Traditional perceptions and treatment of mental disorders in western Ethiopia before the 1974 revolution

Jacobsson L, Merdasa F. Traditional perceptions and treatment of mental disorders in western Ethiopia before the 1974 revolution. Acta Psychiatr Scand 1991: 84: 475-481. This article describes the traditional concepts and treatment of mental disorders in the Oromo areas in western Ethiopia before the revolution in 1974. There are three traditional cultural influences operating: traditional Oromo thinking, the Coptic church and the Islamic culture. One important element in traditional Oromo thinking is that each person is believed to possess an uyuna, which is a special divine agent that can descend upon people, but also means a persons character and personality. In the traditional Oromo society, the Kallu is the religious leader who, through an ecstatic ritual technique, can investigate the causes of the disorder and advise what to do. Mental disorders are generally explained as resulting from disturbances in the relationship between people and divinity. The second important cultural element in western Ethiopia is the orthodox Coptic church, which usually looks upon mental disorders as possession by evil spirits, which are thus treated by specially gifted priests and monks by praying and giving holy water or eventually exhortation. According to Islamic teaching in the area, mental disorders are caused by evil spirits sent by God to punish the unfaithful people. Some Muslim sheiks treat mental cases with prayers, but herbal remedies are also used. There is a great intermingling of these different cultural and religious elements and people attend different healers and religious leaders more depending on the reputation of the person than on cultural and religious affiliation.

L. Jacobsson, F. Merdasa
Department of Psychiatry, University of Urnea, Sweden, Department of Surgery, Hasleholm Hospital Hasleholrn, Sweden

Key words: Ethiopian ethno-psychiatry; traditional treatment; transcultural psychiatry; psychiatric anthropology

Lars Jacobsson, Department of Psychiatry, University of Urnei, S-90185 Umei, Sweden Accepted for publication July 20, 1991

Ethiopia is one of the oldest states in Africa where three major cultural influences have traditionally been operating: the Coptic Christian church, Islam and traditional African thinking. For hundreds of years the government was in the hands of kings and emperors who kept the country in a feudal situation where modern western thinking only slowly was introduced. Still, in the beginning of the 1970, it was possible to find areas where people continued to live rather uninfluenced by western ideas and techniques. This situation was rather abruptly changed by the revolution in 1974, when a series of changes started that will probably change the society fundamentally. For many years psychiatric facilities were scarce in Ethiopia. Still in 1990 only a few Ethiopian psychiatrists and some foreign ones are working in the country. The number of psychiatric beds is less than 500 in a country with more than 50 million inhabitants. This means that very few mentally ill people will ever be offered psychiatric care. Instead, they have been and will be treated and cared for in a traditional system that none the less offers many different possibilities.

There are a few studies on the traditional perception and treatment of mental disorders in Ethiopia. These have mainly considered spiritual healing, but also other traditional ways of managing mental illness (1-6). In a comprehensive and recent study, Kortman (7) described and discussed the traditional way of looking at mental disorders and the traditional treatments offered in the central parts of Ethiopia around Addis Ababa. The aim of this article is to present the perception of the background to mental disorder and the different kinds of traditional healers and treatments that existed in western Ethiopia at the end of the old Ethiopian empire just before the revolution in 1974. Because of a series of circumstances, the data have not been published until now, but we believe that the data are still interesting as a background to understanding the new situation that has developed because of the changes of society during the new political regime and also from a more general transcultural point of view. Forthcoming studies in this field would also benefit from studies such as this.
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Material and methods

The data were mainly collected during 1969 and 1971 when the authors were working at the Tafari Makonnen Hospital in Nakamte in western Ethiopia. Information was gathered through interviews with patients, health workers of different kinds in the hospital and health centers in the area and colleagues. In 1973 one of the authors (LJ) spent 3 months in the field interviewing Coptic priests, Muslim sheiks and other traditional healers. The most important and influential persons in the different groups were chosen for the interviews. For example, the Coptic bishop in Nakamte, the leading traditional healer in the area and the most influential Muslim sheik in Nakamte were interviewed. But also a number of other persons belonging to the Coptic church, the Islamic confession, the group of traditional healers and other key informants in the society. Some further supplementary information was collected during visits in 1976 and 1984. The hospital and the clinical setting have been presented elsewhere (8). The interviews were rather open in character but aimed at receiving a comprehensive picture of the ideas the informant had about mental disorders and their nature, occurrence and treatment in the society. The findings are presented under two headings, traditional teaching and concepts of mental disorders in different cultural and religious groups and traditional treatment.

