Abstract
Background:
Suicide is a public health problem in Uganda among indigenous societies, and different societies manage its aftermath differently.
Aim:
To explore how the Acholi in Northern Uganda manage the aftermath of suicide.
Methods:
We conducted a qualitative study in Gulu district, a post-conflict area in Northern Uganda. We conducted a total of four focus group discussions (FGDs) and 12 key informant (KI) interviews. KI interviews were conducted with community leaders, while the FGDs were conducted with members of the general population. We analysed the data by means of Grounded Theory.
Results:
Our findings indicate that rituals form a large part in managing suicide among the Acholi. Study communities practised distancing (symbolically and physically) as a way of dealing with the threat of suicide.
Conclusion:
Distancing was organized into two broad themes: affect regulation and securing future generations. It is recommended that public health interventions should utilize cultural institutions in the prevention of suicide.
Keywords
This study investigates how the Acholi in Northern Uganda manage the aftermath of suicide. Suicide is a major public health problem in both low- and high-income countries (World Health Organization (WHO), 2014). A recent review concluded that there are over 34,000 (inter-quartile range: 13,141–63,757) suicides per year in Africa alone, with an overall incidence rate of 3.2 per 100,000 population (Mars, Burrows, Hjelmeland, & Gunnell, 2014). Suicide is also a public health burden in Uganda. The age-standardized rate for Uganda is 12.6 per 100,000 (Mugisha, 2012; WHO, 2015). There is thus a great need for effective suicide intervention, prevention and postvention efforts in the country. Culturally sensitive research must inform the development of such efforts, as to provide information on the prevailing values, beliefs and norms, and this should be the target of suicide prevention efforts. This is timely, as the Government of Uganda makes efforts to expand access to mental health services in the country, especially at primary health care level (Mugisha, Ssebunya, & Kigozi, 2016).
Most suicide research in Uganda to date has been quantitative epidemiological risk factor research (e.g. Kinyanda, Hjelmeland, & Musisi, 2004, 2005; Kinyanda, Hjelmeland, Musisi, Kigozi, & Walugembe, 2005; Kinyanda, Hjelmeland, Musisi, & Walugembe, 2005; Kinyanda, Wamala, Musisi, & Hjelmeland, 2011; Ovuga, 2005). The few studies that have been conducted in Northern Uganda have been quantitative (e.g. Mugisha, Muyinda, et al., 2016; Ovuga, 2005). However, such research sheds limited light on the meanings of suicide in this socio-cultural context. Effective suicide prevention will require an appreciation of culture (in terms of norms, beliefs, values and attitudes; Hjelmeland & Knizek, 2010). Culture not only permeates our psychological processes, including attitudes, but also has a bearing on how societies interpret and cope with suicide (Mugisha, 2012; Wyer, Chiu, & Hong, 2009). To be able to develop culturally sensitive suicide prevention efforts, we need qualitative research to consider the cultural context beyond what is possible in quantitative research (Hjelmeland & Knizek, 2010, 2016). A few qualitative suicide studies have been conducted in Uganda to date: a qualitative study on attitudes and cultural responses towards suicide among the Baganda in central Uganda (Mugisha, Hjelmeland, Kinyanda, & Knizek, 2011; Mugisha, Knizek, Kinyanda, & Hjelmeland, 2011) and a qualitative psychological autopsy study among Acholi bereaved by suicide in Northern Uganda (Kizza, Hjelmeland, Kinyanda, & Knizek, 2011, 2012; Kizza, Knizek, Kinyanda, & Hjelmeland, 2012a, 2012b).
Northern Uganda went through civil conflict for over two decades (Kizza, 2012; Roberts, Ocaka, Browne, Oyok, & Sondorp, 2008). High rates of suicidal behaviour were reported. For example, in their study in Internally Displaced Peoples’ (IDPs) camps in Northern Uganda, Kinyanda and colleagues (2009) found an annual suicide rate of 12.5 to 20/100,000 in the period 2005–2007. Ovuga (2005) reported 46.6% for lifetime experience of suicide thoughts in Adjumani district (a district in Northern Uganda which was experiencing active conflict). In our recent study (Mugisha et al., 2016), the prevalence of suicide ideation and attempt were 12.1% and 6.2%, respectively.
