Spiritual Healers as a Barrier to Timely Mental Health Access in Rural Pakistan A Mini-Review

1 Spiritual Healers as a Barrier to Timely Mental Health Access in Rural Pakistan: A Mini-Review by Ahsan Haider Shehzad, MSc Applied Psychology [email protected] Department of Psychiatry, Divisional Headquarters & Teaching Hospital Mirpur AJ&K Abstract Rural Pakistan interprets mental illness in terms of spiritual and supernatural aspects and not biomedical. Jinn possession, black magic, or divine testing are usually blamed as a cause of symptoms of depression, anxiety, psychosis, and trauma, causing families to prefer spiritual healers over mental-health professionals. This narrative mini-review is an integration of cross-cultural psychiatric literature, sociological views, and community-specific knowledge on the reasons why spiritual healers are the main interface of contact in rural areas. The review uses explanatory model theory and pathways-to-care research to explain how cultural beliefs, religious interpretation, stigma, poverty and less psychoeducation led to major delays in clinical intervention, which is a contributor to prolonged Duration of Untreated Illness (DUI) and unfavorable long-term outcomes. The review also evaluates obstacles in the mental health system in Pakistan and suggests culturally conscious and community focused interventions including partnering with spiritual healers instead of competing against them, focused psychoeducation, task shifting through Lady Health Workers, and the growth of mobile and tele-psychiatry. To connect the gap between traditional belief systems and evidence based psychiatric care, a hybrid model of care based on cultural respect must be implemented. Keywords: mental health in rural Pakistan, cross cultural psychiatry, importance of psychoeducation, sociology of mental disorders, religion and stigma of mental health in Pakistan Introduction Psychological distress is not very often described as biomedical when it is observed in many parts of rural Pakistan. Rather, it is usually interpreted in the spiritual, supernatural or moral sense that has a strong cultural background. Whenever victims show some of the following symptoms; constant sadness, uncontrollable fear, hallucinations or uncoordinated behavior, families often refer to the following as being possessed by jinn, being the victim of the evil eye (nazr), the victim of black magic (jadu), or the victim of divine trial. Such meanings are not incidental or marginal; they represent established explanatory paradigms that have been used by communities over extended period of time. In this world outlook, the spiritual healers such as pirs, amils, damdaruds, and caretakers of shrines are trusted cultural authorities and frontline responders to emotional, behavioral crisis. Structural realities continue this pattern of help-seeking. Pakistan, with rural areas has acute problems in terms of mental-health professionals, inadequate psychiatric facilities, and high costs of treatment. Together with widespread stigma of mental illness, these barriers make biomedical care not only inaccessible, but also socially unfavorable. Consequently, families have a tendency to seek more than one course of spiritual intervention before thinking of psychiatric assessment despite the fact that some conditions have clinical treatment greatly enhancing their outcomes so far as one is major depression disorder, psychosis, epilepsy being confused with possession, and severe anxiety disorders. Within the cross-cultural psychiatric understanding, these pathways represent what Kleinman refers to as, the so-called, explanatory models: systems within cultures that individuals use to make sense of the symptoms, to provide causation and to decide on the proper treatment. The models are biased towards supernatural explanations, which are used in rural 2 Pakistani contexts not only to shape an individual perception, but also to define collective codes of conduct in regards to what actions can be taken in response to distress. This has an anticipated and usually hazardous, delay in evidence-based intervention. The mini-review discusses the cultural, religious, and socio structural circumstances perpetuating dependence on spiritual healers and constraining early access to psychiatrists and psychologists in rural Pakistan. It combines the lessons of the cross-cultural psychiatry, medical anthropology and popular-health literature to elucidate the intersection of misunderstandings of mental illness, limited psychoeducation, stigma, and economic constraints that serve to perpetuate the Duration of Untreated Illness (DUI). The review wraps up by describing culturally sensitive solutions to the assimilation of spiritual frameworks and biomedical care to promote mental-health access in rural communities. Why Rural (and Many Urban) Communities