Mental health issues among indigenous communities and the role of traditional medicine

Indigenous communities and their challenges

Before assessing health problems of indigenous populations, we should clearly differentiate ‘indigenous people’ from ‘others’ (Moran, King, & Carlson, 2001). A definition cited by The United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2013) states ‘indigenous peoples are descendants of populations which inhabited a country or geographical region during its conquest or colonization or the establishment of present state boundaries’ and ‘retain some or all of their own social, economic, cultural and political institutions’ (ILO 169, 1989). Traditional indigenous groups are minorities seeking their collective rights and self-determination on the base of their biological and cultural resources.

Indigenous peoples have survived in all the continents: 370 million people in the world, 6% of humanity, fall into the category of indigenous peoples (ILO 169, 1989). They live in 70 modern nations. In some cases, they are somewhat invisible from other communities, in other cases they are very distinguishable from the rest of the population because of their lifestyle. The percentage of indigenous communities in the United States may be variable: it has been reported that it may range from the majority of the population, like in New Guinea, to little restricted minorities or few survivors. Often, they use to live in very different environments and employ technologies that allow them to live in inhospitable environments like iced lands, deserts and forests and also cities, reserves and landfills. Some communities maintain their own social structure, whereas others show different level of adjustments ranging from good integration with the dominant culture, to various types of urban marginalization. About 150 million individuals among indigenous peoples live in tribal-like social structures, also inside modern States (ILO 169, 1989). Some of these groups or individuals do not have regular contact with other communities. Even if they are aware of the civil world achievements and progress, they decide to distance it and to live isolated. Isolation may be due to the fact they mostly are survivors (or descendants of survivors) or witnesses of massacres of neighbouring peoples. Indigenous people are generally composed of a group of farmers or shepherds who speak their own language and have basic education in their national language. They mostly practice the prevalent religion of the population and some local cults; often identify themselves with the nation-state, specifically with regard to their socioeconomic aspirations or goals. They include some populations located in north Siberia, Southeast Asia, India, Bangladesh, Pacific islands, Australia, North America, Centre America, South America, North Europe/Scandinavia (named Aborigines, First Nations, Indio/Indigene, People from the hills, Nomadic population, etc.). It has been difficult to study these communities since there may be a difficulty in testing them and bringing them closer to a scientific setting with adequate tools. These groups, especially hunter–gatherer, may represent a genetic and cultural heritage that could be lost in a generation (Bittel, 1992; Motshoge et al., 2016; Murray, Murray, & Murray, 1980). In fact, in many of these communities, the traditional knowledge and resources are scarce, undocumented and at risk of disappearing. Also, all communities deal with globalization, the crisis of the States and privatization process of healthcare systems. Modern and post-modern western communities are also very different from indigenous societies since their cultures are influenced by the rapid and heterogeneous change of the post-Soviet and post-capitalistic society into a global and Internet-connected society. On the contrary, indigenous communities are heterogeneous groups. They all have serious difficulties to get involved in the processes of cultural transformation. Besides transgenerational traumas, they might not have received the right education to be competitive. Their territories are also far from global centres, poor in financial and natural resources.

Many indigenous communities are no longer settled and had to migrate or join alien traditions. Some indigenous groups are now displaced, for some reasons pushed away and living far from their original places. Mental maladjustment and negative consequences of acculturation have been described among these groups with an increase of alcohol abuse and violence (Bokhan, 2013; Smith, Sabin, Berlin, & Nacherud, 2009).

Health, mental health and culture in indigenous populations

Health is a cultural concept, even when based on biological aspects. All communities report their own concept of health according to their holistic models (Kirmayer, 1988). Culture may also have a healing power (Adelson, 1998). Moreover, culture affects the attitude towards deviant behaviours and mental health models, in fact, some disorders may have different outcomes in different cultural frameworks (Kirmayer, Fletcher, & Boothroyd, 1997). It is known that some psychiatric disorders may be associated with the loss of resources or stability, as well as changes of social connections, expansion of technology, flow of information and economy, and so on (Cianconi et al., 2015). Personal suffering may be symbolically and culturally mediated as the result of psychosomatic processes that express cultural codes. This factor is also associated with the subjective expression of suffering experienced by the patient, as in the distinction between illness and disease (Kleinman, 1988).