There has now been about 10 years of relative peace in the area since the cessation of hostilities between the Government of Uganda and the Lord’s Resistance Army (LRA). However, suicide rates are still higher relative to other communities that are indigenous and politically stable in Uganda (Mugisha et al., 2016), though Government has embarked on an ambitious post-conflict recovery programme in the region (Muyinda & Mugisha, 2015). Within this post-conflict recovery programme, there is need for effective public mental health programmes, and the focus of these programmes should partly be on suicidal behaviour. To improve the effectiveness of suicide prevention packages within the public mental health domain, we need more qualitative research on meanings of suicide in the area in order to design appropriate intervention on prevention strategies. The main aim of the present study was thus to gain an in-depth understanding of how indigenous communities manage the aftermath of suicide in post-conflict Northern Uganda.
Methods
Design and study area
This qualitative study was conducted among the Acholi in Northern Uganda and was one of the sub-studies conducted under the novel Wayo-Nero Mental Health Project (Wayo means aunty and Nero means uncle). As cultural order, the aunties and uncles have a lot of influence among the Acholi. Hence, this project was designed to use the Wayos and Neros to deliver a culturally acceptable programme aimed at reducing the unmet treatment gap for common mental disorders (major depressive disorder, posttraumatic stress disorder and anxiety), as well as suicidality in Northern Uganda. The project was undertaken in three districts: Gulu, Amuru and Nwoya. These were some of the most affected districts during the civil conflict. The three districts are part of the greater Acholi region. However, for this study, all interviews were undertaken in Gulu district and Unyama Parish.
Grounded Theory (GT; Glaser, 1998; Glaser & Strauss, 1967) to capture the viewpoints of an indigenous group, the Acholi, Uganda, on how they deal with suicide. We chose GT because we aimed at developing a contextualized explanation of how the Acholi deal with suicide, and this approach has been useful in studying indigenous views (epistemologies; Charmaz, 2000). The approach enhances the understanding of subjective meanings based on the context as it is expressed in lay knowledge (Ekblad & Bäärnhielm, 2002).
Sampling and selection of informants
Two types of informants were approached in this study and all were purposively selected. Twelve community leaders were used as key informants (KIs) because of their positions in society as custodians of culture. We also organized four focus group discussions (FGDs), two with men and two with women who were from Acholi and had stayed in the area for at least 5 years (so that they were familiar with the community culture). Women and men were interviewed separately. All interviews were conducted at community centres informants could attend.
Data collection
All KIs and FGDs lasted between 45 minutes to an hour. A semi-structured interview guide was employed. All interviews were conducted in English by the first author using a local translator (a community development officer at the local government level), who was fluent in both Acholi and English. KIs were conducted first. FGDs were used for additional data on attitude formation on suicide through group dynamics, which would enrich the information on issues being discussed.
Data analysis
Data were analysed using Charmaz’s (2000) constructivist version of GT. Constructivist GT captures indigenous epistemology and this allows the development of a contextually theoretical explanation (Glaser, 1978, 1998). GT as an approach allows constant comparison of emerging concepts in the data from the cultural perspective of the informants and the researcher is able to develop a theory that is culturally sensitive (Barnes, 1996). We entered the field with some tentative ideas based on our experience from working on a related project among the Baganda in central Uganda (Mugisha et al., 2011). The first and second authors have worked in the Acholi region for over 15 years and therefore have some pre-existing understanding of some of the cultural issues, and this knowledge was treated as a resource in the development of the present study. However, during the process, we were especially aware of these pre-understandings in order to avoid blindness towards new, upcoming material. According to Charmaz, interaction between the researcher and the participants produces data, the meanings of which the researcher observes and defines. During the analysis, data were grouped into emerging themes. For each of the emerging themes, labels were attached to segments of data that depict what they are about (Glaser & Strauss, 1967), and this allows meaning systems to be created alongside the data. By coding and labelling the data, it was possible to compare the KIs and the FGDs. This constant triangulation of views from community leaders (KIs) and lay people in FGDs enriched and contributed to the validity of the findings and culminated in developing a GT.
