Abstract (Knowledge and management of mental illness by traditional healers in Moba country, northern Togo)

Matiéyédou Bomboma,§

Mouftaou Amadou Sanni,

Simliwa Dassa K.,

Bili Douti

&

Faïdibe Yentaguime

Summary: The populations of northern Togo make extensive use of alternative medicine in the therapeutic itinerary of people suffering from mental illness. The aim of this study is to assess the knowledge and management of mental illness by traditional practitioners in Moba country in northern Togo, through an understanding of cultural aspects, in order to better design modern care. This descriptive cross-sectional study involved 87 informants in the prefecture of Tône over a period of 06 months, from March 14 to September 14, 2016. The results come from statistical analyses of frequency distribution and the sum of interviews and show that mental illness is defined in Moba country as a supernatural disorder of reasoning and behavior. The causes cited are mystico-religious, biological and toxic. Psychotic disorders are the best known, compared with anxiety and mood disorders. They can be cured by plants combined with sacrificial and ritual ceremonies performed by fetishists. Patients move from traditional healers to health structures in the event of dissatisfaction, or from health agents to traditional healers in the case of illnesses considered endogenous. For the Moba, mental illness remains a cultural disease. To improve the level of acceptance of modern medicine, it is important that caregivers encode this traditional perception and make it their own.

Key words: Perception, Mental illness, Moba, Nord-Togo

Abstract: This research aims to take stock of the knowledge and management of mental illness by traditional healers in Moba country in northern Togo through the understanding of cultural aspects in order to better design modern care. This is a descriptive cross-sectional study that affected 87 people carried out in the prefecture of Tône from March 14 to September 14, 2016. Mental illness is defined as a supernatural disorder of reasoning and behavior. The causes mentioned are mystical-religious, biological and toxic. Psychotic disorders are the best known compared to anxiety and mood disorders. They are curable by plants associated with the use of sacrificial ceremonies and rituals by witch doctors. Patients pass from traditional healers to health facilities in the event of dissatisfaction or from health workers to traditional healers in "black disease" situations. Mental illness remains a cultural illness for the Moba. Traditional understanding by caregivers will improve patient adherence to modern medical practices.

Keywords: Perception, Mental Illness, Moba, North-Togo

Introduction

Mental health is defined as damage to the psyche resulting in disturbances in behavior. In the African concept, man is a living organism with social, cosmic and spiritual relationships (Guigbile and Erny 44). Health, for its part, is traditionally defined as a proportional qualitative and quantitative balance between the different elements of Man and between Man and all the components of the community in which he resides; between Man and his vertical relationships, which extend from the founding ancestor to future descendants (Konan 13). In Africa, mental illness raises the question of the influence of evil spirits in the explanation of an unfortunate phenomenon or event(WHO 16). In the same sense, the concept of illness in the Moba cultural milieu distinguishes between so-called cultural illness, illness caused by a cause and illness caused by a transgression, and mental disorder is no exception to this rule, which justifies the patient's therapeutic itinerary, which often begins with the traditional practitioner. Even when hospitalized, patients continue to seek the help of healers through their relatives, who either perform rituals on their behalf or entrust them with indigenous products to be administered to patients without the knowledge of the nursing staff (Yangni-Angaté 74). This article aims to explore the knowledge and perceptions of communities and traditional healers about mental illness in Moba country.

1. Methodological framework

1.1 Study environment

The setting for our study was the traditional Moba therapeutic sites in the prefecture of Tône, which is one of seven prefectures in the Savannah region of northern Togo. It covers an area of 1,222 km² with a population of 327,622 in 2016 according to the demographic health survey carried out in 2015. We chose to interview the Moba, the majority community in the Tône prefecture. This ethnic group is made up of different clans, each with its own history. The Moba believe in the existence of invisible powers grouped under three headings: the Supreme Being(Yêdu or Yendu), the spirits and genies and the ancestors (Kanati 101).

