Themes referring to causes of severe mental disturbance such as bewitchment, spirit possession and curse were grouped in one core category ‘supernatural’ and other themes such as infections, substance abuse and loss were grouped under a core category ‘biological and psychosocial’. Themes referring to preferred intervention methods were grouped into three big core categories namely ‘indigenous’, ‘religious’ and ‘modern mental health care’. These themes and categories helped us to provide an overall picture of each interview. As such there was no striking difference reported between the male and female participants. So, we didn’t present the opinions of each separately, only an indication of sex of the participant is given besides the quote. The findings of the study are presented in two parts: (1) conceptualization and perceived causes of mental disturbance among the Borana semi-nomadic community, and (2) preferred interventions when someone from their community develops mental illness.
Supernatural influences
Bewitchment
The majority of participants spoke of the importance of supernatural influences in causing severe mental disturbance. Bewitchment, witchcraft and possession by evil spirits were all reported to be causes of mental disturbance. The concept of bewitchment was particularly related to the evil deeds of others, in order to retaliate to an offence or misdeed. According to the participants, when someone is bewitched, it not only makes the person develop severe mental disturbance, it also causes property loss. And the mental illness could also be transmitted to other people related with the person who is affected. Severe mental disturbance was believed to be caused by god as reported by one of the participants ‘Madness is first caused by Waqa [god].’[FGD 3; R8, female]. Madness was also believed to be caused by a curse from the Borana spiritual leaders as illustrated by one male participant:
FGD2; R1 (male): In Borana there is such thing called murma [translated as bewitchment]. When one has murma [bewitchment], it is difficult to tell who did it. It can happen to him even when he walks on the street. When this thing befalls him, it may make him marata [the Oromo word for ‘mad’]…. It may happen to him when he takes it from someone else. The Borana spiritual leaders may curse someone and this may make him mad. If someone takes [steals] someone else’s money or material, the person who lost the money or material may do something in retaliation which makes the other person mad. He may do some witchcraft on him which may make him mad. People would say he became mad because he took someone else's property.
Evil spirit attack
The following situations were particularly mentioned as making people more vulnerable for attack by evil spirits:
Child birth
Many participants reported that ‘exposure to wind’ before a woman becomes clean from the blood after child birth to be a reason for attack by evil spirits. This idea was reflected particularly by female participants for obvious reasons. Some were reported to have recurrent episodes with each child birth experience as illustrated by the following quote.
"FGD 6; R5 (female): We have seen many kinds of madness. There is a woman who became mad after giving birth to a child. In Borana, such kind of madness is believed to be caused by exposure to wind before the woman becomes clean [vulnerable to evil spirit attack]. My own sister had developed such kind of madness. I took her to many indigenous healers. She is well now. She is completely free. She gave birth to other children afterwards. We are born from the same mother."
Exposure to blood, war and dirty water
Another cause of mental disturbance that was reported by the participants was exposure to blood. The experience of fear when seeing blood was reported to be the reason for developing the disturbance. War was also mentioned as a cause of mental disturbance. Fear from crossing flooding river [during rainy season] was also mentioned to be a cause for mental disturbance. Although stress might be an important factor here, these incidents are believed to involve some bad spiritual interference as well. So, it combines both psychosocial stressor and spiritual influence. The following quotes illustrate the above points:
"FGD1; R2 (male): When he has nose bleeds, the wind will take the blood. The blood will be changed to headache. Because of this, his head will be disturbed. The other reason is fall from accident. Even after falling from a car, the blood may be carried away by the wind. [FGD1] R3: [interrupting R2] and when someone stands by the side of blood in the sun."
"FGD 3; R5 (female): …Madness comes from two causes: when they see this dirty water. The girl who was mad and difficult to handle became mad when she tried to cross the
kobo
river [a river found in the area], which was full. She saw the volume of the water and became afraid. This girl would become better when taken to health facility, but her illness comes back. Her problem was caused by that river. When this mad girl is given some tablets, her condition improves, but she becomes ill again. Now she is totally mad. Sometimes she becomes better. That is how it comes."
Biological and psychosocial factors
Infections, loss: ‘worry’ vs. ‘true madness’, ‘curable vs. non-curable’
Many participants across the group meetings mentioned malaria (a tropical infectious disease) as an important cause of mental disturbance, but they distinguished mental disturbance caused by malaria, which they considered to be a curable condition, from other forms of worry and madness, generally considered a severe and non-curable condition. Another important distinction emerging from the discussions was between so-called ‘true madness’ and ‘worry’. According to their description, ‘worry’ was considered to be more related to psychosocial stressors as a result of loss, such as death of loved ones, loss of property and such events.
The following quote illustrates this belief:
"FGD2; R6 (female): Mental illness has two types. The mental illness caused by malaria is an illness and it improves with medicine. There is another type of mental illness which is the true ‘
marata’
[Borana name for ‘mad’]. Such person is truly mad and his mind is disturbed [lit “his mind is turned inside out”]. There is another variety which is worry. … This is different from madness. Worry and madness are two different things. Worry comes from loss of property in the family. … In madness, the mind becomes totally changed. Worry refers to thinking too much in Borana. Worry comes from ‘thinking too much’. If you had wealth and lose that wealth, worry comes. But the truly mad throws off his clothes and walks naked. It could be man or woman, people take a different path away from him."