Ethics
Approvals were obtained from Makerere University College of Health Sciences Science and Ethics Committee from the Uganda National Council for Science and Technology. Study approvals from the participating district authorities (Gulu district and Unyama sub-county) were also secured. Informed consent was obtained from all study participants after explaining the objectives and procedures of the study. The participants were assured of confidentiality before the start of each interview. All data collected were kept under lock and key and only accessible to the research team. Personal identifiers are not used in the presentation of our findings.
Findings and discussion
The findings indicate two broad themes: affect regulation and securing future generations. These two main themes with appurtenant subthemes are presented below, substantiated by quotes from the informants. Distancing becomes the overall theme across all the other themes.
Affect regulation
Affect regulation has been described as a set of processes individuals use to manage emotions and their expression to accomplish goals (Bell & McBride, 2010). Four different normatively regulated activities were unravelled as vital in supporting affect regulation after a suicide. These subthemes are presented below.
No grieving of a suicide
Among the Acholi, culture demands no grieving of a suicide. It was noted in the interviews that those that kill themselves are a disgrace to themselves and the society, and therefore not worth grieving: ‘Killing oneself is disrespect and a disgrace for yourself and you don’t expect others to respect you. We don’t show emotional devastation [outpour] for such people [the suicide]’ (community leader, Unyama), and ‘Society is expected to grieve only those that deserve [grieving] it’ (community leader, Unyama). We see in the views of these informants that suicide is regarded a disgrace. It affects the relationship of the individual and the society, and this position provokes, within the Acholi culture, normative affect regulation, as the family and community members are meant to believe that they have not lost a valuable person. This is contrary to what is regarded as ‘normal’ death where there is always a lot of emotional outpour (Bukuluki, 2008).
Burying immediately
After deaths, the Acholi have long periods of grieving and mourning extending to weeks or months. This cultural practice partly depicts the respect society had for the deceased person. However, upon a suicide, the body is always buried immediately, because culture demands no grieving. There is never a vigil (e.g. sleeping overnight at the deceased person’s place; a common practice in Uganda and among the Acholi) for such a person, and even in circumstances where the person has died in the house, the body is immediately removed for burial: ‘Even if someone has died in the house; the body will be removed immediately [and be buried]’ (KI). Those that die elsewhere (outside) the house are also buried immediately from where the suicide has taken place: ‘The body of a suicide is always buried immediately [from where the act has taken place] because it [the body] cannot be taken home’ (KI).
Here, we see two important cultural symbols at play relating to a home (house) among the Acholi: (a) a home is deemed a decent place, and since a suicide is regarded a disgrace to society, the body of a suicide does not deserve to be put in the home, and (b) keeping the body of a suicide in a house means conducting a vigil, yet culture demands immediate burial of the disgraced person which society should not be culturally obligated to respect. Since culture demands no emotional expression upon a suicide, burying immediately seems to be one of the ways to support the bereaved family, relatives and the close community members in affect regulation that is normative of the Acholi culture.
This finding is in keeping with what we found among the Baganda in central Uganda. They also undertake a similar practice by burying a suicide immediately and do not allow the body in the house for a vigil (Mugisha et al., 2011). In essence, the community seems to shorten the grieving process (in the Baganda and Acholi culture) in order to prevent the bereaved family (and other community members who may be close to the deceased person) from emotional display which culture seems to forbid.
In addition to the above, the body of the suicide is not only immediately buried, but it is also buried in what communities described as a special way, as the body of the suicide is regarded as dangerous material: The head of a suicide will not face the house [as it is done with normal death], it faces the opposite direction. This is a traditional symbol that the spirit of the deceased should not come or keep near the house or home. It should go somewhere else. (FGD, men)
Another member of the FGD noted, ‘The head should not face the house because the spirit should go into big rivers and forests’. By burying the body in a special way, the communities feel that they have dealt with the threat of the spirit of the suicide, and this is likely to restore calmness among members of the deceased family and the community since they are assured that the spirits will not haunt them. The Baganda display a related practice by sometimes burying in a forest or near a river due to the similar cultural fears and reasons.
