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Perceptions of mental illness in Ethiopia: A profile of attitudes,

beliefs and practices among community members, healthcare
workers and traditional healers

Article  in  International Journal of Culture and Mental Health · July 2014

DOI: 10.1080/17542863.2013.784344

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Perceptions of mental illness in

Ethiopia: a profile of attitudes, beliefs
and practices among community
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traditional healers
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Nicole M. Monteiro & Shyngle Kolawole Balogun
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Department of Psychology, University of Botswana, Gaborone,
Botswana
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 International Journal of Culture and Mental Health, 2013
http://dx.doi.org/10.1080/17542863.2013.784344

Perceptions of mental illness in Ethiopia: a profile of attitudes, beliefs

and practices among community members, healthcare workers and
traditional healers
Nicole M. Monteiroa* and Shyngle Kolawole Balogunb
a
Department of Psychology, University of Botswana, Gaborone, Botswana; bDepartment of
Psychology, University of Botswana, Gaborone, Botswana
(Received 6 February 2013; final version received 7 March 2013)
Downloaded by [Nicole Monteiro] at 13:16 18 April 2013

This study explores perceptions of mental illness in a sample of Ethiopian

community members, healthcare workers and traditional healers. Specifically, the
attitudes, beliefs and practices associated with the symptoms, causes and
treatment of mental illness were investigated. A total of 115 participants were
interviewed using a semi-structured questionnaire to explore their perceptions of
depression, anxiety and psychosis. Qualitative analysis of the interview responses
indicated a range of beliefs about the recognition and etiology of mental illness.
Nine themes were identified in response to the questions how do you identify and
what causes mental illness: Psychocultural appropriateness, Religious/spiritual,
Social difficulty, Behavioral disturbance, Cognitive-emotional impairment, Dis-
aster and economic deprivation, Adaptive functioning, Substance abuse and
Physical/medical. The most frequent response for how to identify depression and
anxiety was negative emotions, while the most frequent answer for recognizing
psychosis was bizarre or unusual behavior. Both modern and traditional
treatments were cited as helpful, depending on the disorder. Implications for
clinical assessment and policy planning are discussed.
Keywords: Africa; Ethiopia; mental illness; perceptions

Introduction
It is widely accepted among researchers and clinicians that culture, which includes a
group’s beliefs, values and normative behaviors (Erchak, 1992), significantly
influences perceptions and the impact of mental illness. The conceptualization of
illness is largely determined by a society’s culture and worldview. Society’s cultural
roots influence everything from an individual’s interpretation of symptoms to the
manifestation and tolerance of behaviors associated with mental illness.
While medical diagnostic systems, such as the Diagnostic and Statistical Manual
of Mental Disorders (DSM) (American Psychiatric Association, 2000), are widely
used globally, there is increased recognition of the importance of understanding
culture-specific beliefs associated with health and illness. Some of the important
questions about the relationship between culture and mental illness include: Are
Western concepts of mental illness and diagnoses universally applicable to other
societies? Are incidences and symptoms of mental illness the same across cultures?

*Corresponding author. Email: drnmonteiro@gmail.com

# 2013 Taylor & Francis

 2 N.M. Monteiro and S. Kolawole Balogun

Do most societies have their own culture-specific syndromes? If so, are they merely
different expressions of the same Western syndromes or are they fundamentally
different? (Al-Issa, 1995)

Mental illness etiology in Ethiopia

Previous studies on mental illness in Africa and Ethiopia highlight the role of
supernatural/spiritual explanatory models in conceptualizing mental illness (Geil,
1968; Jacobson & Merdassa, 1991; Madu & Ohaeri, 1989; Malvaer, 1995). These
supernatural conceptualizations emphasize the importance of understanding the
causes of symptoms
which could include spirit possession, being the victim of a bad
spell or not being protected spiritually
in order to develop the most appropriate
treatment approach (e.g., appeasing spirits through ritual, performing exorcism or
seeking spiritual protection) (Monteiro & Wall, 2011). Remedies are then classified
by type of supernatural cause, symptom constellation and patient characteristics
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(Collignon & Gueye, 1995).