Traditional teaching and concepts Traditional Oromo concepts of humanity and mental health beliefs

The Wollega province is mainly inhabited by Oromo (Galla) tribes. In contrast to the tribes around Wollega, the incorporation of this tribe into the Ethopian empire was rather peaceful because the native ruler, the Galla king of Nakamte, and many of these people were converted to the Coptic church before the incorporation. So the Amharic-Ethopian culture had been very influential for a rather long period of time. Knutsson (9) has described the Galla concept of humanity and divinity. According to his presentation, the traditional concept of humanity in these Galla-dominated areas is threefold. One category of concepts is composed of objective, anatomical knowledge, especially concerning skeleton and muscles, astonishingly rudimentary, however, despite the general knowledge of the anatomy of animals. A second category describes the parts of man thought to be essential in the sense that they are either bearers of life or the mainspring of a mans mental faculties such as gara, the region of the di476

aphragm that is especially linked with a persons mental faculties and personality. The will and expressions of feeling emanate from this region. By judging a mans gara as bad or good, strong or weak, brave of cowardly their whole person is given a characterization. Gara inkabu means he has no gara, he is unable to think and do things well. The eyes also have special faculties, as they are supposed to transmit the power a person possesses, his ayana. The evil eye, buddha, which is a general concept throughout Ethiopia, is a feared cause of diseases, especially in children and young people. Usually nice, handsome children and youngsters who might attract someones envy are the victims. Blood, diga, is connected with life and this makes it difficult to obtain blood for transfusions in medical care; even getting a small blood sample is sometimes impossible - it might not be replaced (10). Third, each person is believed to possess an ayana, which is a special divine agent. Ayana is a concept with several meanings. Apart from a divine being that can possess or even better descend upon humans, it also means a persons quality, character and personality. It is both a character and its cause. It is also regarded as a divine guardian of the family, ayana abba - the fathers ayana, in Amharic: yabatu wukabi. Like the individual and the family, the lineage and clan have their ayana abba and all ayana abbas are ultimately identified with Waka - God, who is the ayana abba of all Galla. He knows everything and above all he has the knowledge of truth and justice - duga, which leads him to punish crime - Cuba. As in the human world, there is a division in the suprahuman between evil and good. On the suprahuman side it leads to the concepts of good and evil ayanas. The evil ayanas are like Waka in power, but yet unlike him because of their immoral quality. The evil uyunas, usually called seytans, are not directly comparable to the Christian concepts of the devil as always and forever the ultimate evil. The seytans can be persuaded and calmed with appropriate respect. To the Oromo, the problem of evil can be satisfactorily explained as the result of mans crime and Divinitys punishment. It is when the duga-Cuba theory is no longer applicable, when no breachers of the rules are found that one refers to seytans. The seytuns represent the seemingly unmotivated chaotic and anarchic type of evil.
Teachings of the Orthodox Coptic church on mental health and disorders

The Coptic church was established in the Wollega province in 1873 and is still expanding into the rural areas where the old Oromo culture and religion are still practiced. Even in areas where the Coptic church