Using strong words and singing songs while burying a suicide
In addition to burying a suicide quickly and in a special way, elders use strong words and songs while leading the community to bury the deceased person. Informants noted that the essence in these words and songs is to display that the elders and the entire community are unhappy with the suicide, which is likely to cause trouble to the family and the entire community: ‘The songs just aim at turning you into a total shame and distress to society’ (KI). Simultaneously, they use the words and songs to remind/pledge with the suicide that he or she should not cause trouble to the family and the community: They remind the deceased in strong words that we are burying you but you should be the last person here to do such an act. An act of disgrace, an act of humiliation, an act of disrespect for culture … Don’t come back to haunt any other person. We did not have trouble with you [as a community or family]. (FGD, men)
One informant noted more directly: ‘[He] is reminded that though he has died an angry person, he or she should not come back with anger’ (KI).
According to our participants, the words and songs send a message/warning that (a) suicide will not be tolerated in the community and (b) the community acknowledges the power of the spirits. Through this, the community is assured that the deceased person’s spirit has been dealt with by punishment through strong words/songs and appeased through pledging for mercy, consequently upholding the normative order and peace for the community. In our project among the Baganda (Mugisha et al., 2011), we indicated that songs might have therapeutic value for the bereaved family during their recovery. We find this assertion equally important here.
Organizing funeral rites
The Acholi allow funeral rites for a suicide: ‘People are allowed to organize funeral rites just like for normal death’ (KI). Another informant added, ‘For us in Acholi, such activities (funeral rites) are ok and community members do not find a major problem with it’ (KI). This is contrary to the common practice in many other ethnic groups in Uganda (Kinyanda, 2007; Mugisha et al., 2012; Ovuga, 2005). In essence, the funeral rite(s) is a public acknowledgement that the family lost their person to suicide, the mourning period is now over and now they are ready to move on with normal life.
Securing future generations
In most African communities, the issue of securing future generations is central (Mbiti, 1989; Mugisha et al., 2011; Verhoef & Michel, 1997). Security is not only a matter of material needs but also reaches into the spiritual area as these are intertwined in African cosmology. Securing future generations among the Acholi is largely in the hands of elders who conduct appeasement of the spirits because they are perceived closer to the spiritual land: ‘The elders are near the spiritual land and the youth are culturally regarded as far from it therefore they [elders] have a traditional role of dealing with spirits’ (KI).
Among the Acholi, spirits are referred to as lachen, literally meaning evil spirit or very bad spirit. The Acholi also believe that spirits have different characters they inherit from the personality of the dead person: ‘They have a tendency of behaving like the personality of the dead person; if he was easily annoyed, it is the very way the lachen will behave’ (FGD, men). The lachen, however, is a dangerous force that the community has to deal with. In the next section, we present the rituals that are employed to create physical and spiritual distance between the spirit of a suicide and future generations. As noted above, all these rituals are performed by elders.
Caning the body
Informants reported that the body of a suicide is caned before burial as a traditional sign of disapproval in that the community cannot tolerate suicide. FGD participants reported that a man is given three strokes while a woman is given four strokes of the cane: ‘a woman is caned more because as a mother she has disappointed the family and the community the more’ (FGD, women). Some informants added that the body of deceased women may be given more strokes because of the traditional belief that the spirit of a woman might be more dangerous than that of a man: ‘women get annoyed over many things and so do their spirits’ (FGD, men). This gender difference, however, was reported not to be a commonly shared belief in most communities. Most interviews conducted indicated that all lachen are the same: ‘whether a person has been your father or mother once he or she dies they are not a friend’ (FGD, men). It can be inferred from the views of our informants that caning has psychological significance as communities believe that by caning the body they are dealing with the dangerous spirit, and this is likely to make future generations secure.