in Pakistan Do Not Believe in Mental Disorders To comprehend this, it is necessary to explore some of the interconnected issues, namely cultural stories, religion, education, and social systems. In most Pakistani families, mental illness was never brought in as a valid health concept. Rather, distress is conceptualized by: • jinn influence • nazr (evil eye) • black magic • moral-spiritual weakness • divine testing • influence of impure spaces or abandoned places These interpretations are clear, simple and comforting to the emotions. They are congruent with narratives that people have been told since their childhood by older persons, neighbors and by religious narrators. It would take a long battle to change centuries of worldview to explain mental illness as a medical condition. Such a transition is gradual and usually opposed. The teachings in Islamic religion concerning the jinn, evil eye, and affliction by spirits are quite common in Pakistan. But scholarly interpretations are usually overshadowed by cultural ones. The people in the village often assume that: • auditory hallucinations (hearing voices) = jinn whispering • dissociative episodes perceived as “body control by a spirit” • depression = lack of prayer or weak iman • panic attacks labelled as “jinn influence” • odd behavior = possession Because these interpretations hold social legitimacy, families prefer healers who promise spiritual protection, Quranic recitations, or exorcisms (ruqya), rather than psychiatrists who diagnose using western techniques. Since such interpretations are socially valid, the families will choose healers who will guarantee them of spiritual protection, Quranic recitations, or exorcism (ruqya), as opposed to psychiatrists who will diagnose using western methods and prescribe medication for something that is not visible. Islam does not reject medical treatment, though local interpretations of it combine religion and folklore. This puts the subject of spiritual healing as something not only an option, but also a religious duty. A pir or an amil is regarded as a person who has God as his means. A psychiatrist is perceived as a person who operates using western devices. To a large number of rural citizens, the decision is morally intuitive. They also feel that there is no sickness that cannot be seen and so it is not in reality. Where education is restricted, concepts in biomedicine such as: neurotransmitters, anxiety disorders, psychosis, trauma responses, mood dysregulation, are unknown. In the absence of psychoeducation, villagers are developing explanations that rely on what they have heard in stories, spiritual systems and shared beliefs. Mental illness is not usually visible, objective and misconstrued. Villagers ask: “Bukhar ho to dikhta hai. Dard ho to pata chalta hai. Pagalpan kaise bimari ho sakti hai?” [If fever can be seen and pain can be felt, then how can madness be considered an illness?] This confusion renders to mental illnesses the appearance that they are not real or fake whereas supernatural events seem real and physical. In the rural environments, reputation is the determinant of marriage opportunities, relationship with the community and social respect. A psychiatric diagnosis is a menace to family pride. A 3 spiritual label does not. Families like a healer since: owning nothing is not harmful to social standing where a mental illness is crippling, the jinn may be expelled, but the tag of madness is permanently imprinted. In this way, spiritual explanations turn out to be psychologically protective. But going to spiritual healer is cheap or donation-based, near home, socially acceptable and free of paper work, visiting a psychiatrist is costly, far away, timeconsuming, and last but not least, comes with a sense of shame. The final one the most powerful one. To a large number of households, the decision is not idealistic. Healers are members of the community. They are present at weddings, funerals, and local parties. There is morality in their word. In comparison, psychiatrists: are strangers, employ foreign lingo, may not understand the local dialect, and may be perceived to be disengaged with living the daily life When families are seeking assistance, they refer to the person who has been with them every significant moment of life, the spiritual healer. Psychologists and Psychiatrists are misunderstood professions many people associate psychiatrists with: • “Mad people” • Electric shocks • Prescribing heavy dose and highly addictive sleeping medications. Mental-health professionals are feared, misunderstood, or perceived as threatening. Villagers often ask: “Hum bewaqoof nahi hain. Doctor hamaray zindagi ke masle kaisay samajh sakta hai?” [We are not stupid a doctor cannot understand a (spiritual) problem] This distrust coupled with profound trust in the healers is the motivation