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has been established for many years there is a great mixing of ideas and practices and Christianity is often only accepted to a limited extent. Its influence is mostly in the ritual and ceremonial sphere, especially regarding funerals and the great feasts of the church such as timket (baptism). The hierarchy of the church is built up from different elements. At the top there are the ubunus - archbishops with the patriarch in Addis Abbaba as the head. These are equivalent to monks. Then there are the priests of very disparate education. Many of the priests in the countryside have only a very elementary church education while others have been studying at the Priests College in Addis Abbaba. The depeterus are a group of teachers and readers of the holy books in the church. The church schools are kept by them and some of the depteras also practice mystic healing and astrology. The monks have to be celibate, the priests married. The priests deal with the sick and disabled to varying degrees according to their personal talents. Some are very famous for their healing capacities, such as Abba Wolde Tensae in Ghion. Many priests are afraid of coming into contact with the possessed. The spirit might take revenge and only a few will try to exorcise it. These evil spirits, seytuns, are everywhere always around humans. According to the Bible they have been angels and have opposed God, so they are fallen angels according to the Coptic church. These seytans are most active at midday when the sun is hottest and they move around to find and strike people. So God orders that people should not be outdoors at midday. It can even be dangerous to open the door at this time. Also when a person is pouring the ashes, the seytuns are closer and more likely to strike. The seytuns may come in the night and frighten a person, make him dream bad dreams and wake him up and cause him to talk and walk in his sleep, etc. There are lots of beliefs of this kind among the mass of priests and depteras. Most educated priests will give the more general answer that if a person has committed a sin he might be caught by the devil but he might also be assailed accidentally. So it is necessary to read verses from the Bible and to pray to remain free and unaffected. The abuse of alcohol is condemned; one priest put it like this: When you see a person drunk for the first time you should advise him, the second and the third times do the same. The fourth time you should take him to Tebel (holy water) and if he still gets drunk after that he should be punished. Such a man will not go to heaven. Unfortunately, people do not do as we say in this case. The use of chat is also condemned - the goats eat leaves, not Christians! Suicide is a crime against the ten commandments and after a suicide the body should not be buried with the others in the churchyard, but in a special place outside to teach others not to do likewise. According to Hubte Muriam Workineh (1 l), more people fall sick nowadays because of lower ethical standards, especially sexual misbehavior. Morals are lower now than before because people are abusing the rules of the Old Testament and because we did not have as many drinking shops as we have now and city life was not as complex as it is now. Discussing sexual life, he stressed the purity and virginity of both men and women until they marry and the obligation not to divorce. The church considers the belief in the evil eye as a false belief as it does the belief in the use of amulets. It does not sanction the work done by Tonquais, Kalichas or Wukabis (vide infra!) even if some cooperation, especially between the Depteras and Wogeshas, is reported from various places. In the Nakamte area, several wells and small streams are supposed to be holy waters where the disabled go to get treatment.
Teachings of foreign Christian mission congregations

Although there are a lot of educated priests and lay people in these congregations, the main belief among lay people is still that mental illness is caused by evil spirits, and exorcism is widely practiced in these congregations. Some of the foreign missionaries share this belief, and others are much concerned about this practice because they feel it is not the whole truth. Even among many of the educated young Ethiopian church leaders, the evil of life is personified in evil spirits, which have their own community, like the human society, with their chiefs, soldiers etc. These evils are also male and female and may be able to reproduce themselves. Possession is increasing in some places, whereas in others it is very uncommon.
Teachings of the Muslims on mental health and disorder

Islam, like Christianity, has concerned itself with the mentally ill and their religious leaders, the sheiks, are consulted in their homes or in the mosques to solve all kinds of problems, somatic as well as psychological (12). In Wollega, the Islamic religion was rather recently established. It is said to have been introduced in Wollega about 1900 and as yet there are not so many educated Muslims in leading positions able to teach and hold the offices of sheiks, etc. In other parts of Ethiopia, Islam has been established for a long time and, in Wollo, there is a center for Islamic tradition, teaching and practice that is said to be one of the most interesting and one of the leading tenters for the Muslims in East Africa. The general concept of life is that God brings health and disease,
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Jacobsson & Merdasa money and poverty, to people. He does so not to hurt people, but only to execute his will and to see whether a person is faithful and believes in Allah he brings these different fortunes or misfortunes upon people. Every disorder has its own treatment and God knows the treatment. So if it is his will he can cure everything. Mentally ill people are ill because they dont pray, dont keep the fast, they visit women and dont wash afterwards and maybe they dont pray enough, etc. Then God sends evil spirits, jinnh (seytans) to punish them. There are two different kinds of mental derangement: jinnh can give physical power but detracts the mental power thus making people violent and mad; or jinnh takes the physical power from a person but the mental functions remain intact. The person becomes weak, might fall down in the street, get a headache, be unable to work sometimes, etc. The concept of the evil eye - buddha - is not a true Muslim belief but it is commonly accepted even among the Muslims. Jinnh comes to a person and locates in his eyes and makes only his eyes buddha. According to the informants, buddha is not supposed to produce mental disorders but mostly stomach trouble. Alcohol is condemned according to Islamic tradition. It is bad for the health, burns the heart and takes your mind off your body. The following story was told as an example of the harmful effects of alcohol. A drunk was lying vomiting on the road when a dog came up and licked the vomit from his mouth. The man said to the dog May God bless you, because you have respected me - thus, demonstrating the fate of man who drinks alcohol, being served by a dog and furthermore, blessing the dog! There is a definite difference in alcohol-drinking customs between the Muslims and the Christians of different confessions. Even the evangelical mission congregations have a rather liberal view of alcohol. On the contrary, the use of chat (Catha edulis) is much appreciated as a gift from heaven and chat is chewed widely among the Muslims, especially in eastern Ethiopia (Harar), but also in the towns along the roads in other parts of the country among the Arabic tradesmen. The habit is increasing among students at the higher grades and at the university of Addis Ababa. It is supposed to help the believer continue praying and facilitate the contact with God and it prevents one from doing bad things. It is also used in some areas as a treatment for mental disorder, for example, by chewing and spitting the saliva on the face of the patient. In Wollega, chat is known only as a remedy for the common cold - the leaves are put into coffee or tea. Otherwise it is only used as a mild stimulant. Suicide always stems from Satan who pushes a person to commit suicide because of lack of faith. Homicide may be the result of a person having been insulted by others and in that case it might be acceptable. Impotence, one skid said, is the greatest problem in Ethiopia. The causes are manifold, some men get tired or old, most get drugs from enemies, which make them impotent, and if a man has visited too many women in his youth he might become impotent.
Traditional treatment The herbologist - surgeon, woggesha (Amharic)

