Perceived causes, diagnosis methods and treatment practices of mental illness among traditional healers of the Berta community in Assosa, Ethiopia

Introduction: Mental illness is a non-communicable disease that is increasingly contributing to the global burden of diseases and disability. It affects a person’s feelings, thinking, behavior, and daily life functioning. Objectives: The purpose of this study was to explore perceived causes of mental illness, techniques for identifying mental illness, and treatment methods used by traditional healers in the Berta community. Methods: The study employed a qualitative research method. Data were collected using semi-structured in-depth interviews with seven traditional healers who were selected purposefully. We used thematic analysis to present and analyze the data. Results: The findings of this study indicated that witchcraft, supernatural power, hereditary, substance use, and food poising as the main perceived causes of mental illness among traditional healers in the Berta community. The traditional healers identify mental illness using different techniques such as patient observation, interviews with a patient’s family, use of religious books, and use of herbals. The traditional healers in the Berta community identify mental illness based on behavioral symptoms like talking about things that don’t make sense, laughing alone, taking off clothes in public places, collecting and carrying dirty materials, eating dirty foods, and harming or intention to harm others. Conclusions: The traditional healers in the Berta community use herbals, religious books, and bone divination to guide their treatment of persons with mental illnesses. Some of these traditional healing practices options are peculiar to the Berta Community that are used to diagnosize and treat mental illnesses. Recommendations: The traditional healing practices of the Berta community should be recognized, licensed, and supported by the Ministry of Health and the Ethiopian Food and Drug Administration and Control Authority.


Introduction
Mental illness is a non-communicable disease which is increasingly contributing to the global burden of diseases and disability (Adgoy & Habtemariam, 2018;Charlson et al., 2016;Singh, 2019). It encompasses health problems which affect a person's feeling, thinking, behavior and daily life (American Psychiatric Association, DSM-5 Task Force, 2013). To respond to this mental health crisis, 80% of the population in Africa use traditional medicine (World Health Organization, 2019). These healing practices are performed by traditional healers who often rely on their experiences and observations to diagnose and treat mental health problems (White, 2015).
The traditional mental illness healing practices and methods differ from country to country as well as from region to region depending on cultural values, personal attitudes, philosophy, and costs of treatment (Harley, 2006;Kahissay & &Fenta, 2015;Ojelade et al., 2014). Studies showed that every region across the world has its own traditional mental illness healing methods based on the people's social beliefs, values, and aspirations (Gielen et al., 2012;Harley, 2006). According to Biswal et al. (2017), all cultures have a system of illness diagnosis to explain the causes of illness, how it can be cured, and from whom to seek help.
Traditional healers have different knowledge and explanatory models and ways of defining mental illness to treat mental disorders (Ningsangrenla & Rao, 2019). Previous studies showed that they usually use herbal remedies, rituals, and prayer for treating many mental illness (Kpobi et al., 2019). For example, Abbo (2011) identified various methods used by traditional healers to treat patients with different mental health problems such as herbs, appeasing the spirits and divination. Similarly, Ngobe (2015) identified different traditional ways of treating mental illness through cleansing evil spirits through steaming, burning herbs, enema administering, induced vomiting, traditional incisions, performing rituals, and traditional medicine.
Many people in Africa attribute the causes of mental illness to supernatural causes and religious reasons (White, 2015). There is no exception in Ethiopia. For instance, many people in Ethiopia believe that mental health problems are caused by supernatural forces, and they seek help through practicing supernatural activities like praying, fasting, sacred holy water, and consulting individuals who are believed to have healing power (Hailemariam, 2015). In addition. traditional healers in different parts of the Ethiopia attribute the causes of mental illnesses to evil spirits like Zar and Jinni spirits, magic, demons, witchcraft, and evil eye (Belachew et al., 2019;Hailemariam, 2015). Traditional healers also attribute mental illness to supernatural causes such as witchcraft, angry ancestors, God's punishment (Teferra & Shibre, 2012).
Overall, previous studies (Belachew et al., 2019;Desalegn, 2016;Ngobe, 2015;Sigida, 2016;Sorsdahl et al., 2010) identified various and diversified perceived causal factors of mental illness such as God's punishment or wrath, evil eye, bewitchments, sorcery, disregard of cultural norms, spirit or demonic possessions, genetic endowment, problems with nerves or brains in general, brain accidents and other physical causes, stress due to loss of belongings, shock due to bad life events like (death and sudden loss of property, curse, spirit possession, economic problems, family conflicts, death of relatives, unresolved love, excessive learning or study, wondering in the middle of the day and the night, and sitting alone in a dark and empty room. A study conducted by Belachew et al. (2019) showed that self-talking, talking nonsense, shouting, unable to perform daily routines, laughing at socially and culturally inappropriate times, eating dirty foods, carrying dirty things, uttering incoherently, wandering away from home, and aggression are symptoms of a mentally ill persons. Traditional healers make their assessment and diagnosis of a person with a mental disorder with the help of religious books such as "Awude-Negest", Metshafe-Tibebi (book of wisdom), Firie-Kewakibt (a book telling one's fate), Metshafe-Fewis (book of healing), Etse-Debidabe (a book listing herbal medicine), and herbal plants (Desalegn, 2016;Wondie & Abawa, 2019).
In doing so. traditional healers have played a major role in the treatment of mental health problems in Ethiopia (Bayih & Usman, 2018). About 90% of the population in Ethiopia relies on traditional medicine for primary mental health care services due to the presence of associated cultural and socio-economic factors, limited access and unaffordable costs of modern public health services (Belachew et al., 2019;Tesfahuneygn & Gebreegziabher, 2019). There have been scant studies on the area of traditional mental healing in Ethiopia few previous studies focusing on conceptualization of mental illness and practice of treating mental illness were conducted (e.g. Desalegn, 2016;Hailemariam, 2015;Ngobe, 2015) were conducted. However, there are minimal studies that demonstrate about the perceptions of traditional healers on the causes of mental illness that deserves investigation for better understanding of traditional mental illness healing. Hence, this study aims to explore how traditional healers of the Berta community perceive causes of mental illness, what methods used to identify the different mental illnesses and what healing techniques they employ to treat the perceived mental illness.

