Perceived causes of mental illness and treatment practices by Traditional Healers of the Berta Community in Assosa, Ethiopia

Traditional healers of the Berta community play important roles in the prevention, diagnosis, and treatment of patients who are with mental illness. The purpose of this study was to investigate the perceived causes of mental illness and their treatment methods used by the Berta community traditional healers. To achieve the intended objectives, seven well known traditional healers were selected using snowball sampling technique from the total Berta community. Data were collected using in-depth semi-structured one-to-one interviews, and they were analyzed by applying content analysis method. The ndings of the study revealed that traditional healers of the Berta community detected mental illnesses through a detailed follow-up of a person’s behaviors/actions and his/her daily life activities. According to these traditional healers, curse/witchcraft, harsh social condition, hereditary, substance use,and food poising are considered as the main causes of mental illness. To treat mental illnesses caused by either of these causes, the traditional healers use traditional and religious books (Kitab), herbal medicine, and divination bones. These traditional healing way of identifying the causes, diagnosis methods and treatment options are culturally specic. This urges collaborative work and study between the modern mental illness treatment options and the indigenous healing mechanisms. Traditional mental illness healers have used several procedures and methods to diagnose persons with mental illness and other illnesses. These methods are physical observation of the patients, asking the patients’ relatives or families, use of religious books (e.g., Kitab), and herbal medicines. The religious books are called (KitabUruk (book of traditional healers), KitabAbumeshar, KitabAlusul, KitabObsubuhan, and KitabAlherar. These books (Kitab) have different purposes in order to diagnose, to identify the causes, and also treat the patient’s problems. The following extracts show how traditional healers identify a mentally ill person:


Introduction
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) de nes mental illness as, a generic term that encompasses health problems which affect a person's feeling, thinking and behavior.It alsoimpacts his or her functioning in the social work and in his/her daily life [3]. Mental illness is a noncommunicable disease which is increasingly contributing to the global burden of diseases and disability [2,7,27]. To respond to this mental health crisis, 80 % of the population in Africa uses traditional medicine for treatment [32]. Based on experience and observation, indigenous healers often diagnosis mental health problems [31].
Traditional healing aims to reduce or eliminate the causes of the illness rather than targeting the symptoms and treatment methods are related to beliefs about the causes of mental illness [ 33 ]. Every region across the world has its own indigenous traditional mental illness healing methods based on the people's social beliefs, values, and aspirations [12,14 ]. For instance, the indian government promotes indigenous healing for diagnosis and treatment of mental disorders [19 ]. .The traditional mental illness healing practices and methodsdiffer from country to country as well as from region to region depending on cultural values, personal attitudes, philosophy, and costs of treatment [14,15 ].Traditional healing is culturally speci c to treat different illnesses including mental illness. 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 [6].
In Ethiopia, traditional healers have played a major role in the prevention, diagnosis, and treatment of mental, health problems [ 4 ]. About 90% of the population relies on traditional medicine for primary mental health care services due to the presence of associated cultural and socio-economic factors, limited access and costs of modern public health services [ 5,30 ].In Ethiopia, many people considered mental health problems as they happen because ofsupernatural powers, and they seek help from the supernatural activities like praying, fasting, holy water sprinklingand consulting individuals who are believed to have healing power [13] .
Traditional mental illness healing is becoming increasingly popular because of the high cost of medical health care services in modern government and private health centersto a majority of people [31] . In spite of this, the Ethiopian governmentdoes not considered mental health as priority, and it does not allocated large amounts of money to it as compared to communicable diseases such as malaria, tuberculosis, and HIV / AIDS.There have been scant studies on the area of traditional mental healing in Ethiopia.The Berta community has its own culturally appropriate indigenous traditional methods to prevent, diagnose, and treat the patients' mental health problems. Few local previous studies [8,13] focused only on conceptualization of mental illness and practice of treating mental illness. Thus, a more comprehensive study seems in need to develop mental health policy and practice in Ethiopia, promote the available Berta community's indigenous healing practice of mental illness, to inform for Ministry of Health to give more value to the traditional mental illness healing practices and to add to the body of knowledge of mental health research which will serve as a reference for other researchers who will conduct research on indigenous healing practices.The current study aimedon investigatinghow traditional healers of the Berta community detect mental illness, identify perceived causes and signs and symptoms, assess the diagnostic methods and nd out the traditional healing practices to treat mental illness.

