask:
“Bukha ho o dikh a hai. Da d ho o pa a chal a hai.
Pagalpan kaise bima i ho sak i hai?”
[I e e can be seen and pain can be el , hen how can
madness be conside ed an illness?]
This con usion ende s o men al illnesses he appea ance
ha hey a e no eal o ake whe eas supe na u al e en s
seem eal and physical. In he u al en i onmen s,
epu a ion is he de e minan o ma iage oppo uni ies,
ela ionship wi h he communi y and social espec . A
psychia ic diagnosis is a menace o amily p ide. A
3
spi i ual label does no . Families like a heale since:
owning no hing is no ha m ul o social s anding whe e a
men al illness is c ippling, he jinn may be expelled, bu
he ag o madness is pe manen ly imp in ed. In his way,
spi i ual explana ions u n ou o be psychologically
p o ec i e. Bu going o spi i ual heale is cheap o
dona ion-based, nea home, socially accep able and ee o
pape wo k, isi ing a psychia is is cos ly, a away, ime-
consuming, and las bu no leas , comes wi h a sense o
shame. The inal one he mos powe ul one. To a la ge
numbe o households, he decision is no idealis ic.
Heale s a e membe s o he communi y. They a e p esen
a weddings, une als, and local pa ies. The e is mo ali y
in hei wo d. In compa ison, psychia is s: a e s ange s,
employ o eign lingo, may no unde s and he local
dialec , and may be pe cei ed o be disengaged wi h li ing
he daily li e When amilies a e seeking assis ance, hey
e e o he pe son who has been wi h hem e e y
signi ican momen o li e, he spi i ual heale .
Psychologis s and Psychia is s a e misunde s ood
p o essions many people associa e psychia is s wi h:
• “Mad people”
• Elec ic shocks
• P esc ibing hea y dose and highly addic i e
sleeping medica ions.
Men al-heal h p o essionals a e ea ed, misunde s ood, o
pe cei ed as h ea ening. Village s o en ask:
“Hum bewaqoo nahi hain. Doc o hama ay zindagi ke
masle kaisay samajh sak a hai?”
[We a e no s upid a doc o canno unde s and a
(spi i ual) p oblem]
This dis us coupled wi h p o ound us in he heale s is
he mo i a ion behind he p e e ence o he spi i ual
p ac ice. These cul u al in e p e a ions, hough no
meaningless, esul in o li e h ea ening men al diso de s
such as being diagnosed and ea ed in dange ous delays.
• schizoph enia
• bipola diso de
• se e e dep ession
• auma diso de s
• epilepsy misin e p e ed as possession
The esul is an inc eased Du a ion o Un ea ed Illness
which causes ch onic symp oms, isk o suicide,
unc ional impai men and long- e m disabili y. Medical
in e en ion o clinical diso de s canno be subs i u ed by
he assis ance o spi i ual com o .
Why Ru al Pakis ani’s P e e Spi i ual Heale s
o e Psychologis s & Psychia is s
Pakis anis in he u al a eas a e o e whelmingly a ac ed
o spi i ual heale s since hey a e i mly embedded in o he
cul u al, eligious and emo ional amewo k o illage li e
in ways ha psychia is s and psychologis s a e no .
Spi i ual heale s o he a ious u al communi ies, be i
pi s, amils o dam-da ud heale s, a e no only seen as
p o ide s o ea men , bu mo al gua dians, he
cus odians o eligious knowledge, he p o ec o agains
he unseen wo ld. Thei wo ld pe cep ions echo he
his o ical belie sys ems ound in he communi y whe e
psychological dis ess is ha dly cons ued as a medical
p oblem bu a he as he in il a ion o supe na u al powe
like jinn, naz (e il eye) o black magic. Anxie y, e.g.
which is exp essed as embling, ches igh ness,
palpi a ions, choking, s omach pain o ea wa es, is
nea ly uni e sally misconcei ed as an ex e nal spi i ual
assaul ins ead o a psychological mechanism. These
eadings coincide wi h olklo e s o y elling p ac ices,
allusions o jinn in he Qu an, and o al adi ions h ough
he use o elde s, which is why spi i ual explana ions we e
eligiously legi ima e and cul u ally in ui i e. Fu he ,
spi i ual heale s speak in he local dialec s, know he
amily se up and can communica e in he amilia
eligious lingo which ins an ly eassu es people in dis ess
gi ing hem hope by u e ing exp essions such as, his is a
jinn waswasa (whispe s)- i will disappea wi h eci a ion.
Con e sely, men al-heal h p ac i ione s a e unknown,
physically a , expensi e and end o be seen as
Wes e nized o de ached o local alues. Low li e acy and
lack o psychoeduca ion also ein o ce he no ion ha
men al issues mus be o supe na u al causes.