behind the preference to the spiritual practice. These cultural interpretations, though not meaningless, result into life threatening mental disorders such as being diagnosed and treated in dangerous delays. • schizophrenia • bipolar disorder • severe depression • trauma disorders • epilepsy misinterpreted as possession The result is an increased Duration of Untreated Illness which causes chronic symptoms, risk of suicide, functional impairment and long-term disability. Medical intervention of clinical disorders cannot be substituted by the assistance of spiritual comfort. Why Rural Pakistani’s Prefer Spiritual Healers over Psychologists & Psychiatrists Pakistanis in the rural areas are overwhelmingly attracted to spiritual healers since they are firmly embedded into the cultural, religious and emotional framework of village life in ways that psychiatrists and psychologists are not. Spiritual healers of the various rural communities, be it pirs, amils or dam-darud healers, are not only seen as providers of treatment, but moral guardians, the custodians of religious knowledge, the protector against the unseen world. Their world perceptions echo the historical belief systems found in the community where psychological distress is hardly construed as a medical problem but rather as the infiltration of supernatural power like jinn, nazr (evil eye) or black magic. Anxiety, e.g. which is expressed as trembling, chest tightness, palpitations, choking, stomach pain or fear waves, is nearly universally misconceived as an external spiritual assault instead of a psychological mechanism. These readings coincide with folklore storytelling practices, allusions to jinn in the Quran, and oral traditions through the use of elders, which is why spiritual explanations were religiously legitimate and culturally intuitive. Further, spiritual healers speak in the local dialects, know the family set up and can communicate in the familiar religious lingo which instantly reassures people in distress giving them hope by uttering expressions such as, this is a jinn waswasa (whispers)- it will disappear with recitation. Conversely, mental-health practitioners are unknown, physically far, expensive and tend to be seen as Westernized or detached of local values. Low literacy and lack of psychoeducation also reinforce the notion that mental issues must be of supernatural causes. To villagers, a spiritual healer is not merely a healer, but mercifully, a dignified, private, morally transparent approach to healing, and a culturally fitting frame of reference into which the biomedical system has never managed to fit within the scope of their social universe. 4 Clinical Consequences of Delayed Treatment of Mental Disorders in Rural Pakistan Delays to obtain psychiatric treatment due to the use of spiritual healers and supernatural attributions - have serious clinical, social, and functional implications. These delays are modeled in psychiatric research with the notion of Duration of Untreated Illness (DUI) which has proven to be an effective predictor of the severity of symptoms, chronicity, risk of recurrence, and permanent disability in a variety of mental disorders. In rural Pakistan, DUI is frequently significantly extended, weeks or even years long, since families spend several rounds of spiritual healing before biomedical evaluation is considered. This trend is particularly worrisome considering that most psychiatric disorders have their most therapeutic era in the initial stages of the disease. The effect of sustained DUI is most impressive in psychotic disorders in which delayed antipsychotic treatment is linked to more extreme symptoms, poor recovery, reduced functional ability, and an increased risk of chronic incapacitation. The process of early hallucinations or delusional thought usually manifested as jinn whispering or the notion of possession is not commonly recognized as a clinical red flag. They are instead construed using spiritual models that bring families to recurring ruqya sessions, visits to shrines or defense rituals. When psychiatric treatment is often sought, it may already be too late and people may be already under the influence of delusion, cognitive impairment, and significant disturbances to education, work or social life. Delay of treatment in major depression disorder predisposes to serious episodes, suicidal thoughts and suicidal attempts. Since these symptoms such as hopelessness, withdrawal, fatigue, or excessive crying are seen as a sign of spiritual weakness, weak faith, or a product of black magic, the family tends to focus on spiritual cleansing rather than the psychological one or pharmacological. This not only increases the duration of misery but also increases vulnerability to such complications as self-harm or treatment-resistant chronic depression. Misinterpretation is most evident in