In addition, Ethiopia has a long history of traditional health beliefs and practices.
An extensive body of Ethiopian medical literature, including translated texts of
diagnoses and cures (Pankhurst, 1968), reveals that, in general, Ethiopians believe
health is derived from a state of equilibrium within the body, as well as balance
between the individual and external world (Hodes, 1997). Traditionally, it is believed
that mental illness can be caused by the malevolent wishes of evil-minded people, bad
spirits, the evil eye (buda) and the hostile feelings, ill will and envy of common people.
Although these causes are external, the sufferer is believed to bear some
responsibility for the problem, for example by offending spirits or provoking envy
(Hodes, 1997). Jacobsson and Merdasa (1991) found that among the Oromo ethnic
group, mental disturbance was believed to be caused by a disruption in the
relationship between humans and the divine or spirit world. Other finidngs indicate
that people believe traditional treatments are best for spirit possession (Alem,
Jacobson, Araya, Kebede, & Kullgreen, 1999) as well as epilepsy and mental
retardation (Mulatu, 1999). The backdrop of traditional Ethiopian ideas about
illness is a worldview in which spirits, words and intentions are all interconnected and
believed to influence the outcome of events (Giel, 1968). Traditional beliefs also
distinguish between temporary and permanent ‘insanity’. For example, some
behaviors, such as walking naked, begging, wandering around aimlessly and talking
to oneself, are labeled cases of incurable mental affliction (Kahana, 1985).
Mulatu (1999) speaks to the multidimensional character of Ethiopians’ illness
causal beliefs that ‘reflect the sociocultural context in which they occur’ (p. 547). This
context includes the centrality of social relations in maintaining mental health and
treating mental illness, the recognition of socioeconomic and biological factors in
causing vulnerability to mental illness and the importance of cultural and social
values in making sense of and treating mental illness. Similarly, Madu and Ohaeri
(1989) discuss developing a broader understanding of mental illness perceptions, as
they predict a gradual decline in supernatural explanations for mental illness in
traditional societies such as Ethiopia.
Several studies have investigated contemporary attitudes about mental illness.
Alem et al. (1999) examined key community informants’ beliefs and practices
regarding mental illness in a rural Ethiopian town. They found that the prototypical
symptoms of mental illness were reported as talkativeness, aggressiveness, strange
 International Journal of Culture and Mental Health 3