Alcohol and khat
Alcohol and khat, a naturally occurring amphetamine-like substance whose leaf is chewed to get the stimulant effect, were considered to play a role in causing mental disturbance by some of the participants.
"FGD 6; R7 (male): Yes. These things [khat and alcohol] are like poison [NB: R7 himself was chewing khat while saying this]. God gives rain one day, and at other times it becomes dry. Just like that people may not always get khat or alcohol all the time. If they get money to buy these things, they may become mad."
"FGD6; R5 (male): As far as this alcohol is concerned, the person who drinks this thing is already mad. There is some guy who wouldn’t hesitate to kill his mother when he is intoxicated with alcohol. He had to leave his mother alone, but he wouldn’t do so. This is madness caused by alcohol. Drinking alcohol is madness, more than chewing khat."
Madness may be inherited
Some of the participants reported that madness could be inherited from parents to children. But compared with the other reasons, this one was mentioned only by few participants. One of the participants gave the following example to illustrate the heritability of mental disturbances:
"FGD 3; R3 (female): The child of a mad person may or may not be mad. There is an old lady known by the name … She was married to a man who wanted to have children. She gave birth to two children. They become mad whenever they drink alcohol. Their madness is obvious. She [their mother] is mad. She escapes to the jungle and then comes back to her home. She sometimes talks to people; at other times she ignores people."
Preferred interventions for mental disturbance
The participants in the various FGDs were asked about preferred interventions among the Borana pastoralist community when someone develops mental illness. The findings were summarized as follows. Several interventions methods were described by the participants. Although they expressed preferences for one intervention over another, their approach was pragmatic, pursuing every possible means of treatment until they got solutions. The intervention methods included indigenous, religious, and modern mental health care. They are summarized under three categories as follows:
Borana wise men and indigenous healers
The overwhelming majority of the participants said they would take their relatives to Borana wise men for consultation. These wise men were recognized by the participants as having the necessary skill to help people who developed mental disturbance arising from a range of problems. The following quote illustrates some of the techniques they use in helping such patients:
"
FGD 1
R5 (male): There are some people who dislike their own homes. Medical treatment does not help for such problem. Such people are better taken to Borana wise men and they reveal what is buried in their houses. They give instructions that it should be removed from the house. For such people they give a medicine and instruct the person to wash her body with it [referring a woman in his neighborhood who had undergone the ritual]. It usually helps. He also requests the person to come back to him. He repeats that same order. She was freed and lives peacefully like you and me."
The second most preferred intervention for the mentally ill was indigenous healers. Such healers use a variety of different methods to treat people who have mental disturbance. This was described as follows:
"FGD 6; R3 (male): [When someone becomes mad] The first thing that is done in Borana is to perform a ritual to exorcise the spirit. They believe the person's madness is caused by
zar
[possession by spirit that is believed to have ancestral origin]. The person may not show improvement. They will not take him to a health facility. They will say that the person has
murma
[bewitchment] and will consult an indigenous healer, taking coffee and tobacco with them [as payment for his service]."
Prayer, Holy water: ‘The devil will scream and leave the patient!’
Seeking help from religious institutions which offer prayer and treatment with holy water were strategies reported by several participants. It was reported that consulting religious institutions, such as Christian and Islam prayer places is common in this predominantly animist population signifying the more pragmatic approaches they follow as illustrated below.
"FGD3; R3 (female): We will take him to prayer place. If he is very sick, it may be possession by the devil. He might scream. If he refuses the prayer and asks for traditional ritual, we might take him to the place where they exorcise the spirit by ritual. If these interventions fail, I will take him to the indigenous healer, and he might give him some herb to wash his body with or to rub his body with or fumigate with. I will do these things even if he refuses… If all the above means fail, he will be taken to hospital. If all fail to help him become well, he will be left to be on his own. He will move around and may live in the jungle like a beast, just like we said earlier."
"FGD 6; R4 (male): It is like what has been said. Some people try hard with
kalichas
[Muslim wise men]. These
kalichas
would say the person was attacked by Satan that came out of termite hills [common in the area] and would do different things. Some people may be freed from the illness after they removed Satan from them."
Modern health care as a last resort
Modern health care was mentioned by a few participants who said it was usually a last resort when other modes of interventions had failed. Again the majority had a more pragmatic approach ready to try anything that would help the sick person.
"FGD 3; R3 (female): There will also be a traditional ritual ceremony to intercede with the spirit. They make coffee, and perform rituals [dancing]. Yet others will take him to an indigenous Borana healer to deal with the evil deeds of others [witchcraft]. When all this fails they will take him to hospital. They will take him to Addis Ababa [the capital of Ethiopia where they find the only specialized mental hospital in the country]. They will try all these means and if he fails to improve, they will leave him alone [depending on his condition the patient has two choices: either to remain with his family where he would be provided with his basic needs or leave his village and wander in the streets of towns being homeless]."