Offering sacrifices to the spirits
The body is buried immediately, but the suicide act leaves a risk that has to be dealt with right away. Some informants noted that suicide means human sacrifice, and therefore one of the ways to respond to this tragedy is to sacrifice an animal. Among the Acholi, animals are used for traditional cleansing, especially in case of a violent death/shedding blood: ‘Among us, animals are used for traditional cleansing. We shed their blood for this purpose especially in case someone has died of a violent death’ (KI). It was further noted that the most preferred animal for ritual sacrifice is the sheep. The sheep among the Acholi is regarded as a humble animal, which is used for cleansing purposes where there is violence, as it is believed that it can restore calmness: The sheep is a humble and cool animal; it is not like a goat. A goat is stubborn therefore it is used for normal things like rape, adultery and other light crimes. A sheep helps in dealing with violence unlike the goat. (KI)
Informants reported that the sheep should be ‘pure’ white in colour since white means purity among the Acholi, and traditional cleansing culturally means restoring purity: ‘A sheep should not have any dot on its skin of any color. Pure white for us Acholi’s is purity’ (KI).
Hence, the sheep should not have any blemishes and something unnatural. It must be looking ‘holy’. It was, for example, noted that a black sheep regardless of size and age cannot be sacrificed. Equally, a lame sheep cannot be sacrificed as this will be regarded as mocking the spirits and it can easily invoke their wrath: ‘Here we respect our spirits so much and we are also aware that they can be dangerous. One cannot use a lame sheep because it can easily invoke their wrath’ (KI). It was also urged that a diseased animal cannot be used for sacrifice proposed for anything in the spiritual domain: ‘Spirits only like good things, if you give them diseased animals they can also pay you back in the same way and more’ (KI).
The sex of the animal used is the same as the sex of the person who has taken his or her own life. ‘If a man commits suicide, they use a male sheep and vice versa’ (KI). It was further noted that a sheep used in sacrifice should be of age so that the spirits can appreciate it: ‘The sheep should be independent of the mother. It must be able to eat grass otherwise the spirits will not appreciate it’ (KI).
When the sheep has been sacrificed, they throw it in the cave for animals to eat it as people deem it risky to eat the meat: ‘No member of that clan [clan of the suicide] can eat on such meat. The non-members are free to eat it, if they so wish, but some people see it as risky’ (KI). The rwot- mo (traditional chiefs) have to endorse where the sacrificial lamb should be thrown and whether the meat could be eaten by non-clan members. The blood of the sheep can be used to cleanse the place where the suicide has occurred: Some of the soft tissues in the sheep’s womb are removed, put on a piece of leaf and blood from them is sprinkled where the body of the deceased is going to be buried. The rest is sprinkled around the base of the tree where someone has taken his/her life. (KI)
Once the sheep is sacrificed, the family, clan and the entire community gain the confidence that calmness has been restored in society.
Although not popular, in some instances, community members can be allowed by cultural leaders to offer birds for sacrifice. This is only possible if the cultural leaders are sure that the family in question is very poor and cannot easily get help from the extended family: ‘In some occasions, the cultural leaders can seat and allow a family where there is abject poverty to use a bird [e.g. a cock] for sacrifice’ (KI). When asked why there is preference for sheep and not chicken, it was explained that ‘the hen has two legs while the sheep has four legs. Something of four legs is culturally more valuable than that of two legs’ (FGD, men). Just like for animals, the birds given to the spirits must have no blemish. This is the only way they can be appreciated by the spirits. These practices indicate rational spirits, which can appreciate someone’s status in life and accept the sheep for the able families and birds for the poor families. However, once a white bird has been sacrificed, calmness is restored in the poor family, clan and the community. Baganda equally use animals and birds as sacrifices to restore calmness after a suicide (Mugisha et al., 2011).
The FGDs also indicated that although there is a lot of emphasis on a white sheep during such traditional ceremonies, elders are likely now to accept any colour once there is no immediate alternatives: ‘… but with the modern times and due to war, there is scarcity of animals and these days the color does not matter’ (FGD, men). The rituals thus have been adjusted to the financial circumstances, which had changed due to the long-lasting war.
Uprooting and burning the tree where someone has taken his life
Among the Acholi, a place where someone has taken his life is regarded as a taboo area. The common practice is to uproot and burn the tree into ashes in broad daylight by the community members: ‘The tree where a suicide is hanging is regarded a bad omen so it is uprooted. Those that are still living should not use it for shelter’ (KI). Another community leader underlined that this was an endeavour for the entire community and that it had to be done properly: ‘The community gathers, uproots the tree and burns it to ashes. Even the small branches are burnt’ (KI). The reason for all these precautions was the threat by the evil spirit that would take other community members with him: ‘if that tree is not removed, lachen will remain and keep on taking community people one after the other’ (FGD, men). The community can neither use the tree for firewood nor charcoal, because traditionally it is regarded as an object where evil has occurred and can be transmitted: ‘Once used for cooking [the tree], it can be an instrument of transmitting evil’ (KI).