In the framework of globalization, changes and mental health consequences involve also the so-called post-modern societies in many countries such as Sweden, United States and India. They also adopt reactions to what the modern society stood for: industrialism, rapid urban expansion and rejection of many past principles. Ethno-psychological factors like the permanence of a narrative identity, some religious practices and cohesion in the community are considered protective for indigenous populations and their resilience (Kirmayer, Dandeneau, Marshall, Phillips, & Williamson, 2011; Tafoya, 2005). The same cultural factors are protective for individuals and communities against any possible identity attack coming from the past or from the future (Cloud Ramirez & and Hammack, 2014). Medicine, including traditional healing, aims to meet local community needs. Local cultures affect illness models and how ‘illness experience is culturally shaped’ (Kleinman, 1988). Also, medicine and culture both increase resilience of human groups in general (they contribute to social resilience) (Gyasi, Mensah, Adjei, & Agyemang, 2011).

Traditional medicine

TM is seen as a medicine based on an indigenous knowledge and culture. It is also defined by the WHO (2002) as ‘diverse health practices, approaches, knowledge and beliefs incorporating plant, animal and/or mineral based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illness’. TM is also recognized as Complementary-Alternative Medicine (CAM), local traditional treatment, traditional Indian medicine (TIM) and so on. The authors who dealt with indigenous health were initially missionaries, ethnologists and physicians from the colonies. They supported indigenous communities through the traditional culture of medicine during the colonialism and across the changes they were subjected to. In India, among people from the tribe Santals, the missionary Paul Olaf Bodding (1925) provided thoughts and reports useful for scholars and humanists over the centuries, which focus on traditional groups and their cultures. The Santal is a traditional society, an Adivasi ethnic group native to Nepal and India. In the beginning of the past century, they were described as relatively static. They also integrated new influences with their solidified and preserved traditions, superstitions and beliefs. Specifically, Santal medicine employed the available technology, and the community seemed satisfied with their own healers in spite of the outcomes of diseases and deaths. Later, they advanced towards modernization, leaving behind obscurantism and closure, as well as magic thoughts and superstition, and they currently join biomedicine (Bodding, 1925). Bodding described that Santal healers employ stable methodologies that rely on divination (leading to diagnosis) and treatment with mantra, sacrifices and disease-object-extractions. Bodding concluded, ‘To bring about recovery from any disease it is necessary to find the medicine which suits or is intended for any particular disease or illness’. The theory of an existing relationship between diseases and therapies is considered also in traditional societies with pre-scientific tools. In Central America, for example, healing plants are considered ‘spiritual entities’ of the same class of the diseases. As often stated by healers from different traditions, ‘the plant knows the disease because both are spirits’. Bodding (1925) argued that the patient recovers if medicine and disease meet each other. According to this rather frequent vision in the narratives of the natives, plants and supernatural entities and diseases are part of a complex network of social relations that intersects human beings. Some decades later, Ernesto De Martino (1948) wrote on similar issues regarding the mental health and sense of magic in subaltern cultures of southern Italy. He also confirmed that pre-industrial agro-pastoral traditions often believe that illnesses are the result of bad encounters, lack of protection, adverse fate and punishment in forms of specific influences (De Martino, 1948/1973). During the 20th century, science, based on the evidence and methodological research, proposed a more solid amount of knowledge clearing away older colonial theories and the cultural Darwinism. Biological medicine has been employing technologies with a concrete help for populations and has gained more respect and trust thanks to the achievements regarding the infectious and metabolic diseases.