He or she usually starts as a bone-setter. Often his father has done this before him and he has learnt from him. It is, however, also possible for a person to start from scratch and gain a reputation as a good bone-setter and by and by he will add more and more abilities as people come to him with different sorts of disorders. Often he will carry out circumcision and open abscesses with a piece of hot iron. The cutting of the uvula and the extraction of the roots of the front teeth in small children are measures used rather frequently in different disorders among children. Some of them also take on complicated deliveries. Their treatment consists above all of massage of the uterus which might end up in the rupture of the uterus. They prepare plasters and bandages of different kinds often with great skills and practice the massage of muscles and aching parts of the body. Cupping is also within his field - in cases of headaches, a scalp artery is opened along-side and the horn is put around and blood is sucked out. He also uses plants in his practice. Oil extracts from certain trees are used in some delivery cases. Mental cases, fevers, and allergies from snake poisons are treated with the smoke of certain kinds of wood, which is collected and cut into pieces and put into a small pit in the ground and set on fire. The patient has to kneel above the fire covered with a piece of cloth, as if he were in a tent, with the smoke from the fire causing him to sweat copiously, sometimes so much water will come out of his body that the fire will go out. Three courses of this treatment expel the evil spirit from him. The ensets, false bananas, are sometimes used in the treatment of impotence; bread prepared from enset will cure this ailment. People also use to take their children to let him touch them for many different troubles often of an apparently psychosomatic kind.
Spiritual and mystic healers

Dealing with psychologic, parapsychologic and natural ailments.

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Coptic church ofJicials:deptera andpriests. The deptera is a scribe-chorist of the Coptic Orthodox Church who is learned in the Bible and the holy books, who teaches in the school and takes part in the services in the church reading and praying. Some of the depteras prepare amulets with writings from the Bible or the holy books. These amulets are written on skin or paper and folded into a small parcel, which should be carried around the neck either for protection or as a cure for mental disorders among other things. Some of the depteras specialize in astrology and own a book in Geez which is said to be forbidden by the Church, in which formulas for different purposes are written down. From these it is possible to tell the future through calculation from the figures of the clients name and his birth date, which have their special sum. By dividing this by various figures according to what you want to know it is possible to tell what will happen. In this book there are also the prayers to pray and the remedies to give in special disorders. In some mental cases the depteras give some preparations to drink or inhale together with the prayers or writings. They also give advice about which holy water (tebel) is the best in a particular case by making an astrologic prognosis about the outcome of the disease, what date to make the journey and where to go to be sure of getting the best treatment. The Coptic priests treat mental disorders in two stages. First, the priest will pray and read from the Bible and the holy books and then he will give tebel. The holy water can be prepared from any kind of water that is prayed over in a special way. The tebel can be sprinkled on the patient or given to him to drink or both. At this moment evil spirits will be exorcised if this is supposed to be the cause of the disorder. Often it is necessary to have many courses of holy water or to go to different places before a definite cure is achieve. Some patients stay for weeks at a special tebel until they are cured or their money runs out. Some monasteries or other places with wells with healing powers are more famous than others: for example, the one at Debre Libanos and Ghion (Wolisso) where crowds of disabled of all kinds gather and often stay for weeks and months (13). Some of the more reputable spiritual healers, such as Abba Wolde Tensaye in Ghion, send some of their patients to the Amanuel Mental Hospital in Addis Ababa when they are not successful, but mostly the patient is left with his psychosis or epilepsy, which is frequently regarded as a case of spirit possession. Neurotic disturbances are often relieved through these sessions. The diviner-wizard (tanquai). This is mainly an Amharic office that is not very widely spread in Wollega.