Research Questions
To address the target objectives, the following research questions were stated to guide this study How do the traditional healers of the Berta community know about mental illness, its causes and its symptoms?
What methods do traditional healers use to identify people who are with mental illness?
How do the traditionalhealers of the Berta community treat mental illness?
Perceived Causes of mental illness and their treatment methods used by traditional healers Indigenous traditional healers in African countries have their own perspectivesabout the causes of mental illness. While Africans explain or understand the causes of mental illness as because of supernatural causes and religions facts, people in western countries considered itas it is because of biological and psychological causes [31] In Ethiopia, traditional healers in different parts of the country attribute the causes of mental illnesses to evil spirits like zar and jinni spirits, magic, demons, witchcraft, and the evil eye [ 5,13]. Traditional healers also attributed mental illness to supernatural causes such as witchcraft, angry ancestors, and God's punishment [29 ]. Overall, previous studies [5,6,22,26,28] identi ed various and diversi ed 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 event (death, sudden loss of property), curse, spirit possession, economic problems, family con icts, death of relatives, unmet or unresolved love, excessive learning or study, wondering in the middle of the night, sitting alone in the dark empty room, wondering in the middle of the day.
Coming to the target community, many Ethiopians also attributed mental health problems to supernatural powers and tends to seek service from the supernatural agents such as praying, fasting, holy water sprinkling, and consulting individuals who presumed to have special powers of healing mental health problems [5]. This study showed that self-talking, talking nonsense, shouting, impaired self-care such as not washing, laughing at inappropriate times, eating dirty foods, carrying dirty things, uttering incoherently, wandering away from home, aggression, ghting, confusion and strange behavior, crying, and isolation (desire to be alone) are perceived symptoms of a mentally ill person [ 5 ].
Diagnoses methods used to identify people with mental illness by Traditionalhealers Traditional healers use a culturally accepted diagnosis of illness, and they have their own mechanisms to classify people with mental illness.spiritual and traditional healers in Ethiopia make their assessment and diagnosis of a person with a mental disorder based on traditional and religious books such as 'Awudenegest, Metshafe-tibebi (book of wisdom), Firie-Kewakibt (a book telling one's fate matching your birth date with stars), Metshafe-fewus (book of healing), Etsedebdabe (a book listing herbal medicine), and they also use herbal plants [ 6,34 ].
Traditional mental illness healing methods Various treatment methods are used by traditional healers in the Berta community. Herbal remedies, ritual objects, prayer methods, and prescribed behaviors for preventive purpose have been mostly used to treat mental illness patients by traditional herbalist [ 18 ]. There are various traditional methods used by traditional healers including herbs, appeasing the spirits and divination depending on the perceived cause [1]. Likewise, [22] found mental illness treatment methods such as cleansing evil spirits through steaming, burning herbs, enema administering, induced vomiting, traditional incisions, performing rituals and traditional medicine.

Theoretical framework
Many conceptual-explanatory frameworks of mental illness have not been put forward in the science. However, Explanatory Model of Mental Illness isimportant to theoretically framework and to explainperceived causes, diagnoses, and treatment methods of mental illness.The explanatory modelprovides valuable information about the in uence of the illness for the patient and their family, and it helps to build an understanding of their wider beliefs systems,to give properattention and to explain several mental and physical illnesses [ 9 ] . The explanatory model of mental illness assumes mental illness as a culturally determined process of understanding the causes, symptoms and treatments of mental illness [17]. According to this model, culturally determined beliefs explain other illness people's behaviors, health and help-seeking [9].

Study Area
The study was conducted in Assosa town. The city is the capital of Benishangul Gumuz Regional State (BGRS) which is located at 670 km in the West of Addis Ababa. The Berta community is oneof indigenous societies in Asossa Zone. The community is well known in traditional practices to prevent, to diagnose, and to treat health problems including mental illness.

Participants
Traditional healers from the Berta community were selected using snowball sampling technique. After conducting initial interview with a well-known traditional healer in the community,he was asked to point another traditional healer whom he knows. In every successive interview, the participants were asked to referanother traditionalhealer whom they know. Accessing indigenous healers was continued in this way until the required interviewee number reached. The information collected from seven indigenous healers was found to be adequate enough to assess perceived causes, symptoms and treatment practices of mental illnessesby traditional healers of the Berta Community.