Objectives
The general objective of this study was to explore the traditional healers' perception on the causes of mental illness, ways and signs of identifying mentally ill persons and treatment practices in Berta community at Assosa Town, Western Ethiopia. More specifically, this study aims to (1) explore the perception of traditional healers about the causes of mental illness, (2) identify the different traditional healing ways healers use and (3) describe traditional healing practice to treat mental illness.

Setting
This study was conducted in Assosa town which is the capital of Benshangul-Gumuze region. It is located 663 km away from Addis Ababa in the western part of Ethiopia to the Sudan border. Different ethnic group live in Assosa town including the Berta community. The main sources of livelihood include petty trade, traditional gold mining, and bamboo production.

Participants
We approached seven participants in Betra Community through snowball sampling. All of the participants were males. After the initial interview, participants were asked if they know another traditional healer to access more participants. Accessing traditional healers continue until data saturation. Participants have been engaged in a traditional healing service for a longer time which ranges from 25 to 36 years. Six of the participants attended religious education while some of them attended elementary school education. One of the participants was illiterate.

Data collection procedures
We interviewed seven traditional healers in Berta community. We used semi-structured in-depth interviews to elicit the views of traditional healers about what ways they used to identify the illnesses, what perceived reasons they assume during identification and what healing methods they use to treat mental illnesses. Probing questions were used to explore additional in-depth information when it is necessary. Most of the interviews took place at the participants' homes and places of work. The average length of the interview was about 2 hours. The interviews were conducted with two of the predominantly spoken local languages: Amharic and Afan Oromo based on the participants' choice. All the interviewees signed an informed consent form before interviewing.

Data analysis
The interviews were transcribed verbatim and translated into English. Thematic analysis was employed to analyze the data. Interview data were used to analyze, identify, and develop themes that respond to the research questions. This process started with open coding during which an extensive in-depth combing of the data to find significant terms, phrases, or themes. Then we present each of the themes with selected data extracts to support our interpretations.