As contact with the tree is perceived as extremely dangerous, nobody is supposed to pass near it before it is burnt: ‘Children are not supposed to get into contact with such a tree and they are not allowed to play near it’ (KI). Even when the tree is uprooted and burnt, the place where it stood still is perceived dangerous and the children are discouraged to use that place for generations: ‘Because it is a place of evil and evil cannot be easily be uprooted or washed away in one day’ (KI). By banning the place where the tree stood and erasing all traces after the tree, the community seems to take measures to protect their community and future generations.
Burning down the hut
Huts are the most common shelter used by the Acholi. Once someone takes his life in the hut, it is pulled down and burnt. Those who live in permanent houses can pull down a section of the house: ‘They can just put down part of the house like the shed and burn it. Otherwise modern houses are expensive’ (KI). The rest of the house can be secured with traditional measures: ‘They can then sprinkle the rest of the house [hut] with blood from the sheep’ (KI). In a permanent house, the Acholi remove the pole someone has used for hanging as they think it is dangerous: ‘they aim at a pole where someone is hanging as what they remove first’ (FGD, men), as this is deemed to be the most dangerous material. By burning the hut or pulling down a section of a house, the Acholi believe that they have chased away the dangerous spirit that would ‘disturb’ their present life and future.
Burning the rope
The rope that was used for the suicide is the most feared object in the Acholi culture. It is regarded as the most risky material mankind can ever come into contact with: ‘It is completely burned to ashes but also under great fear’ (KI). Given its sensitivity as a dangerous object, this traditional ceremony can only be done by ‘strong’ cultural leaders. Any small remains of the rope are deemed risky material and dangerous to the children, family and the entire community: ‘The rope cannot be carried home because of this cultural interpretation’ (KI). And if it is carried home, it is believed other family members of all ages will take their life. When a rope is burnt, the community is convinced that they have dealt with a very dangerous material, and therefore this restores calmness in the community.
It was further reported that when cutting off the suicide from the rope, they don’t do it in a dignified way. They cut the rope and the person just falls in a pit and she or he is quickly buried. Nobody is allowed to touch such a person: ‘The way you fall in the ditch is the way they bury you. You are not supposed to have a dignified exit’ (KI). A similar practice is reported among the Baganda (Kinyanda, 2007; Mugisha et al., 2011).
Cleansing the woman
Among the Acholi, the woman is traditionally property of the clan. Upon the death of the husband by suicide, the clan leaders perform some rituals so that she can easily be taken on by another clan member. They can use blood from a sheep during or after the funeral rights to cleanse the wife of the deceased person as well as her future husband: ‘The elders can sprinkle blood from the intestines of the lamb on the man who intends to marry her. The woman gets to know that this is going to be my next husband’ (KI). Cleansing the woman means that not only does she become secure but also those that will be into close contact/association with her in future.
Cleansing upon marriage
Community leaders noted that if a woman comes from a family where there is a history of suicide, her family has to provide a sheep for sacrifice: ‘Otherwise, even in marriage she will take her life’ (KI). Interestingly, this practice does not apply to a man who has the same family history: ‘For a man, elders might ignore’ (FGD, women).
We see gender issues here, whereby culture becomes strict on the woman and becomes more lenient on the man. Similarly, among the Baganda, women bereaved by suicide cannot be married unless they have performed traditional cleansing ceremonies (Mugisha, 2012). The lamb used in this traditional function for women is not thrown to the wild animals, but cooked without salt and eaten by the elders: ‘We eat it without salt and even the woman can taste it’ (KI). If it, on the other hand, is the man who has lost the wife, he is free to look for any other woman in the community: ‘It is common for people to fear such a man but elders will always come in’ (KI). They perform the traditional cleansing ceremonies so that such a person is acceptable in society.