Data collection tools
Qualitative data were collected through in-depth semi-structured one-to-one interview. A one to one interview is more exibility and gives freedom to express personal issues [11]. Probing was used when there is a need for clarity before closing the question.The interviews took place at the participants' homes and places of work. They took about two hours, and theywere conducted in the language that the participants most comfortably speak either Amharic or Afan Oromo.

Method of data analysis
The interviews were transcribed verbatim and translated into English, and then back-translated into the local language by a linguist to ensure accuracy and consistency. Content analysis was applied to analyses the data. The main ideas raised by the participants were clustered thematically.The main themes that emerged from the study include:(1) Traditional healers understanding about mental illness, (2) Perceived causes of mental illness (3) Knownsymptoms of mental illness (4) Diagnostic methods used by traditional healers and (5) traditional healers mental illness healing practices.

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 collectorsalso verbally described the purpose of the study, the procedure to be used, the reasonable risks and bene ts associated to the study. After they agreed to participate, they signed on a consent form before proceeding to the interview. The socio-demographic information of the participants include: pseudo names of participants, age, gender, educational status, experience year. As shown in Table 1, all the traditional healers were males whose work experience ranged from 25 to 36 years. Except one, all the traditional healers have religious education while some of them have lower level of modern education.

Traditional healers understanding about mental illnesses
Most of them have a good understanding about mental illnesses, and they de ne mental illness by closely observing a person's behaviors/action, and his/her daily life activities. Besides, their understanding of mental illness was similar,and it seems to be culturally de ned.They closely associated their understanding about mental illnesses with their own experience and knowledge. The participants said that mental illness in Berta community is called SulMajinun (madness) or Yeamiro-Ebdet in Amharic and Maraata in Afan Oromo. The traditionalhealers understood mental illness as a deviated and unusual behavior/action that an individual shows in the community. One of the traditional healers expressed his understanding of mental illness as follows: I understand mentally ill people through his/her action and thought that they show. For example, they always insult people and takes off the clothes in public, play as a child on the road, and in front of some people, eat and drink whatever on the place, move here and there continuously through collecting dirty things, talk none senseless words." (Participant AM) In a similarly way, another participant explained his understanding about mental illness as: I understand mentally ill people through his/her behavior and personal hygiene. That means the behavior/action that mentally ill people show differs from a normal person in society and their hygiene is not good as a normal person. As an example, they do not keep their hygiene, they are easily tempered, unreasonably crying, laughing alone and generally their behavior is not constant especially those who have experienced mental illness for many years. For these reasons the social, psychological well-being of an individual is affected." (Participant AI) The above narratives indicatedthat the participants understood mental illnesses through an individual's behavior/ action. They understood mental illness as a condition that has some behavioral manifestations that are not considered normal within their social context such as insulting community, laughing and crying without any reason, wondering here and there, sleeping everywhere, eating and collecting dirty things, play as a child on the road and in front of the public, drink whatever on the place, speaksenseless words, and change his/her personal hygiene.Therefore, they understood mental illness as the behavior/action of the person different from the social contexts in society.Besides,the traditional healers understood mental illness witha person's physical and emotional conditions such as they cannot manage their physical in a good way when doing something and go, they do not want to eat and talk with their collagenous, aggressiveness, their hygiene is not good.