1.2 Material and method

Two informant profiles, namely: carers of the mentally ill (63) and traditional mental health practitioners (24) in traditional mental health care settings. A total of 12 cantons in the prefecture were surveyed: Dapaong, Nioukpourma, Pana Bagou, Dalwak, Kantindi, Lotougou, Pana, Tami, Tidonti, Toaga, Warkambou and Korbongou. This descriptive cross-sectional study was conducted from March 14 to September 14, 2016, a total period of 6 months. Participants were subjected to two types of questionnaires depending on their positioning (tradipraticien- accompagnant). Questionnaire items were formulated in Moba languages, and completion for one informant took an average of 35 minutes after informed consent. The questionnaire included information on the respondents' marital status, and their opinions on the definition, causes, types and treatment methods of mental disorders. In addition to these elements, the form intended for traditional practitioners includes a few items on the possible existence of a framework for collaboration between traditional and modern medicine. Quantitative data analysis was based on statistical analyses of frequency distribution in SPSS 21 software, after input into epi-info 7. For the interviews, we used discourse analysis and content analysis. It should be noted that the WHO's 10th revision of the International Classification of Diseases (ICD 10) for mental disorders was used as a diagnostic reference.

  • Main results and discussion

2.1. Profile and gender of respondents

A total of 87 subjects were surveyed, including 63 (72.41%) patient attendants and 24 (27.59%) traditional healers. In our study, we noted a predominance of men in the two target populations (sex ratio of 1.33 for patient attendants and 5 for traditional healers). This could be explained by the fact that, in Moba country, in mental health matters, it is the man who, in addition to decision-making power, is concerned with cultural affairs. In most cases, women are mere spectators. The low number (4/24) of women in our study corroborates (Sow 33). It would also explain the reluctance of women to assert themselves in certain fields of activity.

2.2. Age of respondents

The average age of the respondents was 48.35, with a minimum of 21 and a maximum of 93. This shows the maturity of the people surveyed, as the care and management of the mentally ill is an adult affair among the Moba.

2.3 Education level

A predominance of non-educated people (66.70%) was found in the group of traditional healers and those accompanying patients. In contrast, (Assoumatine 18) found 47.14% and (Tona 27) 36.40% among traditional practitioners in his study carried out in Ewe environments. This statistical difference in the three studies could be explained by the fact that the Savannah region, which includes the prefecture of Tône, has the lowest school enrolment according to the results of the Togo MICS 39 survey.

2.4. Religious practice

Traditional religion was practiced by 79.17% of traditional practitioners and 46.00% of those accompanying patients. This practice is consistent with the mystical therapeutic means sometimes used by traditional medicine practitioners in relation to their ancestral Moba beliefs. These results are in line with those found by traditional practitioners (59.10%) in Ewé country, south of Togo Tona (26). The second largest religious group are Muslims (10%). Traditional therapeutic practice seems incompatible with Christian spiritual approaches.

2.5. Origins of the profession

Three types of occupational acquisition were found in our study. For 50% of cases, it was innate power, discovered during the first episode of mental illness, followed by 37.50% through family and 12.50% through apprenticeship. (Tona 29), found that 40.9% of traditional practices were transmitted from father to son, and acquired in 27.3% of cases. These results confirm the African reality of the transmission of ancestral knowledge, which remains relevant in Moba country. These results also correspond to those of (Collomb 11), who found that traditional practices are acquired from masters who train their assistants over many years, at the price of sacrifice and suffering. In other cases, as in our context, it is the illnesses associated with initiation rites that have enabled them to gain access, always at the cost of suffering, to that hidden truth that everyone carries within themselves.

  • Definition or explanation of mental illness

All those surveyed defined mental illness as a supernatural disorder of the subject's reasoning and behavior. They also declared it to be a shameful illness. This definition is in line with that given by (Assoumatine 20), in his study of the Lamba environment. (Mukau et al 7), emphasizing the same logic, said that the mentally ill live on the bangs of society for the simple reason that they constitute a burden, a disgrace that affects the social prestige of the family; these people are exposed to all kinds of bad weather (rain, wind, heat, cold, etc.).