To illage s, a spi i ual heale is no me ely a
heale , bu me ci ully, a digni ied, p i a e, mo ally
anspa en app oach o healing, and a cul u ally i ing
ame o e e ence in o which he biomedical sys em has
ne e managed o i wi hin he scope o hei social
uni e se.
4
Clinical Consequences o Delayed T ea men o Men al
Diso de s in Ru al Pakis an
Delays o ob ain psychia ic ea men due o he use o
spi i ual heale s and supe na u al a ibu ions - ha e
se ious clinical, social, and unc ional implica ions. These
delays a e modeled in psychia ic esea ch wi h he no ion
o Du a ion o Un ea ed Illness (DUI) which has p o en
o be an e ec i e p edic o o he se e i y o symp oms,
ch onici y, isk o ecu ence, and pe manen disabili y in
a a ie y o men al diso de s. In u al Pakis an, DUI is
equen ly signi ican ly ex ended, weeks o e en yea s
long, since amilies spend se e al ounds o spi i ual
healing be o e biomedical e alua ion is conside ed. This
end is pa icula ly wo isome conside ing ha mos
psychia ic diso de s ha e hei mos he apeu ic e a in he
ini ial s ages o he disease.
The e ec o sus ained DUI is mos imp essi e in
psycho ic diso de s in which delayed an ipsycho ic
ea men is linked o mo e ex eme symp oms, poo
eco e y, educed unc ional abili y, and an inc eased isk
o ch onic incapaci a ion. The p ocess o ea ly
hallucina ions o delusional hough usually mani es ed as
jinn whispe ing o he no ion o possession is no
commonly ecognized as a clinical ed lag. They a e
ins ead cons ued using spi i ual models ha b ing
amilies o ecu ing uqya sessions, isi s o sh ines o
de ense i uals. When psychia ic ea men is o en
sough , i may al eady be oo la e and people may be
al eady unde he in luence o delusion, cogni i e
impai men , and signi ican dis u bances o educa ion,
wo k o social li e.
Delay o ea men in majo dep ession diso de
p edisposes o se ious episodes, suicidal hough s and
suicidal a emp s. Since hese symp oms such as
hopelessness, wi hd awal, a igue, o excessi e c ying a e
seen as a sign o spi i ual weakness, weak ai h, o a
p oduc o black magic, he amily ends o ocus on
spi i ual cleansing a he han he psychological one o
pha macological. This no only inc eases he du a ion o
mise y bu also inc eases ulne abili y o such
complica ions as sel -ha m o ea men - esis an ch onic
dep ession. Misin e p e a ion is mos e iden in case o
anxie y and panic diso de s. Soma ic symp oms, which
include palpi a ions, ches igh ness, sho ness o b ea h,
emo s, dizziness, a e commonly pu down o
supe na u al inju y o jinn possession. The anxie y could
p og ess o panic diso de , a oidance pa e ns ha hinde
mobili y, employmen , and schooling, due o he delay o
he clinical in e en ion. Unless hese diso de s a e
add essed a an ea ly s age, hey may de elop in a ch onic
o m and se e ely a ec e e yday ac i i ies. Diso de s
ha a e ela ed o auma, such as PTSD (Pos T auma ic
S ess Diso de ), a e also neglec ed. In usi e
lashbacks/memo ies, nigh ma es, hype igilance,
i i abili y, and dissocia ion can be a ibu ed o he
spi i ual dis u bance and no psychological inju y. Wi hou
auma-in o med ca e, hey canno ge ou o cycles o
a oidance and dis ess which is usually enhanced by
socie al silence ega ding auma. Mo eo e , he
inaccu acy abou he diagnosis o neu ological diso de s,
especially epilepsy, as possession o spi i ual a ack can
cause signi ican heal h damage. O he han aking
an icon ulsan he apy, some people can be subjec ed o
nume ous exo cisms, smoke sessions o soli ude which
exposes hem o uncon olled seizu es, bodily ha m o
s a us epilep icus. Impai ed psychia ic ca e has a
eached implica ions. This pu s emo ional and inancial
p essu e on he amily sys ems, social ela ions a e
comp omised and he unc ioning o he communi y is
a ec ed because un ea ed indi iduals isola e hemsel es,
lose jobs o beha e in a manne ha e okes ea o s igma.
In he case o young people, un ea ed men al illness
in e e es wi h majo de elopmen al miles ones, a ec ing
academic pe o mance and economic s abili y in he
u u e.