Perceived causes of mental illness by traditional healers
Based on their own experience and knowledge, traditional healers who were participated in this study attributed mental illnessesto several factors.They listed different causes of mental illnesses including: curse/ Witchcrafts, harsh social conditions, jealously, hereditary, substance use, and food poising. They described the causes of mental illness as follows : There are different causes of mental illness. For example, if there is con ict between people, insult, and jealously. Then, they are bewitched you by their ability and bewitched on you by money for this case. These people who are affecting the mental health of individuals in our community are called Arama by the local language of our community. Therefore, if an individual developed such a severe mental illness, we treat them based on our knowledge and experiences, and according to the causes of illness.
(Participant AK) Another participant added: Some people are harming the mental health of others by using their malicious power gained from evil spirits and religious education or training. These people do these evil practicesfor money or to revenge by their ability to harm the mental health of individuals in society. To treat these mentally ill people as a traditional healer, I use different mechanisms and these are well known to me. In the past times, people who developed severe mental illness were treated only by traditional healers because there was no modern medicine,but traditional healers know its causes of illness." (Participant AJ) Participants of the study also believed that mental illness is caused by a supernatural power. Finally, participants of the study also indicated that excessive use of a substance is another cause of the mental illness.
Perceived signs and symptoms of mental illness Participants described that mentally ill persons showed different signs and symptoms that differ from a normal person in the community. The symptoms may include talking about things that don't make sense or they tend to talk and laugh alone, taking off the clothes in in public places, collect and carry dirty things, crying and laughing alone, talking nonsense, laughing at inappropriate times, eating dirty food, and being aggressive.
. Most people who have mental illness are talking about things that do not make sense or they tend to talk and laugh alone, and they become easily tempered." (Participant MM).
Some of the mentally ill people are always taking off the clothes in community, in the market, collect and carry dirty things. More patients who have severe mental illness have this sign and symptoms."(Participant AI).
Some mental ill people mostly nd them talking about things that don't make sense or they tend to talk and laugh alone, crying alone.This inconsistent behavior is a symptom among mentally ill persons especially on people who have severe mental illness formanyyears." (Participant MI). When the patient comes to me, rst of all, I look at him/her behavior carefully before diagnosis as a mental illness. At this time, the patient shows signs and symptoms of mental illnesses such as laughing and crying without any reason, smell very bad, he/she cannot manage his/her body, he/she talk alone and sometimes he/she doesn't know what we talk about and his/her talk. When I see all these signs on the patient, then, I know it is sulmajinun or maarata (madness). Furthermore, I interview the patient's relatives and parents about the illness, its cause, when, and where the illness was started before concluding on the speci c nature of the mental illness. In addition to this, I use traditional and religious books (kitab) speci cally kitabAlhusul to clearly diagnose and treat the patient." (Participant MI)

Most
As a traditional healer, rst I ask his/her family to check if the patient is able to talk with me and his/her with his/her relative's. In this case, his/her relative's or parents speak about patient's feelings and pains. I also use visually examining of the patient's appearance and its probable cause to determine the problem. Then, I check it in front of the patient using a book(Kitab) or different techniques in order to determine whether his/her family has mental illness issues or not. Sometimes the information that gathered from patients are not true, and they do not helps to diagnosis his/her illness because sometimes mentally ill patients are talking and give unrelated information. But this kitabcan tell me the real causes and treatment methods of the patient's problems. Therefore, I observe the patient's behavior and ask the patient's relatives and family for additional information about the illness before I conclude about the causes of the mental illness (kitab Firstly, when the patients who have severe mental illness come to me to get treatment, the patient takes shower, and then I make herbal medicine for drinking by mixing with soft porridge.I also make herbal medicine mixed with water and used for bathing and steaming. However, this treatment is given rarely.Most of the time, I give herbal medicine mixed with soft porridge which should be eaten in the morning, afternoon and evening and I even prepare herbal medicine for use during steaming." (Participant JM) "When the patient comes to me to get treatment, the rst thing that I do is to give for the patient an order to take a wash and eat. After I gave this wash and eat orders of herbs, then I have to give for the patient some herbs that I have boiled to inhale, and I give a mixture that he/she has to take (orally) again. Following those procedures, I give him some special creams to paint all over his body as well on his/her brain because the mental illness distributed in all body parts are connected to the brain function. For example, I have seen patients who developed severe mental illness beat on their legs. Therefore, as traditional healer, I used and I follow the above steps to treat the patients in our community. However, these steps differed according to the patients' problems and their diagnosis." (Participant MI) Sometimes, I give herbal mixtures which the patients will drink and others times which they will use to wash before they eat the medicine. For instance, sometimes, there is a special kind of herbs that we can burn and the personwho have eye evil/Buda will have to breathe the smoke to treat the patient's illness. However, the herbs that I used to treat the patient's illness depend on the causes and severity of illness.