2.7. Denomination of mental disorders

The people surveyed unanimously gave a common name to each mental disorder.

- Psychotic disorders: " war'enm " literally means "madness". In Lamba country, this disorder is called " Kponne ", which also means "madness" (Assoumatine 20).

- Anxiety disorders: " Yam-poud-tchiam ", meaning "excessive fear". In Lamba country, anxiety disorder is still referred to as " amaasse ", meaning "leap of the heart" (Assoumatine 21).

2.8. Types of mental illness

Respondents unanimously determined two types of mental illness. One type oὺ sufferers are agitated, aggressive and violent and another oὺ the sufferer is calm, thoughtful and isolated. Tona (31), also found the same result in her work. Mukau et al (8) found four types of mental illness among the Ntandu people in Congo: hallucinatory disorder, disorder with manifest epileptiform seizures, deviant behavior as soon as the moon appears, significant difficulty in social adaptation.

2.9. Manifestations of mental disorders

2.9.1. Psychotic disorders

This type of disorder is called "kponne" in the Lamba environment (Assoumatine 20) and "warm" in the Moba environment. All the respondents mentioned symptoms of bizarre behavior, a person walking naked and alone in the streets and garbage dumps, difficulty communicating with others, talking alone with "spirits" "genies", isolation, disheveled outfits, aggressiveness, sometimes isolated, bizarre diet, lack of sleep as manifestations of psychotic disorders. In Tona's study (33) in Ewè country, all the traditional healers affirmed that the mentally ill person is someone who walks on rubbish dumps, naked in the street, who talks alone, someone who doesn't reason well and as a test he is given a basket to fetch water, add 2 people, which he would do if he were really ill. In the study carried out by Mukau et al(7) among the Ntandu people in the Democratic Republic of Congo, which involved 50 people, 26 (52%) stated that the sufferer lived on the margins of society (lu zingu lu bu kaka), and 24 (48%) that they were dehumanized (lu zingu lu mpasi).These results are in line with our own, and confirm the daily reality experienced by the mentally ill in Africa: opprobrium, stigmatization, feelings of rejection by family and society.

2.9. 2 Anxiety disorders

The most frequently cited symptoms were startle reaction (65.07% by caregivers and 75.00% by traditional healers) and fear for no reason (60.32% of caregivers and 62.50% of traditional healers), in line with those found by Assoumatine (21) in his study, which were fear of going out alone at night, hyper-vigilance and a constant desire to be accompanied by a third person. This is also perfectly in line with the nosography described in the ICD 10. This type of disorder is not easily identifiable by the general population or by people with more specific knowledge.

2.9. 3 Mood disorders

The manifestations of mood disorders most frequently mentioned by respondents were: suicide (84.13% of caregivers and 75% of traditional practitioners) and sadness (73.02% of caregivers and 83.33% of traditional practitioners). This result is in line with the ICD 10 nosography. In Moba circles, this illness is known as "yampoug-tchiong". Moba people recognize these types of illnesses quite easily, as those who do so clearly manifest it. 

2.10. Causes of mental illness

The three main causes cited by all those surveyed were mystico-religious (possession/selection by "genies", bewitchments, witchcraft, "divine" punishment, theft, a spell cast by someone else, a curse) for 100% of those surveyed, then biological or somatic (worms, microbes, parasites) for 60.92% and finally toxic (excessive consumption of alcohol and other psychoactive substances) for 24.13%.Tona (30) in the Ewè country of southern Togo, in his study of traditional healers, also noted mystico-religious and toxic causes in 100% of traditional healers, and causes linked to a biological or organic disorder in 22.7%.Mukau et al.(10) found that 46% of respondents believed that mental illness had a mystical-spiritual cause, such as witchcraft, magic, fetishism, bewitchment, transgression of ancestral laws or norms, a curse following theft of another's property, diabolical possession emanating from bewitchment or punishment by disgruntled ancestors. The difference between Mukau et al's (10) proportion and our own could be explained by the fact that our study took place in rural or semi-urban environments, which are not readily open to the knowledge of modern medicine. As for Sow (120), he wrote in his work: les structures anthropologiques de la folie en Afrique (Anthropological structures of madness in Africa) that the complex, often ambiguous relations between humans and African genies; invisible but powerful, good or evil, gratifying or persecuting, they can drive people mad. The representation of mental disorder among the Moba confirms the Egyptian conception of mental illness, according to which illness comes from an external attack and the sick individual is considered a victim of society. Sow (134) goes on to point out that traditional treatment is always etiological, since every mental disorder has a cause which is, at the same time, of social significance, the discovery of which alone, according to tradition, leads to healing, i.e., in fact, to the resolution of tensions; mental illness is merely a call for the strengthening of ties between men and spirits.