Although it can vary a lot, in traditional societies, supernatural factors are the main causes of illnesses; religion and spirituality are considered in the framework of healing system (Sexton & Sørlie, 2008). Processes of care and treatments can greatly vary among these societies. It might depend on different cultural representations of health and illness, local healers’ knowledge, nature and world-view perceptions shared by healers and patients, spiritual and mythological conceptualizations (Kajawu, 2016), rituals and symbols that legitimize the efficacy of treatments as well as botanical approaches or knowledge of the healers itself. TM is also a wide heterogeneous area. It may include remedies, prays and music (Hämäläinen, Musial, Graff, Olsen, & Salamonsen, 2017); the power of contexts and the use of traditional environmental practices (Tanner, 1979) also seem to have beneficial effects of care. In some cultures, being in certain places or temples may have a healing impact in reducing severe psychotic symptoms (Frazão-Moreira, 2016; Hatala, 2008; Raguram, Venkateswaran, Ramakrishna, & Weiss, 2002). According to Santal healers’ culture, also, when TM cannot provide a remedy to the illness, this may be due to the fact that the illness is even stronger than healers’ knowledge/power. According to Bodding, Santals give up fighting for existence; they make up their mind that they are going to die – and die. Bodding (1925) added,

they may sometimes believe, that they have got a call from the other world, and start on the long journey, often at a previously specified time. Anyone who has had to do with the Santals will have met with, or heard of, examples of this kind.

The Santal healers believe that the success of a treatment still depends on the power and the type of magical attack and sometimes it may be impossible to contrast them. Usually healers are not discredited because of its failure of a cure. Traditional communities have to contend with very dangerous and deadly diseases, such as cancer, or with mental disorders producing stigma, they take good care of their healers. According to Bodding (1925), these phenomena are of considerable psychological interest.

WHO recognizes the importance of TM around the world in providing health care to vulnerable populations thanks to its accessibility, affordability and cultural appropriateness. UN in the United Nations Declaration on the Rights of Indigenous Peoples recognizes the right to practice TM for the full achievement of mental health (United Nation, 2007). Indigenous peoples have the right to promote their cultural and genetic heritage and to protect their intellectual property, traditional knowledge, environment and territory. Medicine must be part of the culture in which the individuals believe. The complexity of this subject is explained in the studies on the placebo response. It is also of note that elements of placebo response are part of each response to any therapy (Bhugra & Ventriglio, 2015). Interpretation of significances of patients’ illness reduces distress and impacts the effect of care (Kleinman, 1988). This represents the crucial point of the principle ‘Culture is medicine’. Patients’ culture may have protective and therapeutic value, promoting resilience and recovery from traumatic events. The details of each treatment will clearly differ depending on the cultural aspects related to one’s culture (Bassett, Tsosie, & Nannauck, 2012; Bhugra & Ventriglio, 2015). Culture includes different notions and some of them must be central to any mental health programme (Kirmayer, 2001). If a culture of medicine is well shared, it can better support individuals with disorders, even though the hopes of healing are poor. TM has more than one role. It tries to support the transits and stresses faced by individuals, relies on a narrative of care and supports hope and cohesion. An effective medical system not only heals the individual but also contributes to the social resilience against stressful events. TM also includes explaining models of chaos and diseases for some pre-scientific societies.

Traditional medicine and biomedicine

TM is generally opposed to the allopathic medicine. Allopathic medicine is also known as Western medicine, Biomedicine (with a biomedical approach) and pharmacological medicine. Although biomedicine is largely replacing TM in many developing countries, complementary approaches are still very popular. Throughout the last century, colonial administration has brought discredit to TM to weaken resistance, to colonization or to control slaves (Wendy & Jicinta, 2014). Sometimes modern medicine has also ridiculed tradition and disqualified the other valid techniques of healing and the healers (Bhargavi and Davar, 2014). Traditional native healing practices have been diminished, then unpractised for generations and finally forgotten. Inevitably, TM became weak with the advent of biomedicine in the territories of indigenous communities. Sometimes, these two paradigms of medicine were in competition. WHO was quite proactive in advocating the integration of TM into public health programmes of developing countries; the Alma Ata Declaration of 1978 proclaimed ‘health for all’ in 2000. According to WHO, the most important challenges for TM/CAM for the upcoming years are to identify the possibilities of a traditional complementary healthy medicine for the needs of poorest populations, to recognize the role of TM practitioners and upgrade their skills in the framework of modern medicine, to protect and preserve the knowledge of indigenous medicine, to encourage the cultivation of medicinal plants and to implement information on the correct use of TM. However, many indigenous communities have not seen the replacement of traditional models of care and new drugs and medical procedures never came: hospitals or nursing facilities still are poorly accessible for various reasons, and such communities experience economic segregation as well as geographical or racial separation (Burns & Tomita, 2015).