Ethical considerations
All interviews were audio-recorded during receiving consent from each participant. The participants were orally asked about their willingness to give responses to interview questions. The data collectors also verbally described the purpose of the study, the procedure to be used, the reasonable risks and benefits associated to the study. After they agreed to participate, they signed informed consent form before proceeding to the interview.

Results
Our thematic analysis resulted in the generation of four themes. The main themes that emerged from the study include perception of traditional healers about the causes of mental illness, known symptoms of mental and diagnostic methods used by traditional healers, and traditional healers' healing practices to threat mental illness.

Traditional healers' perception about the cause of mental illnesses
Traditional healers attributed mental illnesses to several factors including curse/ witchcrafts, unhealthy social relationship, jealously, hereditary, substance use, punishment of God, and food poising. In the quote below, one participant who was 45 years old with 32 years of traditional healing experience explained the causes of mental illness as follows: There are different causes of mental illness. When there is conflict and jealously among individuals, they may attack each other through a magic or witchcraft which cause mental illness.
Another participant with 25 years experiences added: Some people affect the mental health of others by using the power they gained from evil spirits and religious education. These people do evil practices to make money or to take revenge on a person.
All of the participants also believed that mental illness is caused by a supernatural power. They said that individuals can develop mental health problems because of punishment of Allah when they do wrong acts or failing to pray. For instance, one participant with 25 years experiences described that when individual violets of Allah commandments, he/she can develop mental illness.
In addition, most of the traditional healers perceived that mental illness can be caused by stressful life events such as family problems, being stressed about general life, bereavement, divorce, and failing to succeed in academics. For instance, a participant with 25 years of experience perceived unhealthy social relationship with families and neighbors as a cause for mental illness in the following way: A person may develop mental illness due to conflict with his/ her families, and neighbors. In this situation, the person may begin to isolate himself/herself and become overly stressed that disturbs his or her mental health.
Similarly, another participant with 40 years experiences said: A sudden death of close relatives, family, loved one, and loose of precious properties like gold may lead to serious mental illness in. For example, if a person is emotionally too attached with his/her mother and if the mother suddenly dies, the person's mental condition will be disturbed. I have seen many persons who are came to me to get treatment for such a case.
Many participants also believed that mental illness can be caused by heredity factors that pass from one person to another person. One participant with 25 years experiences said: Mental illness can be transmitted through biological descents. Suppose if there is any kind of mental illness among family members, there is a chance of transmitting to other family members.
Some of the traditional healers perceived that taking intentionally poised food leads to mental illness. For example when a person intentionally mix poisoning substance in the food or drink to harm the mental health of an other person. Finally, all participants of this study also witnessed that excessive use of substance as a cause of the mental illness.

Perceived signs of mental illness
The traditional healers of the Berta community consider certain symptoms to identify mental illness. These include talking about things that don't make sense laughing alone, taking off clothes in public places, collecting and carrying dirty things, crying, eating dirty food and harming or intention to harm others. being aggressive. For instance, one participant with 36 years work experience described the symptoms in mentally ill persons as follows.
Some persons with mental illness talk and laugh alone while others take off their clothes in public, collect and carry dirty things, and crying alone. Most of the time people with mental illness laugh at inappropriate times, eating dirty food, and become aggressive.

