Religion and Spirituality in Psychiatry

272 Laurence Borras and Philippe Hugueletthe sick person or against the group to whichthis person belongs. Social changes brought bymodernism or by imported religions (Islam andChristianity) have not always affected this primarymodel. Even if, according to their socialorigin, people may sometimes refer to a “vague”notion of “illness caused by a natural cause,” theunderstandings of this attack are always verydynamic and are shared by the sick person, his orher entourage, and the healers. These modalitiesof understanding can be schematically reducedto two possibilities: the individual is beingattacked by another individual or he is attackedby a spirit that is understood as a real creatureand that is most often produced by the religioussystem. (22) In Africa, for instance, the attackby an individual is essentially set up accordingto two systems: anthropophagic-witchcraft andmaraboutage. The attack by “spirits” is referredto in indigenous religions, as well as in importedreligions. These explanations of mental disordersare found in most African societies.Designations may differ, indeed, but what isimportant and constant in the understandingsof diseases is the association of their causes withsome attackers recognized by everybody. Thesemodels of understanding of mental diseasesattempt to explain the phenomenon and to situateit in a familiar framework of categories, butit still opposes the biological explanation of thedisease. (23) It follows that the sick person carriesa message (the disease), which needs to bedecoded and integrated into the symbolic languageof the culture, a language shared by theindividuals of the same social group. (24)4. CONTAINING THE FLOODOF UNDERSTANDINGSTh e different representations of the disease asthey are developed by patients may influencesimultaneously or in turn the treatment choices.The logic of these choices can result from acombination of several signification areas, correspondingto the various ways of expressingpain. In developing countries, indigenous healers,religious therapists (priests and healingprophets), doctors, or nurses are the “significationcarriers.”( 25) Traditional therapists are theprotagonists of traditional medicine. For them,“madness” may be seen as a sign that the familyhas deviated from cultural norms or as a formof harm instigated by some jealous third party,but it may also be understood as a form of socialjustice or a mere physical problem.( 26 , 27 ) Theyprovide health care by using methods based onboth religious and sociocultural foundationsas well as on knowledge, behavior, and beliefsrelated to physical and mental well-being and tothe etiology of disease and disabilities prevailingin the community. (28) In Africa, for instance,more than half of the population appeals totraditional therapists for health problems. (25)Their etiotherapeutic understanding of the diseaseis essentially of a magical-religious nature,and they share the same beliefs with their religioustherapists as a basis for the healing process.Religious therapists are those who claimto be able to heal via the word of God and inhis name. They attribute “madness” to the evilinfluence of Satan or of Jinnh. (26) There are twotypes of religious therapists: priests and healingprophets. For the first, healing is not immediatebecause it is considered in terms of hope;for the latter, healing is an end in itself. Beingconfronted with populations for whom healingis a process combining both supernaturalelements of faith and medical elements, societyentrusted priests with a therapeutic role. Thisrepositioning of priests was accompanied bythe birth of new practices with therapeutic purpose,with new names such as the “independentchurches” and the “charismatic prayer groups.”Interventions include prayers for deliveranceand counseling. (29)Doctors and nurses are trained in medicalinstitutions and act according to a biomedicalconception of the disease. They areofficial health professionals, unlike the indigenousand religious therapists, who are consideredto be nonofficial practitioners.( 30 , 31 )Anthropologists such as Helman or Good considerthem to be the representatives of a distinctmedical culture, which is the biomedical