In particular, patients still have problems in accessing to mental health services (Burns, 2014). This is confirmed by the evidence that a considerable proportion of individuals seek help from traditional and religious healers for a range of health problems, including mental disorders (Davy et al., 2010; Sorsdahl et al., 2009). As a result, health services often fail to meet the needs of individuals and communities, not only for indigenous communities (Dos Santos, Huang, Menezes, & Scazufca, 2016).

In remote rural areas, health services, in particular mental health services, are simply not available, and any movement to clinics or hospitals is expensive. For example, the traditional healers (Balian) in Bali are the primary source of care for all sorts of health problems, mental and physical problems. Balians use a number of methods and techniques for diagnosis and treatment. There are about 2,500 traditional healers in Bali, and, in 1992, there were nine practicing psychiatrists. It is of note that Balinese people seek treatment from traditional healers, than go to psychiatrist, than 80% of patients go back to Balian (Suryani & Jensen, 1992).

It has been seen that ‘pathways to care’ in these communities are often not linear, but rather recursive and complex. In any traditional family, the decision to consult formal or informal practitioners is a complex issue (Burns & Tomita, 2015). The concept of mental illness is often associated with the fear of potential threat of patients with such illnesses. In India, a large number of people from rural areas with low socioeconomic status hold beliefs in supernatural powers as the cause of mental illness. Because of this stigma, people usually do not accept medical reasons for mental disorders (Kishore, Gupta, Jiloha, & Bantman, 2011). Traditional healers are often more accessible, perhaps more familiar, they may give explanations and assurances. Moreover, they are responsible for the cultural symbols that families use and can understand their local culture, stress and anxieties. On the other hand, healthcare workers are distant and busy. In many cases, resorting to TM can mean delaying proper medical treatment especially for alcohol problems and suicide (Savchenko et al., 2015).

Traditional medicine as a resource to be preserved

Some native cultures have survived someway thanks to their social resources and also with the protection of organizations that fight with them providing legal help and global resonance against their threats (dictators, corruption, invasion of illegal trade and exploitation of land resources and bacteriological contamination). Currently, indigenous communities are ambiguous about what to trust in medicine. It is difficult for them to establish definitive medical paths between TM and biomedicine. Until today, the decisions about which practitioner to be consulted are made according to their believes, choice or preference as well as to reasons related to the failure or lack of structured health services (Akol, Moland, Babirye, & and Engebretsen, 2018).