Compensation to the family
Acholi generally have a traditional compensation scheme for any suicide that is caused by a spouse. It was reported that if a woman forces a man to take his life, the woman will pay the in-laws compensation, otherwise the spirit haunts her. The elders determine the compensation and the clan pays it; it can be three to six cows. These are taken to the home of the clan leader where the deceased person belonged: ‘Because it is done [compensation] by the whole clan there is no possibility of someone failing to do it. How can a whole clan fail?’ (FGD, men). In case it is the man who makes the woman take her life, compensation will be done through the same process. However, if it is a man, the compensation is bigger: ‘the man will be told to pay 10 cows’ (FGD, men).
It was further noted that some suicides cannot be blamed on anyone. When elders investigate and find that there is no culprit, no compensation is made: ‘Unprovoked suicide is not compensated. For example if a woman wakes up and on her own goes to the garden and takes her life, no one is blamed and there is no compensation’ (FGD, men). Elders investigate whether in the lineage someone has ever died of suicide and was not compensated and his or her spirit is haunting the family/clan: ‘they investigate the past and find out and if compensation was not made, it is done there and then’ (FGD, men). The question of guilt, thus, is investigated through the entire family history and not only for the actual incident.
The animals that have been given to the man as compensation for the loss of the wife can only be used to get a substitute for the wife: ‘the cows can be sold but can only be used to marry another wife; you cannot use that money for any other purpose’ (FGD, men). As seen from the views of informants, compensation occurs to prevent the spirit from haunting the individual and the family that is blamed for the suicide.
Cleansing children
Traditional cleansing ceremonies are conducted on the children losing a parent to suicide. They are similar to those performed on a female who has lost a spouse to suicide: ‘The children are sprinkled with blood from a sheep. While they are performing this ceremony, the clan leaders proclaim that the evil should go away with the sunset [and should not haunt the children]’ (KI). We see children here being disentangled from the spirit of a suicide and therefore able to go on with normal life thereafter.
Sharing of belongings and disabling the spirit
The clothing and other belongings of the deceased person are taken immediately after burial by maternal uncles and not family members. They go with one shoe and leave the other one at the grave. This implies that the spirit of the deceased person cannot follow them as one shoe means loss of mobility: ‘One shoe means one leg. That means that the bad spirit has been disabled’ (KI). The spirits are perceived mobile and have to be symbolically destroyed, if the communities are to be secure. But once it is done, community members move on with life.
It was also explained that at the last funeral rites, the property of the deceased person can be distributed to clan members after a cleansing ceremony: ‘The clan members are called, they get a hen, sacrifice it to cleanse the property [including clothing] of the deceased and thereafter they distribute them to clan members’ (FGD, men). As noted earlier on, traditional cleansing ceremonies of living people as well as places and objects are used partly to disentangle the evil spirit after a suicide from current and future generations.
Naming an heir
Naming a person after an elder is traditionally regarded as carrying the elder’s legacy and personality into the future. In contrast to other communities in Uganda (Kinyanda, 2007; Mugisha et al., 2012; Ovuga, 2005), it is possible to name a child after a suicide among the Acholi. Although this possibility exists among the Acholi, the chances of actually doing so were reportedly rare: ‘The name gets off the list’ (KI). Another informant in the same zone added, ‘Among the Acholi, elders who are not of good character their names are not supposed to be carried forward’ (FGD, men). In the same vein, another informant noted, ‘There is the thinking that once children are named after those that have committed “evil” to society, they will also do the same’ (FGD, men). Despite the existing possibility, it seems that the Acholi are precautious and seldom name a child after a person who has taken his or her life. This probably is part of the efforts to protect the child and future generations for suicide.
General discussion
This study adds to some of the few studies conducted in Africa on the meaning of suicide among indigenous communities (e.g. Kizza et al., 2013; Mugisha et al., 2011; Osafo, Hjelmeland, Akotia, & Knizek, 2011; Osafo, Knizek, Akotia, & Hjelmeland, 2011). The cultural context in which people live plays a major role in shaping the meaning to their life experiences. Moreover, culture plays a major role in influencing attitudes and cultural responses towards suicide (Colucci & Martin, 2007; Mugisha et al., 2011; Osafo, Hjelmeland, et al., 2011). The Acholi seem to have a strong negative attitude towards suicide, which is communicated both explicitly and by means of their rituals. In keeping with other studies (Bukuliki, 2008; Mugisha et al., 2011), we found that rituals are perceived to have power through the message they communicate.