case of anxiety and panic disorders. Somatic symptoms, which include palpitations, chest tightness, shortness of breath, tremors, dizziness, are commonly put down to supernatural injury or jinn possession. The anxiety could progress to panic disorder, avoidance patterns that hinder mobility, employment, and schooling, due to the delay of the clinical intervention. Unless these disorders are addressed at an early stage, they may develop in a chronic form and severely affect everyday activities. Disorders that are related to trauma, such as PTSD (Post Traumatic Stress Disorder), are also neglected. Intrusive flashbacks/memories, nightmares, hypervigilance, irritability, and dissociation can be attributed to the spiritual disturbance and not psychological injury. Without trauma-informed care, they cannot get out of cycles of avoidance and distress which is usually enhanced by societal silence regarding trauma. Moreover, the inaccuracy about the diagnosis of neurological disorders, especially epilepsy, as possession or spiritual attack can cause significant health damage. Other than taking anticonvulsant therapy, some people can be subjected to numerous exorcisms, smoke sessions or solitude which exposes them to uncontrolled seizures, bodily harm or status epilepticus. Impaired psychiatric care has far reached implications. This puts emotional and financial pressure on the family systems, social relations are compromised and the functioning of the community is affected because untreated individuals isolate themselves, lose jobs or behave in a manner that evokes fear or stigma. In the case of young people, untreated mental illness interferes with major developmental milestones, affecting academic performance and economic stability in the future. Altogether, the long-term use of spiritual healing, which is culturally significant, forms a consistent trend of delayed clinical involvement. This has impacted the prognosis, increased disability, and resulted in heavy family and community costs. Having made this point, Duration of Untreated Illness among rural Pakistani women is not merely a clinical priority, but also a social and a publichealth obligation. 5 Toward a Culturally Respectful Mental-Health Model: A Way Forward Spiritual healers have deep rooted social power and in most cases, they are the initial source of contact when families are in distress. They should not be an opponent to psychiatric care but rather be seen as a potential partner. Educating the role of spiritual healers to recognize psychiatric red flags, such as hallucinations, suicidal thoughts, extreme anxiety attacks, self-neglect, and uncontrolled aggression, can establish a referral infrastructure that will maintain cultural trust and redirect cases with high risks to clinical services. The outcomes of successful programs in Ethiopia, India, and Tanzania show that respectful cooperation can help a great deal in reducing the Duration of Untreated Illness and decreasing the stigma that the community has towards biomedical treatment. It is not the answer to eliminate spiritual practices among rural population since such initiatives would be met with backlash and further estrange the populations. Rather, Pakistan requires neither compartmentalized nor culturally blind interventions: • Work with spiritual healers, not against them. Train them to identify psychiatric red flags and support referrals. • Bring mental-health services into rural areas. Mobile clinics, tele-psychiatry, and trained lady health workers can fill gaps. • Provide psychoeducation in mosques, schools, and community centers. • Allow cultural practices to run alongside clinical treatments i.e Dam-darud + medication > dam-darud alone. • Reduce stigma through religious scholars who support and understand the importance of medical care. Conclusion Spiritual healers are still highly respected people in rural Pakistan and their services cannot be neglected. Nevertheless, in cases where supernatural models take priority of clinical realities, people suffer adverse delays in the provision of relevant mental-health care. Pakistanis of rural and low-income urban areas are not ready to reject psychiatry due to lack of knowledge, they are simply ready to reject it because their worldview, traditions, religious interpretations and social systems include alternative explanations that are more familiar, moral as well as accessible. Spiritual healers are called to comfort, meaning, and culturally oriented coping but should not be an obstacle to a clinical care. A caring, culturally sensitized, and integrative mental-health system can bridge the gap between faith and fact, that is, where each person is given spiritual assurance and medical care, as needed. Rural Pakistan needs an ecosystem of mentalhealth in which spiritual and clinical care do not work against each other but