(Participant MM)
Allah also reveals some treatments to me in different ways..Sometimes I will get it as a vision, or sometimes I can immediately fall asleep and then I will dream about the patient's problem . . . or through other people whom he sends to me. He could use other people to show me what speci c treatments to use to treat speci c diseases. In addition, burning herbs which is traditionally known in the community is used to treat the patients with mental illness. The patients have to sniff these herbs through his/her nose, then it goes straight to the brain awaking brain sense of the patients and they also used to peace and harmony, purifying and banishments of evil intrusions."(Participant AI) Some wild animals are used to treat patient's problems in a different way in our community. For instance, to treat severely mentally ill people, I use medicine prepared from the brain of hyena because it's very important to treat mentally ill patients. This can take according to the causes and severity of the patient's illness with other medicine. During this time, when I treat the patients, I don't use these things only. In our community, Dua is the most important and common treatment of any illness in our community, especially if the illness is caused by evil spirits." (Participant AK) I can use different types of medicines, some of which I prepare for the patient to eat, some I make it for the person to be steamed depending on the individual age, illness, cause of illness symptoms of illness that patients show." (Participant AM) In addition to traditional herbs, divination bones which are made from different wild animals such as hyena, snake, leopard, tiger, and hinging dog are used to treat mentally ill persons.

Discussion
The nding of the present study revealed that most of the participants of the study (traditional healers) detected mental illness through a person's behaviors/action, daily life activities of the individual. In addition, few of the participants of the study called the term mental illness by their own words in our community they called that SulMajinun (madness for Berta community) in Arabic, YeamiroEbdet in Amharic and Maraatain Afan Oromo. Most of the traditional healers who participated in this study were familiar with these terms (Sulmajinun, Ebdet, and Maraata) that are given as calling name for people who developed mental illness. This is consistent with how mental illness is conceptualized in the academic literature. The American Psychiatric Association (2013), conceptualizes mental illness as being a manifestation of behavioral, psychological, or biological dysfunction in the individual. However, the way traditional healers diagnose and treat the patients differ from the western treatment methods of patients who are with mental illness. Traditional healers treat mental illness based on culturally speci c methods and using traditional healing methods.
These ndings of the present study are consistent with the earlier nding conducted by [ 26 ] that shows mental illnesses as something that is displayed through a person's behavior and its condition that has some behavioral manifestations that are not considered normal within their social context. The ndings of the present study are also similar with previous studies that considered mental illness as a distortion in thought patterns and behavior whereby an individual losses contact with reality [ 5,8].
The results of the present study revealed that the behavior/actions among people with mental illness areplaying with their ngers, insult community, laughter and crying without any reason, moving here and there, sleeping where people are not sleeping, eating and collecting dirty things, self-injuries, getting easily tempered, self-mutilation, talking alone, try to harm others, singing, laughing, and shouting uncontrollable, takes off the clothes in public, play as a child on the road and in front of some people, collecting dirty things, talk none senseless words, eating his/her nger, and walk without appropriate time and place. They understood mental illness as the behavior/action of the patients' shows in the community is different from social contexts in society. The results of the present study are supported by various previous indicating the aforementioned behaviors as signs and symptoms of mental illness [8,20,22,26 ].
The ndings of the current study also revealed that a curse/ witchcrafts, harsh social condition, jealously, hereditary, substance use, and food poising as major causes of mental illness by Berta community. In this study, participants explained that excessive substance use, God's punishment, curse/witchcraft, and social problems as causes that lead to mental illness. This corresponds with previous studies [22, 26, and 29]. Similarly, stress in daily life, punishment from God and Evil sprite can cause mental illnesses or it can be genetically inherited [2 ].
The present study was supported by a study in Zimbabwe which indicated the role of witchcraft causing mental health problems. According to this study, those who are bewitched and may become depressed, patients presenting with psychosis and confusion through witchcraft, some have become unconscious, some patients have inserted witchcraft objects in their bodies which would make them suffer from untold pain, and many similar issues [ 16 ]. In addition, when people had stopped following their cultural prescriptions which descend from their ancestors withdrawing their protection from them is another cause to prone illness. The nding of present study received support from another study which indicates that mental illness to be a direct result of witchcraft or evil spirits [26]. The reasons for witchcraft included envy, jealousy, or being motivated by other evil intentions like having to hurt the victim's parents [26].
The nding of the present study indicated that individuals can develop severe mental health problems by the punishments of God/Allah for instance if the people do wrongful acts, not praying/ Dua. Similarly, [21] indicated that people were born mentally ill because God predestined them to live like that and it considered the will of God.
The current study also showed that stressful life events such as; family problems/con ict, stressed about his/her general life, bereavement, divorce, failing on education are perceived as a cause of mental illness. Similarly, [26] indicated that the cause of mental illness includes stressful-life events or problems. Likewise, [22] indicated that social stressors such as poverty, lack of employment, and family disruptions can lead to the development of mental illness. Besides, the nding of the present study has consistency with in which identi ed poverty, nancial challenges, and stressful life events as common causes of mental illness [21].The nding of the present study wad further supported by different studies which revealed stress in daily life and many socioeconomic factors such as disease, political unrest, violence, and any kind of addictions are all play a role in the incidence of mental illness [2,10,25] .
Coming to methods of diagnosis, the nding of the present study revealed that observation of the patients, asking the patients relative's and family, use different traditional and religious books (Kitab), divination bones, and other herbal medicines have been used to diagnosis the patient's problems among the study area. In particular, the nding of the study pointed that in order to identify a patient's problems various diagnostic methods which are culturally appropriate methodswere used by the traditional healers to identify the patient's problems.These includes: different kinds of tradition and religious books that are called Kitab such as Kitab Uruk (book of traditional healers),KitabAbumeshar, KitabAlusul, kitab Obsubuhan, Kitab Alherar. These books (Kitab) have their own different purposes. For instance, Kitab Abumeshar is used to identify the illness itself and to know whether the illness will be a cure or not. Kitab Alheralis telling you the illness and why you get the illness. In addition, to identify the patient's problems, these books (Kitab) are also used to diagnose patients who have developed mental illness and other illnesses, to identify their cause of illness.
The ndings of the present study further indicated that most of the traditional healers also used other methods like herbs and divination in addition to traditional and religious books (Kitab) and their own experience and knowledge to treat patients with mental illnesses. These ndings are similar with study nding in Ghana the herbalists used observation, patient interviews, third-party informants, and, undertook a physical examination of the patient, divine revelation as a means of diagnosing the patient's illness [18]. In addition, in the study by [26] who indicted that traditional healers can see if someone has a mental illness through their behaviors and the divination bones.
One of the methods that are used by traditional healers of Berta community to treat patient with mental illness is traditionalherbs. This involves giving different herbal preparations taken from roots, different plants, barks, and leaves of a plant to a mentally ill person. In addition to traditional herbs, divination bones which are made from different wild animals such as hyena, snake, leopard, tiger, and hinging dog are also used to treat and diagnose patient problems. The methods of treating mental illness described are similar to what has been found in other studies [18, 22, and 26]. In addition, traditional bones are used in the diagnostic process of mental illness in the traditional healing process in Uganda [ 23].