Preserving community practices has had a concrete effect on decrease suicide rates and group distress in some indigenous communities (Chandler & Lalonde, 1998). Among the natives, some young people do not want to learn from their elders, considering their knowledge obsolete and ridiculous, other groups are under pressure from the official churches that push them to leave the old shamanic traditions. In contrast, indigenous groups attempt to ensure the survival of traditional cultures and spiritual medicines around the territories where these communities live. They do so with their healers who have been able to solve damages, diseases and disorders for years. The remaining healers (as shamans), who have preserved the wisdom of medicine of ancestors and spirits were sent to live in the forest, far away from the villages, in order to protect them from the western people. Often, these healers remained animists and preserved their contact with spirituality, while the rest of the population converted to the religion of the western. This defence and safeguarding of cultures can be described in South America, for example, among the indigenous Kuna in Panama, among Bribris in Costa Rica and so on. In this framework, there still are many difficulties. Highly experienced traditional healers often were not able to transmit their own knowledge to the next generation of healers (loss of ethnological competence). The wisdom of plants can be lost while other plants, especially those with a psychoactive effect, enter the interest of the globalized market. The misuse of plants, especially if psychoactive, is often due to over-exploitation, neo-shamanism (Atkinson, 1992) and tourist market without resulting in a lack of sustainability (e.g. Amazonian Ayahuasca (Banisteriopsis caapi), Datura (Brugmansia spp.) and San Pedro (Echinopsis pachanoi)). In general, traditional healers’ knowledge of medicinal plants has diminished (Bussmann, 2013). The use of medicinal plants for treating specific psychiatric disorders by indigenous healers cannot be ignored by modern science; this ethno-botanical information needs further studies in order to develop possible newer therapeutic strategies (Rahmatullah et al., 2009) avoiding bio-piracy of their knowledge (Creative Spirit, 2018).

New healthcare models for the indigenous communities

A flexible indigenous healthcare system depends on the general health of the group, the environmental and social conditions and the access to the resources. In some indigenous communities, difficulties to access to basic health services are mostly due to slow recovery from economic crises and fewer years of education (especially among women and children; Lemstra et al., 2009). The use of alcohol may reflect the subdivision of the group: part of the group may hold on to traditions, living nomadic or anyway close to their environment, whereas another part may move and live in settlements closer to western cities. Those two groups may have big difference in alcohol consumption. Similarly, suicidality may be related to identity issues, in particular, when the ethnic identity is lost after migration or acculturation (Stoor, Kaiser, Jacobsson, Renberg, & Silviken, 2015). Another reason may be the impossible return to the past. The resilience of groups may also be weakened by the destruction of their environment, by the unbearable evidence of progressive climate changes (Furberg, Evengård, & Nilsson, 2011), alcohol and substances consumption (Ahlm, Hassler, Sjölander, & Eriksson, 2010). ‘Psy’ knowledge has been spread within Western hermeneutical cultural production while many indigenous peoples have their own conception of mental health (Stock, 2011). Indigenous communities also have some weakened points: sometime disorders arise from situations like dispossession of land/loss of stewardship (Laughame, 1999). In fact, Mental Health promotion has to consider culture (Kirmayer, Sheiner, & Geoffroy, 2016), eco-environmental factors (Alcántara & Gone, 2007) and globalizing contexts. Also, the success of a mental health programme depends on specific training of professionals and the creation of culturally appropriate screening tools that can be employed (Janca et al., 2015), avoiding cultural mistrust (Silversides, 2010), recruiting and training people from indigenous communities as psychologists, anthropologists, social workers, practitioners and policy-makers. Their ability to translate the codes of the natives’ narratives into symptoms is a strength point (Hämäläinen et al., 2017). It has been well noted that it is necessary to promote culturally competent therapies, combinations of traditional local knowledge, psychiatry and psychotherapeutic approaches (Redvers et al., 2015). Also, community-based and culturally guided interventions are requested among indigenous groups (Redvers et al., 2015). Training is also essential for mental health workers working in some areas with indigenous communities. They may feel guilty for being the descendants of those who have harmed colonization damage to the ancestors of the natives, whom they now see as patients. The operators may feel demotivated, unable to understand, inspired by racist thoughts and unable to experience care pathways in the indigenous communities (McGough, Wynaden, & Wright, 2017). Lacking of an appropriate psychiatric service model contributes to worsening mental health (Hepworth et al., 2015).

Many Western doctors in Asia, Africa and South America operate alongside their spiritual healers. The importance of specific regions of the brain and their functioning is still little known and therapeutic effects of the spiritual elements shall be studied in future (Lesmana, Suryani, Tiliopoulos, & Jensen, 2010). ‘Spiritual healing’ has been one of the most important aspect that elders identified for mental health clinicians when working with Native patients. The United Nation protect the spiritual vision and relationship with which the various indigenous peoples have with the earth (United Nations, 2007).