Methods of identifying mental illness
Traditional healers use various techniques to identify a persons with mental illness. A participant of 29 years of experience described about how he identifies metal illness: As a traditional healer, I use different herbal medicines that a person can take in different ways to identify mental illness. I mix herbals with water for washing, creaming, drinking and eating by a patient. In addition to herbal medicinal, I sometimes use Kitab-Alherar to know a patient's problem.
Another participant with 36 years of experience reported his ways of identifying mental illness as follows: When a patient visits to me to get treatment, first of all I carefully look at his/her behavior. When a patient laughs and cries without any reason, smells very bad, and talks alone it is a sign of Sulmajinun or Maarata (madness). Besides, I ask a patient's relatives and parents to know about the causes, as well as when, and where the illness started, I use religious books specifically kitab-Alhusul so as to clearly know a patient's mental health problem.
Another traditional healer 27 years experience also use similar methods of diagnosing mental illness. He described it as follows: As a traditional healer, first I ask a patient's family to check if the patient is able to talk with me. I also visually examine the patient's [physical] appearance. Then, I check and confirm whether or not it is a mentall illness by using a book called Kitab. Sometimes, the information gathered from patients are not correct, but the Kitab can tell me about a patient's mental problems.
However, another traditional healer use other methods in addition to Kitab to identify mental illness. He reported how he identifies mental illness as follows: I use different methods to diagnose patients' problems. These are reading Kitab, dream, and herbs. Sometimes Allah tells me about the patient's causes of illness and its treatments in the dream. I directly apply the herbs Allah tells me during dream to diagnoses the patient's problems. My dream tells me about the kind of illness the person is suffering from, even before he/she comes to me.
The other traditional healer 36-year experience use a different method of to identify mental illness.
First, I ask the patient's name and his/her mother's name to know his/her illness. Sometimes I use my knowledge and experiences to diagnosis a patient's problems. Because, I know the kind of illness when I observe the patient's behavior. I also prepare herbal medicine and use it to know the problem of a patient.

Traditional mental illness healing practices
Traditional healers often use herbs to treat patients with mental illness. They prepare different herbal medicines from the root, bark, and leaves of plants. Herbs are used with mixed drinks. The following narrative by a participant (27 year experience) indicated how he treats a mentally ill person. First, when the patients come to me to get treatment, I let the patient to wash his or her body. Then, I prescribe herbal medicine mixed with soft porridge be eaten by a patient in the morning, afternoon and evening.
With a different treatment, another participant 36 years experience said the following: The first thing that I do when a patient comes to me is asking him/her to wash his/her body and then to eat food. After this, I let the patient to inhale boiled herbs in his or her nose and also to take them into his or her mouth. Following these, I give him/her some special creams to paint all over his/her body in order to get relief from mental illness. .
Another participant with 25 years of experience treats mentally ill persons in the following way: Sometimes I give patients herbal mixtures to drink and others times to wash their body. For instance, there is a special kind of herbs that has been used to treat mental health problem due to evil eye. Of course, the herbs that I use to treat the patient's illness depend on the causes and severity of illness.
The treatment of mental illness was also related to religion. One participant treats mental health problems through his spiritual connection. He said: Allah reveals some treatments to me in different ways. Sometimes, I get it [treatment] through my dream. When I immediately fall asleep I dream about the patient's problem and the specific treatments to cure a pertient. In addition, I burn herbs to treat the patients with mental illness. The patients sniff the smoke of burned herbs through their nose to create peace and purify and exile evil intrusions.
In addition to traditional herbs, divination bones made from different wild animals such as hyenas, snakes, leopards, tigers, and dogs are used to treat mentally ill persons. A participant with 32 years experience treats mental illness through medicine prepared from wild animals. He said that wild animals are used to treat mental illness. For instance, he uses medicine prepared from the brain of hyena to treat severe mental illness.