2.11. Therapeutic methods

The mental disorders examined in our study can be cured by the use of plants. All plant parts are used, fresh or dried: leaves, flowers, fruit, seeds, trunk, wood, bark, stem, roots. Preparations are obtained by maceration, decoction or infusion. These materials can also be heated in alcoholic beverages, and/or honey or other materials. Alice Konan, in her thesis, stated that plants constitute the most important part of the traditional therapeutic arsenal.

For psychotic disorders, in addition to the use of herbs, the 24 practitioners associated mystical practices with the invocation of ancestors/spirits through animal sacrifices and the utterance of incantatory words, with the aim of making a diagnosis or choosing a remedy. These rituals involved invoking these spirits, with whom they communicated either through speech or through the interpretation of certain phenomena and instruments. Animal sacrifices were offered to them to satisfy their needs, they were unanimous in saying.

This is in line with the results obtained by Tona (35), who found that 68.20% of practitioners, or 100% of fetish healers, associated rituals and magic incantations with plants, which are used in various forms. The aim of rituals and magic incantations is to unblame the patient, to remove all obstacles to the proper functioning of the herbs (ama).

2.12. Cure criteria

In the case of psychotic disorders, the majority of those surveyed (92% of practitioners and 71.43% of carers or relatives of patients) stated that there were at least two criteria for recovery, namely: the patient's resumption of normal activities after cessation of symptoms, consultation of the geniuses, and completion of the proposed treatment. The two (2) herbalists maintained that the treatment was limited solely to the use of plants. As for the healers, they also claimed to carry out mystical consultations, sometimes without the knowledge of those accompanying the patient, before declaring the patient cured.

On the other hand, in Kona's thesis (42), the cure criteria mentioned were: cessation of herbs (72%), confirmation by complementary control examinations (63%) and correct therapeutic compliance (35%).

In the case of anxiety and mood disorders, all those who claimed that these disorders were curable argued that only one criterion was needed to speak of a cure. This was the resumption of activities after the patient's symptomatology had ceased. These two disorders were less well known to the majority of respondents, perhaps because of the rarity of their symptomatology, or a lack of awareness of the link between their symptoms and the aforementioned disorders.

2.13. Framework for exchange and collaboration with modern medical players

2.13.1. Referral of traditional practitioners to health facilities

All traditional healers claimed to refer patients to hospitals in cases of treatment failure, for complementary treatments, and by decision of the genies/spirits (29.17%). In Konan's dissertation (56), 96% of traditional healers referred patients to health centers for serious cases, cases beyond their competence, and for clinical and para-clinical diagnosis. This is similar to the results of our study.

2.13. 2 Referral of health workers to traditional medicine

In the other situation, where health workers from modern structures were referred to traditional practitioners, 50% of traditional practitioners stated that they had received patients referred by health workers for reasons such as failure of treatment by modern medicine, witchcraft, bewitchments, curses, possession/selection by genies or spirits. This reference was made either verbally between caregivers, who asserted that these were "black diseases" and that modern medicine could do nothing to cure them; or between caregivers and those accompanying the sick. In some cases, on the advice of family and friends, the carers would take their patients out of the health facilities to traditional therapeutic sites. The categories of health personnel referring the patients were not mentioned by the traditional healers. The results of a doctoral thesis show that 65% of traditional healers acknowledged having received patients referred by health personnel of all categories (doctors, nurses, midwives, biologists, laboratory technicians or pharmacists (Konan 57).