The tanquais who practice in Wollega are often people who walk around, coming originally from the central parts of Ethiopia. They are supposed to be in direct contact with the devil. Often they have some church education and are able to read Geez, the official language of the church, but they are supposed to have committed themselves to the devil as a kind of fallen angel. These tanquais are often difficult to distinguish from the deptera. Often it is just a matter of words whether a practitioner is called deptera or tanquai, although being tanquai is not so very reputable nowadays. The tanquais prepare amulets with writings on them; they make offerings or give advice about offerings to special spirits if necessary. They do this for money and are feared a lot by the people, but still they are consulted as the last resort in severe cases. Direct contact with the devil is a dangerous thing, even for the tanquai, and this is the reason why he charges a lot of money for his services.
The kallu. A counterpart to the Amharic tanquai in Oromo society is the kallu - kallicha - who, in his pure form (the kallu) is a ritual leader of great dignity, but whose role has been imitated by more unscrupulous people who use their capacity to become possessed to treat people in return for payment (kallicha). People go to the kallichas, often as a last resort in their attempts to get cured. The two important elements in the kallu institution are the ecstatic ritual technique and the capacity to become possessed combined with special moral qualifications. These moral qualifications (for example, the kallu should be genealogically clean, he must respect traditional taboos and rituals and he must be truthful in his dealings with other people) give him his position as a leading ritual expert in traditional Oroma areas. Ultimately, his position and power stem from his possession of ayana and his connection with divinity - Waka. The kallu (Oromo) must be separated from the kallicha (Amharic), although this is not always done even amongst the Oromo themselves. Both display possessional capacities, but one of the differences between them is the much lower social status of the kallicha, who is often looked upon as using his powers for his own profit and above all using black magic and sorcery, unlike the kallu, who is in contact with the good spirits and untimately with Waka. A kallu doesnt ask his clients for gifts or payment but the kallicha is notorious for his attempts to get money from his clients, sometimes even by threats. It is impossible to absolutely distinguish between these two roles. They constitute two social extremes in the category of ritual experts characterized by ecstatic ritual technique and possession (9). The kallu is the main healer in the traditional Galla so479

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ciety and his sphere of responsibility is very wide, ranging from care of the acute insane to acting as judge in protracted conflicts about land. In its present form, the kallu institution is a rather new phenomenon and the possessional element has been introduced recently. The kallu is consulted for all kinds of problems and the ritual has been described by Knutsson (9) as the wovega system. Woregu means to promise, specifically to make a vow. There are three important elements in this system: 1) a public confession made in the kallus ritual house during a dalugu ritual; 2 ) a vow which says that the supplicant will make a gift to the ayana when his problem has been solved; and 3) the votive gift, for example, the regular offering every year, every 6 months and so on of an animal or salt bar or whatever. Through the wovega system a contractual relationship is created between a kallu and his client and the vow is considered to be absolutely binding. The investigation of a case starts with a kind of cross-examination and if a cubu can be identified the kallu can immediately advise some act of ritual penance but, if this is not possible, the case is referred to the uyana during possession. Generally, the problems are explained as resulting from some kind of disturbance in the relationship between people and the divinity through breaches of the customary rules. These ways of explaining sickness, crop failure, childlessness, accidents and other problems together with the indirect method of dealing with them are typical of the kallu institution. The kallu is not a magician or a medicine man in the sense of knowing directly effective remedies. Some of these kullus have a very strong position, even in relation to the government, and have been appointed district governors; one was even a provincial governor. The relationship between the kallu and his client is much like that between the patient and his psychotherapist.