Discussion
Following the findings of this study, the discussion mainly focus on the perceived causes of mental illness, methods of diagnosis (identifying mental illness, and the available line of treatment by traditional healers in the Berta Community. Perceived causes of mental illness, as the other major focus in this study, has been widely researched in different countries around the world. The popular perceived causes of mental illness as perceived by traditional healers include a curse/witchcrafts, God/Allah punishment, poor social relationship, jealousy, hereditary, substance use and, food poisoning. In keeping with a previous study by Kajawu et al. (2019) who indicated that witchcraft played a central role in the causation of mental health problems, the traditional healers of the Berta Community showed a strong belief about that. Similar perceptions and as to why people perform witchcraft on to others and how these curses cause mental illness have been described in previous studies from African countries like Nigeria and Ethiopia (Belachew et al., 2019;Ngobe, 2015;Teferra & Shibre, 2012). According to Hailemariam (2015), many people in Ethiopia believe that mental health problems are caused by supernatural powers, and they seek help from the supernatural activities like praying, fasting, holy water sprinkling and consulting individuals who are believed to have healing power.
The traditional healers of the Barta community use different mechanisms to identify mental illness. These include observation of the physical appearances of a patient, interviews with patient's families, use of different traditional and religious books like kitab, divination of bones from dead animals, and use of herbal medicines. These findings were similarly reported by a study from Ghana by Kpobi et al. (2019) who indicated that use of observation, patient interviews, third-party informants, physical examination of the patient, and divine revelation as a means of diagnosing mental illness.
Similar to other previous findings (Adgoy & Habtemariam, 2018;Desalegn, 2016;Murambidzi, 2016), the findings of the present study revealed that traditional healers believe that individuals can develop severe mental health problems by the punishments of God/Allah. For instance, if the people have done wrongful acts, not performing the right religious practices.
Traditional healers of Berta community perceived mental illness as something that can be observed from people's behavior which are socially and culturally inappropriate such as talking about things that don't make sense, laughing alone, taking off clothes in public places, collecting and carrying dirty things, crying, eating dirty food. Similar understandings across other communities and among different traditional healers have been reported by other previous researchers (Desalegn, 2016;Sigida, 2016;Teferra & Shibre, 2012).
Coming to healing practices, one of the commonly employed methods to treat mental illness by the traditional healers of the Berta community is use of indigenous herbs. This may involve giving different herbal concoctions aimed at relieving symptoms; or targeting the perceived cause of the mental illness. In addition to indigenous herbs, divination of bones, which are collected from different deceased wild animals such as hyena, snake, leopard, tiger, and dog are also used to treat patients with mental illness. The methods of treating mental illness described above are similar to what has been found in other studies (Kpobi et al., 2019;Ngobe, 2015;Sigida, 2016).
The Berta community like many Ethiopian communities mainly seek treatment from traditional healers than modern psychotherapists or people who are trained to deal with mental health issues. However, over use of traditional healers may expose to health risks due to lack of check mechanisms and standards on dose and frequency of medication and quality (Ansani et al., 2003;Wang et al., 2016). Despite this, there is no legal policy to monitor traditional mental illness healing practices and no traditional healers has license from Ministry of Health of Ethiopia (Demeke et al., 2022). There is gap in communication between traditional healers and trained mental health professionals in Ethiopia. There seems to be a gap that both sides were not willing to bridge. Unless the work of one of these parties is recognized and a reconciliation is achieved between them, the possibility of achieving more together will be lost. Government officials, especially at the Ministry of Health in the country, should take the lead in organizing a possible way through which these two belief systems not only co-exist but also complement each other to better bridge the under resourced and under funded healthcare sector.

Conclusions
The traditional healers of the Berta community perceived curse/witchcrafts, supernatural power, poor social relationship, hereditary, substance use, and food poising as the major causes of mental illness. Traditional healers perceive that mental illness is manifested through different socially and culturally deviant symptoms such as talking about things that don't make sense, talking and laughing alone, taking off clothes in public areas, collecting and carrying dirty things, laughing alone, laughing at inappropriate times, eating dirty foods, and intention and act of aggression. Traditional healers identify persons with mental illness through observation of a patient's activities, and asking relatives or family members. They mainly use different religious books such as Kitab-Uruk, Kitab-Abumeshar, Kitab-Ahlusul, Kitab-Obsubuhan, and Kitab-Alherar to identify mental illness. The traditional healers mainly use herbal medicine, religious books and divination bones to treat persons with mentaly illness.

Recommendations
Traditional healers have played an important role in providing mental health services to the communities in Assosa Town. The Ministry of Health and the Regional health office should recognize and integrate traditional healing with modern medicine and psychotherapy. The traditional healing practices in the Berta Community should be systematically managed, monitored and licensed to avoid potential health risks due to lack of standard herbal dose given to patients. Thus, The Ministry of Health and Ethiopian Food and Drug Administration and Control Authority should design and implement initiatives to collaborate with traditional healers in treating mental illness and reducing the disease burden through socially and culturally acceptable ways.