The case for traditional healers in mental health
There are two arguments for traditional healer involvement in mental health provision; one pragmatic and one theoretical. The pragmatic argument turns on the huge shortfall in human resources to deal with mental health problems in low- and middle-income countries (LMICs). Traditional healers could make up for this shortage in human resources in the formal sector. A theoretical argument for the role of traditional healers turns on cultural factors. The argument here is that traditional healers are ideally placed to intervene in conditions with social origins, or when symptoms are coloured by cultural assumptions. Traditional healers, one might suppose, can tap into the beliefs and expectation of local people to reach parts of the mind that are simply inaccessible under a ‘medical model’. According to this argument modern medicine is the appropriate vehicle for the diagnosis and management for the conditions that are mainly of the body. It would be unwise, for example, to rely on traditional healers for the treatment of an acutely febrile child, or for provision of contraceptive advice. However, the traditional healer might be the appropriate first port of call for people with conditions of the mind.
The case against traditional healers in mental health
An argument against the above position is that the most serious types of mental health condition, psychotic illnesses, require modern pharmacotherapy, at least to stabilise patients. While all psychiatric conditions are of both brain and mind, psychotic conditions can be closer in form to those of standard medical diseases and the effects of properly targeted chemotherapy can be dramatic. There are many well documented cases where access to appropriate pharmacological therapy was denied or cruelly delayed while patients were treated unsuccessfully by traditional healers. From this perspective one should no more consult a traditional healer for a mental illness than for suspected malaria.
Reconciling the case for and against: a topic for investigation and research
On the one hand, traditional healers can offer culturally sensitive treatment for non-psychotic conditions, while on the other hand, severe mental illness requires medical services. It could be argued that traditional and modern medical services should be integrated so that traditional healers could treat the majority of patients, i.e. those with non-psychotic diseases, while allopathic clinicians treat the more severe cases. Moreover, different people have different preferences, and individuals may wish to receive care from both types of providers, even for the same illness. These would seem to be further arguments to integrate traditional and allopathic services within the same system and, indeed, in an integrated reimbursement system. Before implementing such a system it would surely be sensible to evaluate the effectiveness of traditional healers in the treatment of various psychiatric conditions and to ensure that, with the appropriate education, they would be able to refer cases that need medical treatment.
Philosophical problems in collaboration between traditional healing and modern medicine
The CLAHRC WM Director is keen to explore the relative effectiveness of traditional and allopathic treatments for non-psychotic mental illness but he is concerned that there may be irreconcilable philosophical differences in the traditional versus allopathic approach. This concern arises from different ontologies that underpin the different kinds of service. That is to say these traditions have different views on what counts as truth. Modern medical practice is very much a product of what might be called ‘enlightenment thinking’; practice built on an understanding of biological mechanisms / scientific explanations. Such a world view is a far cry from the assumptions that underpin traditional healing, and which are guided by a set of traditional beliefs, often of a religious nature. So the question is whether it is possible to truly integrate systems with such different sets of underpinning assumptions? This is partly an empirical question – different systems could be examined to understand how well they can work together. The CLAHRC WM Director understands that moves are afoot to integrate allopathic medicine with traditional Chinese medicine in China, and in Ayurvedic medicine in India. It would be interesting to make independent studies of these systems. But in the meantime I would suggest a thought experiment. Let us imagine a proposed trial of rose-hip water vs. anti-depressant medication taking place in an integrated hospital. The allopathic practitioners present this as a placebo-controlled trial, while the traditional healers present this as a trail of two effective alternatives – the underlying belief systems determine how the treatments are presented. The CLAHRC WM Director suspects that it is very difficult to really integrate two systems based on very different philosophical premises. It is one thing to make irenic statements about mutual respect and so on, but another to supress tensions that seem likely to arise from fundamentally irreconcilable philosophical assumptions.
Living with contradictions
The question of integrating these different systems of thought is, perhaps, unresolvable. The systems have existed side by side for a hundred years or more. In high-income countries there is a thriving industry in complementary therapies and the list of alternative methods is almost too long to recite. Likewise traditional medicine and modern medicine have existed side by side quite happily in Africa, South Asia and China for many years. The populations in all these countries seem, on the whole, pretty savvy at working out which method is more appropriate for them in which condition. I have never heard of anyone going to a homeopath for their family planning needs. But systems co-existing in society is one thing, integrating them in common administrative and reimbursement systems is another. Every now and then there is an attempt to unite religion and science around a common purpose – the Lancet commission is currently involved in such a process.  However, it may be the case that like religion and science; traditional and allopathic medicine can live happily side by side within the same community and within the same individual. Whether and how they can really be brought together in a structural / organisational sense, for example in the same institution or within the same reimbursement system, is a matter for analysis and exploration. One thing I am sure of is that policy should not be made as though this were a technical issue and without considering the very different world views that lie behind each type of provision. Maybe the best that can be accomplished is for the systems to become more aware of each other and cross-refer when necessary, but to continue to make their own independent contributions?
— Richard Lilford, CLAHRC WM Director
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