Conclusions
Traditional healers in the Berta community understood mental illness through a person's behaviors/actions, daily life activities. The traditional healers of the community perceived curse/ Witchcrafts, harsh social conditions, hereditary, substance use, and food poising as the major causes of mental illness. Mental illness is manifested through different symptoms or signs such as talking about things that don't make sense, talk and laugh alone, takes off clothes in public areas, collect and carry dirty things, crying and laughing alone, laughing at inappropriate times, eating dirty food, and aggression.Traditional healers diagnosisand identify persons with mental illness through observation of their behaviors and activities, asking their relativesand family members. They mainly use different traditional and religious books such as KitabUruk (book of traditional healers), KitabAbumeshar, KitabAlusul, KitabObsubuhan, and KitabAlherar as a diagnostic tool. Herbal medicine and divination bones are mainlyused to treat mentally ill persons.

Recommendations
Traditional healers understanding about mental illness is linked to the academic conceptualization of mental illness and they have played an important role in providing mental health services to the communities. So, it can be suggested that traditional healers need to be recognized as mental health providers since they provide culturally appropriate treatments to people in their communities.The regional health o ce should encourage the traditional healers to increase the use of indigenous medicineand licensing the works of the healers. The ndings of the study were shown that herbal medicine, divination bones, traditional and religious books are used to diagnose and treat persons with mental illness in the Berta community. Thus, concerned bodies (Ministry of Health and Regional Health Sectors) should design and implement initiativesto collaborate with indigenous healers in treating mental illness. The Ministry of Health and Ethiopian Food and Drug Administration and Control Authority (EFDACA) should work to integrate indigenous healers to improve the general health care services.

Declarations
Ethics approval and consent to participate: We received approval and clearance from Psychology Department at University of Gondar. Informed consent was prepared and signed by each participant.
Consent for publication: All the participants of the study allowed to publish this study in scienti c journals.