behavior, wandering, nakedness, self-neglect and destructiveness. The symptoms

considered the most serious were those associated with the DSM diagnosis of
schizophrenia, as well as mental retardation and epilepsy. Symptoms associated with
the DSM depression diagnosis were rated the least severe. Mulatu’s (1999) findings
identify four causal belief dimensions for mental illness: psychosocial stressors,
supernatural retribution, biomedical defects and socio-economic deprivation. Ulman
and Minas (1977) found that Ethiopian respondents listed worrying too much,
poverty and death of a family member as causes of mental illness. Finally, Patel
(1995) cited thinking too much and poisoning as commonly listed explanations for
mental illness in Ethiopia.
The Zar ceremony, which includes repetitive dancing, singing and intense
attention focused on the possessed person, has been described as a ‘treatment of
last resort with powerful therapeutic effects’, used to address hysteria, anxiety,
depression and psychosis (Kennedy, 1967, p. 187). Zar is a spirit possession deity
system that is found throughout parts of Northeast Africa and the Middle East. It is
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thought to have originated in Ethiopia (Levine, 2000) and is part of cultural belief
about mental illness in Ethiopia. Despite the history of these traditional beliefs and
treatments, there is currently a gap in mental healthcare in the country due to
economic constraints and the inadequacy of these traditional explanations alone to
address the current manifestations of mental illness in the country. In order to assist
in properly diagnosing mental illness in Ethiopia, it is important to understand
Ethiopians’ more recent perceptions of the symptoms, causes and preferred
treatment for specific mental illness.
Standard psychiatric diagnosis is based on the presentation of universal
symptoms and patterns of behavior. Instruments developed to aid in making DSM
diagnoses typically focus on the broadest and most common symptoms across
cultures. To be clear, numerous studies support the high disease burden of mental
illness based on assessing these universal symptoms. Keegstra (1986) used the
Standardized Assessment of Depressive Disorders (SADD) to assess psychiatric
outpatients in Ethiopia. Results indicated that patients exhibited core depressive
symptoms, with somatic complaints, specifically burning sensations or pain in the
head, being prominent. Jacobsson (1985) surveyed the outpatient population of a
western Ethiopia general hospital. There was an 18.3% psychiatric morbidity, with a
majority of the conditions being neurotic, although a small number of patients were
psychotic. More women displayed morbidity and rates increased with educational
level and income. In a study of patient diagnoses at a psychiatric clinic in Addis
Ababa, Khandelwal and Workneh (1988) explained the role of somatic complaints in
Ethiopian patients’ expression of mental illness. They suggested that patients often
embellish their problems with physiological complaints to get the doctor’s attention
in busy clinic settings. Other research in Africa underscores people’s association of
behavioral features with psychotic disorders and cognitive and somatic features with
neurotic disorders (Patel, 1995). As Alem et al. (1999) concluded, many traditional
beliefs and popular lay beliefs are strikingly aligned with modern medicine.
However, research also highlights problems identifying culture-specific psychia-
tric symptoms using Western developed instruments. Studies using the Self
Reporting Questionnaire (SRQ) (a psychiatric case finding instrument developed
by the WHO) and similar instruments in Ethiopia have discovered difficulties due to
problems in cultural communication. Kortman (1990) found that the SRQ had
moderate validity in a group of clinic outpatients, but revealed problems when
 4 N.M. Monteiro and S. Kolawole Balogun

Ethiopian patients were exposed to the language of Western psychiatry. The SRQ’s
sensitivity to health-seeking behaviors and its inability to decipher the meaning of
such behaviors for Ethiopian patients was problematic.

Rationale for the present study

There is one psychiatric hospital in Addis Ababa and the number of psychiatrists per
100,000 population is just 0.02 (WHO, 2005). Outside of the capital, mental health
care is provided by psychiatric nurses (Alem, 2000). Conditions for psychiatric
patients are sub-optimal, with limited resources and personnel contributing to
patient neglect and inadequate treatment. In terms of progress, 36 mental health
units have been established countrywide and a postgraduate psychiatry program was
started at Addis Ababa University in 2003 (WHO, 2005). However, conditions for
patient care are not likely to improve drastically in the near future. Therefore, it is
imperative to understand as much as possible about Ethiopians’ beliefs and needs in
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regards to mental illness so that resources that are available can be used optimally
and efficiently.
In addition, there is limited literature on perceptions of specific mental illness
diagnostic categories. The issue at stake here is how to clearly understand beliefs
about these diagnoses to help bridge the gap between traditional and modern
conceptualizations. Currently, there is no uniform way of diagnosing. Laypersons are
thought to lean more toward traditional spiritual beliefs, while healthcare workers
are believed to align with scientifically-based explanations. It is better for the
profession to have one way of identifying mental illness, rooted in the cultural beliefs
of Ethiopians.
One of the problems is that of classification. The widely used DSM is not
applicable to every culture without integrating supplemental cultural information
from that society. This study would add to the validity of using the DSM psychiatric
diagnostic system with Ethiopian populations by providing information on
laypersons’, health workers’ and traditional healers’ perceptions of mental illness.
The following research questions were explored using qualitative interviews:

(1) What are Ethiopians’ ideas about the definition and expression, causation
and treatment of mental illness?
(2) What are perceptions of depression, anxiety and psychosis?
(3) Do community members/laypersons, healthcare workers and traditional
healers differ in their attitudes, beliefs and practices regarding mental illness?

Methods
General design
The research design was cross-sectional survey utilizing a qualitative semi-structured
questionnaire to interview participants.

Population and setting

Interviews were conducted with participants in urban Addis Ababa and rural Asella.
Addis Ababa is the capital and the economic, political and educational center of the
 International Journal of Culture and Mental Health 5

Ethiopia. It is a densely populated city inhabited by people of multiple ethnic groups

from all over the country, as well as refugees and ex-patriots from other countries.
The rural area was the town of Arsi in the district of Asella, which is 420 km south of
Addis Ababa. It is a small town surrounded by peasant dwellings.