instead co-exist. The spiritual healers are very powerful people in the culture, but with training and teamwork, they can be their helpers in the early diagnosis rather than the hindrances. Nowadays, though, the prevailing fact is that Families do tend to exhaust all their available spiritual solutions before they resort to psychiatric attention. At that point, a lot of suffering that could have been avoided has already been done. Pakistan should turn around its mental-health status in order to ensure that religious convictions do not override the medical care that is timely. The goal is brief and clear alleviate suffering by harmonizing cultural beliefs with clinical realities. Ideally, it is not to substitute one system with another, but to close the epistemological divide between cultural belief and biomedical knowledge. By working together and not competing, spiritual frameworks and clinical care will be more likely to increase early help seeking and treatment compliance by rural populations and lead to better outcomes. Any further development of mental-health care in Pakistan thus requires a caring and culturally-sensitive strategy one that acknowledges the existence of community world-view, and yet, makes sure clinical needs are identified, confirmed, and met without loss of time. By integrating in this manner, Pakistan can proceed towards the mental-health ecosystem where relief, dignity and healing are made available to everyone. 6 References Kirmayer, L. J. (2001). Cultural variations in the clinical presentation of depression and anxiety: Implications for diagnosis and treatment. Journal of Clinical Psychiatry, 62(suppl 13), 22–30. https://doi.org/10.4088/JCP.v62n0105 Patel, V., Saxena, S., Lund, C., Thornicroft, G., Baingana, F., Bolton, P., … & Unützer, J. (2018). The Lancet Commission on global mental health and sustainable development. The Lancet, 392(10157), 1553–1598. https://doi.org/10.1016/S0140-6736(18)31612-X Penttilä, M., Jääskeläinen, E., Hirvonen, N., Isohanni, M., & Miettunen, J. (2014). Duration of untreated psychosis as a predictor of long-term outcome in schizophrenia: Systematic review and meta-analysis. British Journal of Psychiatry, 205(2), 88–94. https://doi.org/10.1192/bjp.bp.113.127753 Thornicroft, G., Chatterji, S., Evans-Lacko, S., Gruber, M., Sampson, N., Aguilar-Gaxiola, S., & Kessler, R. C. (2017). Undertreatment of people with major depressive disorder in 21 countries. World Psychiatry, 16(3), 303– 315. https://doi.org/10.1002/wps.20414 Kaiser, B. N., Kohrt, B. A., Keys, H. M., Khoury, N. M., & Brewster, A. R. T. (2013). Strategies for assessing mental health in Haiti: Cultural relevance and local concepts of illness. Transcultural Psychiatry, 50(4), 532– 558. https://doi.org/10.1177/1363461513502697 Gureje, O., Nortje, G., Makanjuola, V., Oladeji, B., Seedat, S., & Jenkins, R. (2015). The role of traditional healers in mental health care in Africa. The Lancet Psychiatry, 2(8), 675–683. https://doi.org/10.1016/S2215-0366(15)001236 Rahman, A., Hamdani, S. U., Awan, N. R., Bryant, R. A., Dawson, K. S., Khan, M. F., … & van Ommeren, M. (2016). Effect of a WHO-developed mental health intervention delivered by Lady Health Workers in rural Pakistan: Cluster randomized controlled trial. The Lancet, 388(10055), 514–522. https://doi.org/10.1016/S01406736(16)30721-7 Dein, S., & Illaiee, A. S. (2013). Jinn and mental health: Looking at jinn possession in modern psychiatric practice. The Psychiatrist, 37(9), 290–293. https://doi.org/10.1192/pb.bp.113.042721 Hanlon, C., Luitel, N. P., Kathree, T., Murhar, V., Shrivastava, S., Medhin, G., … & Lund, C. (2014). Challenges and opportunities for implementing integrated mental health care: A district level situation analysis from five lowand middle-income countries. PLoS ONE, 9(2), e88437. https://doi.org/10.1371/journal.pone.0088437 Sorsdahl, K., Stein, D. J., & Grimsrud, A. (2015). Traditional healers in the treatment of common mental disorders in lowand middle-income countries: A critical review. African Journal of Psychiatry, 18(3), 1–6. https://doi.org/10.4102/ajpsy.v18i3.473 Raguram, R., Weiss, M. G., Channabasavanna, S. M., & Devins, G. M. (1996). Traditional community resources for mental health: A report of temple healing from India. BMJ, 312(7031), 570–572. https://doi.org/10.1136/bmj.312.7031.570 Gater, R., Ahuja, S., Pednekar, S., Daniel, M., & Weiss, H. A. (2014). Combining traditional and modern treatments for mental illness: A qualitative study of faith healer and clinician collaboration in India. Transcultural Psychiatry, 51(5), 631–653. https://doi.org/10.1177/1363461514532510 Gureje, O., Nortje, G., Makanjuola, V., Oladeji, B., Seedat, S., & Jenkins, R. (2015). The role of traditional healers in mental health care in Africa. The Lancet Psychiatry, 2(8), 675–683. https://doi.org/10.1016/S2215-0366(15)00123-6