Conclusion

The aim of this study was to explore knowledge and perceptions of mental illness in the Moba country of the Tône prefecture in northern Togo. The study sites were the houses of traditional practitioners, mainly fetishists, most of whom had acquired their profession through innate power. The study involved 24 traditional healers and 63 people accompanying patients, the majority of whom were male, in 12 localities in the prefecture. For the Moba people surveyed, mental illness is a supernatural disorder and is considered a serious and shameful disease. Psychotic disorders are referred to as " war'enm ", anxiety disorders as " Yam-poud-tchiam ", and the causes cited are mystico-religious, organo-biological and toxic. As for the manifestations, they are in line with those described in the 10th revision of the International Classification of Diseases for psychotic disorders, which are the best-known of the disorders, and less so for anxiety and mood disorders. If they can be cured, it's through the use of plants in all their forms and mystical rituals. There is a non-formalized referral system between traditional and modern medical practitioners in cases of treatment failure, complementary treatment or beliefs about the probable causes of illness. If we are to improve the care of the mentally ill in Togo's health context, we need to ensure that professionals take on board community knowledge and perceptions.

Works quoted           

Assoumatine, Abbé. La conception étiopathogénique des troubles mentaux en milieu lamba, Dissertation, EAM- UL, 2016. 

Collomb, Henri. journal Socialiste de culture négro-africaine; Éthiopiques number 2, 1975.

Guigbile, Dominique Banlène and Pierre Erny. Vie, Mort et ancestralité chez les Moba du Nord Togo. Paris: L'Harmattan, ouvrage, 2001.

Kanati, Laré. Les représentations sociales du VIH/SIDA à la construction d'une identité séropositive : analyse de discours en pays Moba (Nord-Togo). PhD thesis in Sociology, Université Paris-Ouest Nanterre La Défense, 2011.

Konan, Alice. Extent of trauma exposure and PTSD symptom severity as predictors of anxiety-buffer functioning. Psychological Trauma: Theory, Research,Practice, and Policy, 4, 47-55. Rapport d'activité scientifique, Faculty of Psychology and Educational Sciences, University of Geneva, 2012.

......... Place of traditional medicine in primary health care in abidjan (côte d'ivoire). Thesis of medicine from the University of Toulouse III, Paul Sabatier. February, 2012.

MICS. Report of the Multiple Indicator Cluster Survey in Togo, generating evidence for children. 2009.

Mukau Ebwel, Joachim, Corneille Kinsala Kinsala and Liesson Mbayamvula Mawula. A semantic approach to mental illness among the NTANDU, Article in International Psychology, Practice and Research, 3; 19p. 2012.

WHO: WHO Strategy for Traditional Medicine: 2014-2023, WHO Geneva: WHO/EDM/TRM/2014.1

Sow, Ibrahima. Psychiatrie dynamique africaine. Payot, Paris: In-8°, 1977.

Tona, Kodjo, Pratiques thérapeutiques traditionnelles des maladies mentales en pays Ewe au sud du Togo et du Bénin, Communication journal Psy-Cause, n°76. 2018.

......... Les lieux thérapeutiques traditionnels des maladies mentales en pays Ewe au sud du Togo, master's thesis in mental health, EAM-UL, January 2016; 61p. 2016.

Yangni-Angate, Antoine. La revalorisation de la médecine traditionnelle africaine en Côte d'Ivoire. Abidjan: CEDA, 182p. 2004.

How to cite this article:

MLA: Bomboma, Matiéyédou et al. "Connaissance et gestion de la maladie mentale par les tradipraticiens en pays Moba au Nord Togo". Uirtus 1.2 (December 2021): 113-124.


§ University of Parakou / [email protected]