In post-modern societies, we are experiencing a rapid recombination and reassessment of medicine, in light of the factors described above. In modern western advanced countries a small amount of people still consult CAM (Contemporary and Alternative Medicine; WHO, 2002). The current indigenous communities still largely depend on TM (Gyasi et al., 2011). In order to treat elderly indigenous people, an appropriate training of western doctors on traditional practices should be very helpful.

The training on indigenous psychotherapy should be based on a cross-cultural evaluation model used in order to introduce a certain spiritual quota in the understanding the symptoms (Gone, 2010; Mohatt, 2010). This would avoid the risk of a counselling that does not help indigenous people but rather renews the risk of a misunderstandings and feeling of new rhetoric oppression (Duran & Duran, 1995). At the same time, among the traditional populations, there are adult generations that have not been educated in the same manner as their parents. These new generations may still be sensitive to spiritual issues, or perhaps they have been pushed into the mindset of post-industrial globalization. It may be that they are not so responsive to traditional techniques and more prone to psychological interpretation and techniques. As stated, some plants and some traditions of indigenous communities are a source of medical projects for Westerners. This is a typical aspect of post-modern society: exchanging symbols and using them according to their own visions of the world and disease (Bassett et al., 2012). A combination of both approaches (traditional and biological) may be represented by people drinking a cup of herbal remedies, while also taking pills and joining psychotherapy.

Opposition between biomedical medicine and traditional indigenous knowledge may be just useless (Cooper, 2016). Some researchers have found a surprising degree of correspondence between traditional categorizations of psychopathology and psychiatric classification systems, highlighting the potential collaboration between traditional and biomedical practitioners and suggesting that a common ground can be found in conceptualizing what constitutes mental illness, despite highly divergent explanatory models (Janiri & Cianconi, 2014).

Moreover, there is a need for appropriate supervision on traditional healers, due to the fact that they may lack correct mental health knowledge, or perhaps mental health legislation, or may be unaware of possible human rights violation. The Cultural Concepts of Distress (CCD) proposed in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) contributes to identifying vulnerable populations (Kohrt et al., 2014). The goal may be to identify best practices in cross-cultural psychiatry in order to improve research on CCD and encourage its application into the mental health services (Kohrt et al., 2014)

The term ‘cultural concept of distress’ is a new definition of the DSM-5: ‘Cultural Concepts of Distress refer to ways that cultural groups experience, understand, and communicate suffering, behavioural problems, or troubling thoughts and emotions’. This DSM-5 session helps psychiatrists in including traditional beliefs, identifying vulnerable populations (at risk groups), public health measures and secondary prevention initiatives.

There are examples of successful collaboration between biomedical services and traditional healers for some infective disease and mental health issues; for example, in the rapid identification of cases by traditional healers and in sending them to the hospitals (Colvin, Gumede, Grimwade, Maher, & Wilkinson, 2003). Traditional healing working in mental health services has been seen as the correct integration of both (Sexton & Sørlie, 2009). Integration has been noted among holistic approach and biopsycosocial interventions, populations of the villages to limit the use of restraint, to facilitate the confidence of families towards biomedicine, to promote the use of meditation practices to manage post-traumatic stress disorder (PTSD) (Suryani, Lesmmana, & Tiliopoulos, 2011). Many groups in post-modernity, not only traditional communities, have lost their heritage of caring and healing, or no longer trust it, or consider it inadequate and dogmatic. Those people belonging to native minorities, are at a greater risk – more than any other ethnic racial group – of experiencing traumatic life events, when compared to the general population. Moreover, these groups are more likely at risk to develop PTSD. Biomedical interventions alone, such as antidepressants, can improve the biological and psychological symptoms of mental illness, yet they are unlikely to address underlying social factors including poverty and gender-based victimization (Clarke et al., 2014).

Global Mental Health (GMH) should promote a comprehensive model including initiatives dedicated to low- and middle-income countries and all variables mentioned above (Jain & Orr, 2016).