Al oge he , he long- e m use o spi i ual healing, which is
cul u ally signi ican , o ms a consis en end o delayed
clinical in ol emen . This has impac ed he p ognosis,
inc eased disabili y, and esul ed in hea y amily and
communi y cos s. Ha ing made his poin , Du a ion o
Un ea ed Illness among u al Pakis ani women is no
me ely a clinical p io i y, bu also a social and a public-
heal h obliga ion.
5
Towa d a Cul u ally Respec ul Men al-Heal h
Model: A Way Fo wa d
Spi i ual heale s ha e deep oo ed social powe and in
mos cases, hey a e he ini ial sou ce o con ac when
amilies a e in dis ess. They should no be an opponen o
psychia ic ca e bu a he be seen as a po en ial pa ne .
Educa ing he ole o spi i ual heale s o ecognize
psychia ic ed lags, such as hallucina ions, suicidal
hough s, ex eme anxie y a acks, sel -neglec , and
uncon olled agg ession, can es ablish a e e al
in as uc u e ha will main ain cul u al us and edi ec
cases wi h high isks o clinical se ices. The ou comes o
success ul p og ams in E hiopia, India, and Tanzania show
ha espec ul coope a ion can help a g ea deal in
educing he Du a ion o Un ea ed Illness and dec easing
he s igma ha he communi y has owa ds biomedical
ea men . I is no he answe o elimina e spi i ual
p ac ices among u al popula ion since such ini ia i es
would be me wi h backlash and u he es ange he
popula ions. Ra he , Pakis an equi es nei he
compa men alized no cul u ally blind in e en ions:
• Wo k wi h spi i ual heale s, no agains hem.
T ain hem o iden i y psychia ic ed lags and
suppo e e als.
• B ing men al-heal h se ices in o u al a eas.
Mobile clinics, ele-psychia y, and ained lady
heal h wo ke s can ill gaps.
• P o ide psychoeduca ion in mosques, schools,
and communi y cen e s.
• Allow cul u al p ac ices o un alongside
clinical ea men s i.e Dam-da ud + medica ion
> dam-da ud alone.
• Reduce s igma h ough eligious schola s who
suppo and unde s and he impo ance o
medical ca e.
Conclusion
Spi i ual heale s a e s ill highly espec ed people in u al
Pakis an and hei se ices canno be neglec ed.
Ne e heless, in cases whe e supe na u al models ake
p io i y o clinical eali ies, people su e ad e se delays
in he p o ision o ele an men al-heal h ca e. Pakis anis
o u al and low-income u ban a eas a e no eady o ejec
psychia y due o lack o knowledge, hey a e simply eady
o ejec i because hei wo ld iew, adi ions, eligious
in e p e a ions and social sys ems include al e na i e
explana ions ha a e mo e amilia , mo al as well as
accessible. Spi i ual heale s a e called o com o ,
meaning, and cul u ally o ien ed coping bu should no be
an obs acle o a clinical ca e. A ca ing, cul u ally
sensi ized, and in eg a i e men al-heal h sys em can
b idge he gap be ween ai h and ac , ha is, whe e each
pe son is gi en spi i ual assu ance and medical ca e, as
needed. Ru al Pakis an needs an ecosys em o men al-
heal h in which spi i ual and clinical ca e do no wo k
agains each o he bu ins ead co-exis . The spi i ual
heale s a e e y powe ul people in he cul u e, bu wi h
aining and eamwo k, hey can be hei helpe s in he
ea ly diagnosis a he han he hind ances. Nowadays,
hough, he p e ailing ac is ha Families do end o
exhaus all hei a ailable spi i ual solu ions be o e hey
eso o psychia ic a en ion. A ha poin , a lo o
su e ing ha could ha e been a oided has al eady been
done. Pakis an should u n a ound i s men al-heal h s a us
in o de o ensu e ha eligious con ic ions do no
o e ide he medical ca e ha is imely. The goal is b ie
and clea alle ia e su e ing by ha monizing cul u al
belie s wi h clinical eali ies.
Ideally, i is no o subs i u e one sys em wi h
ano he , bu o close he epis emological di ide be ween
cul u al belie and biomedical knowledge. By wo king
oge he and no compe ing, spi i ual amewo ks and
clinical ca e will be mo e likely o inc ease ea ly help
seeking and ea men compliance by u al popula ions
and lead o be e ou comes. Any u he de elopmen o
men al-heal h ca e in Pakis an hus equi es a ca ing and
cul u ally-sensi i e s a egy one ha acknowledges he
exis ence o communi y wo ld- iew, and ye , makes su e
clinical needs a e iden i ied, con i med, and me wi hou
loss o ime. By in eg a ing in his manne , Pakis an can
p oceed owa ds he men al-heal h ecosys em whe e
elie , digni y and healing a e made a ailable o e e yone.
6
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