act as a guardian spirit. The seances might last for one or several days while the members are dancing and drumming and then negotiations between the Zar doctor and the newly introduced person are going on. Often the members of the seance are women and there is a clear sexual content in the cult. The spirits are usually of the opposite sex and are supposed to have marriage-like relations to their victims. The possessed women often report that they have had intercourse with their male spirits. The Zar cult seems to be losing its status more and more in the areas where it has been strongest. In the central and southwestern parts of Ethiopia, the cult did not apparently gain such a position in society as it did in the north. In Wollega, for example, even well-informed people hardly know of it.

The Muslim sheik. The Muslim sheik has a role in Islamic society very much like that of the kallu in the Oromo society. His treatment consists of prayers, reading the words of Allah for the patient and then the jinnh (the devil) will cry and jump inside the afflicted person and finally leave him. Preparations of charms with writings on paper or skin with the words of Allah are also used for treatment of mental disorders. These charms, however, are mainly used as preventive measures. The sheiks also practice healing with herbs and surgery and many of them practice as wogeshas (bone-setters).

Conclusion

The Zur cult. This spiritual cult in northern Ethiopia has been described in detail by Messing (1) and Leiris (14). From Ethiopia it has spread to the neighboring countries of Egypt and Sudan and to the Arabian peninsula. It is headed in each locality by a person, usually a woman, who has come to terms with her spirit and who is able to manipulate the spirits of her patients through her own more powerful spirit. As there is no definite cure, but only remissions of the disease, the patient has to remain in the cult-society. Illnesses being treated include hysteria, severe apathy, migraine, epilepsy, rheumatism, infertility, miscarriage and numerous functional ailments. The Zar doctor calls on his spirits when in trance and negotiates with the spirit of the patient about sacrifices and gifts that will please him and get him on good terms with his victim - maybe even to

In western Ethiopia, as in other developing countries, there are recognized mental disorders that easily fit into current psychiatric classification. This mainly refers to psychotic states or more severe mental disturbances. In general, however, there is no clearcut division between physical and mental disorders as there is in the industrialized societies. Accordingly, there is a clear interaction between physical and spiritual healing, for example when spiritial formulas have to be ingested or when verbal remedies have to be gathered with proper spiritual ceremony. Although there are three major religio-cultural systems operating in the area, the Coptic-Amhara, the animistic-Oromo and the Islamic, there is a commonly shared belief that mental disorders are caused by evil spirits or other evil forces such as bewitchment and curses. There are several different indigenous institutions for dealing with mentally disturbed people and it is apparent that they have an important social function. Particularly in the sphere of neurotic disturbances, the psychotherapeutic techniques that the various traditional healers and priests have developed fit very well into the culture and

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seem to be the therapy chosen by the greater number of people with neurotic disorders.
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7. KORTMANN F. Popular, traditional and professional mental health care in Ethiopia. Transcult Psychiatry 1987: 24: 355274. 8. JACOBSON L. Mental disorders in patients admitted to a general hospital in western Ethiopia 1960-1970. Acta Psychiatr Scand 1985: 71: 410-416. 9. KNUTSSON KE. Authority and change, a study of the kallu institution among the Macha galla of Ethiopia. Goteborg, 1967. 10. HOFVANDER Y. Hematological investigations in Ethiopia with special reference to a high iron intake. Acta Med Scand 1968: SUPPI 494: 1-74. 11. HABTE MW. Teaching of the Ethiopian Orthodox Church on matters related to health and disease: In: TORREY EF, ed. An introduction to health and health education in Ethiopia. Addis Ababa: Artistic Printers, 1967. 12. RACYJ. Psychiatry in the Arab East. Acta Psychiatr Scand 1970: suppl 211. 13. GIEL R, GEZAHEGN Y , VAN LUIJKJN. Faith healing and spirit-possession in Ghion, Ethiopia. SOCSci Med 1968: 2: 63-79. 14. LEIRISM. Pa possession et ses aspects theatraux chez les Ethiopiens de Gondar. Paris, 1958.

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