Our findings show that due to the extreme fear for suicide, the Acholi embark on a wide range of rituals to deal with its perceived threat, which is quite understandable due to the lack of any meaningful public health services. This can lead to psychological distress. For example, less than 20% of the entire population can access formal mental health care in Uganda (Okello, 2006). Access to mental health services is even more limited in post-conflict areas such as Northern Uganda (Muyinda & Mugisha, 2015). As public health services are virtually absent, traditional remedies for healing and protection prevail in communities.
The rituals performed are culturally prescribed with little or no individual input from the bereaved family. While this might be useful for the general recovery of the community, it could impede the recovery of individuals bereaved by suicide (Mugisha et al., 2011). Interventions that target negative life events and general psychological welfare among families bereaved by suicide are vital. Just like in Ghana and among most tribal groupings in Uganda (Mugisha et al., 2011; Ovuga, 2005), suicide attracts a lot of stigma at community level. Most Africans practise both modern and traditional religion (Mbiti, 1989), and both contribute to stigma. Reducing community stigma will therefore involve targeting both modern and traditional religious/spiritual beliefs on suicide. Stigma negatively affects those that are involved in suicidal behaviour and the bereaved families in terms of help-seeking. If not targeted, traditional and modern institutions are likely to perpetuate stigma at community level.
Since rituals form a larger part of the African way of life (Mbiti, 1989) and among the Acholi, it is possible to bridge the treatment gap for suicidal behaviour in this region by ensuring that the modern health system works closely with traditional/community leaders. The elders are the custodians of culture and are in charge of rituals. This requires, however, addressing the current polarization between the traditional and the modern systems. The modern system seems to largely disregard traditional/spiritual practices despite the big influence that traditional/spiritual practices have on communities in Africa and our study area (Okello, 2007).
Indigenous societies struggle for their continued existence and some of this is done through ritualization. Suicide is not only a social injury (Osafo, Hjelmeland, et al., 2011; Osafo et al., 2011) but also threatens the existence of the indigenous society. The rituals performed should therefore be understood as means/quests for recovery from a stressful event as well as for survival of the community from suicide. Our study among the Baganda and this current study among the Acholi can facilitate some level of theoretical comparison. It is plausible to suggest that in Uganda, indigenous communities deal with suicide by ritualization. These two studies can be a basis for developing large-scale studies to investigate this theoretical position among Uganda’s some 50 tribal groupings.
Uganda is currently making efforts towards integration of mental health services in primary health care. Suicide prevention and postvention should be part of mental health programmes. This is especially important in a post-conflict area such as Northern Uganda, where suicide rates have been reported to be the highest in the country (Mugisha et al., 2015). By delving into the cultural beliefs and practices associated with how the Acholi manage the aftermath of suicide, this study informs the development of suicide prevention in the region. It is clear that some of the cultural practices such as the cleansing rituals help the family of the deceased person cope with the loss. However, other practices such as ‘no grieving of the suicide’, ‘immediate burial’ (hence not allowing for adequate grieving) and ‘caning the body’ may be psychologically harmful to the grieving family members. As we develop suicide prevention programmes in Africa that are also aimed at the development of postvention services to help grieving families cope with their loss, we should encourage and incorporate those cultural practices that are positive and discourage those cultural practices that may have a negative psychological impact on grieving family members and that continue to perpetuate stigma towards those bereaved by suicide.
Conclusion
Ritualization is important among the Acholi in managing the aftermath of suicide. In view of the limited access and impact of modern health care, the most obvious way of dealing with life-threatening events in the study communities is by use of traditional remedies and coping mechanisms. The extensive application of traditional rituals largely indicates the low level of influence of modern mental health services in the study area. Effective public mental health services that are culturally sensitive will be vital for people in this study area.
Footnotes
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by Grand Challenges Canada and Bill & Melinda Gates Foundation (GMH 0094-04).