Participants
A total of 115 participants completed the interview questionnaire. They were selected
using purposive sampling. Inclusion criteria for participants were: males and females
age 16 and older, Ethiopian nationals and residents of the respective study regions,
Addis Ababa and Asella. Three categories of participants were recruited

laypersons, healthcare workers and traditional healers. The laypersons were people
in the community, including clinic patients, high school and college students and
others in the community who had no formal or traditional healthcare training. The
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healthcare workers were individuals who work in hospitals and clinics such as
formally trained physicians, nurses, psychiatrists and psychiatric nurses. The
traditional healers included healers who treat a variety of physical, spiritual and
mental illnesses. Participants were selected from the following specific locations in
Addis Ababa and Asella: secondary schools, Addis Ababa University, hospitals,
churches, neighborhoods and community dwellings.
Of the sample, 60% was male and 40% female. In terms of religion, 32% identified
as Christian, 17% as Muslim and 49% as Ethiopian Orthodox Christian. The mean
age was 28.52 years (SD10.79), with participants ranging in age between 16 and 63
years old. In all, 75 participants were classified as community members, 35 were
healthcare workers and 5 were traditional healers. Of the participants, 82 were in
Addis Ababa and 33 in Asella. Participants were largely from the Amhara and
Oromo ethnic groups, with smaller percentages from the Tigre, Gurage and other
smaller ethnic groups. Participants’ income ranged from 0 to 2,000 birr per month,
with the mean being 510.04 birr per month (SD388.64). This is equivalent to
approximately US $65 per month. More than 50% of the sample had post-secondary
education and more than 50% was single (Table 1).

Table 1. Demographics.

Occupational classification Average age Age range Ethnicity Frequency Percent

Community member / 23.57 16
63 Amhara 45 39.1

layperson
Healthcare worker 36.4 22
54 Gurage 6 5.2
Traditional healer 34.6 20
62 Oromo 33 28.7
Tigre 7 6.1
Other 12 10.4
Missing 12 10.4
Total 115
Education Frequency Percent Marital status Frequency Percent
Illiterate 4 3.5 Single 60 52.2
Grade 3
8 7 6.1 Married 40 34.8
Grade 9
12 44 38.3 Divorced 3 2.6
Post-secondary 60 52.2 Widowed 5 4.4
Total 115 Missing 7 6.1
Total 115
 6 N.M. Monteiro and S. Kolawole Balogun

Instrument
The questionnaire was developed in English and then translated and administered in
Amharic, Ethiopia’s official and national language. Demographic information,
including participants’ gender, age, education, marital status, religion, place of
residence and occupation, was collected. The survey instrument was an open-ended
questionnaire that explored participants’ perceptions of mental illness, which was
developed by the principal investigator. It asked about the symptoms, causes and
treatments of three categories of mental illness: anxiety, depression and psychosis.
These categories were selected based on the disorders that have the highest disease
burden globally. Questions were classified into four domains: symptoms, causes,
treatment and most common mental illness:

“ Domain 1 questions related to describing and identifying symptoms of mental

illness.
How would you describe mental illness?
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How would you know if someone is mentally ill?

How would you know if someone is depressed?
How would you know if someone is anxious?
How would you know if someone is psychotic?
“ Domain 2 questions related to explaining the causes of mental illness.
What causes people to become depressed?
What causes people to become anxious?
What causes people to become psychotic?
“ Domain 3 questions related to preferred treatment of mental illness
What is best way to deal with (treat) depression?
What is best way to deal with (treat) anxiety?
What is best way to deal with (treat) psychosis?
“ Domain 4 questions related to naming the most commonly observed and the
most severe mental illnesses in the society.
What are the most common mental illnesses in this society?
What is the most severe mental illness a person can have?

Translation process
The questionnaire was translated by two Addis Ababa University students (a
Master’s level Language Studies student and an undergraduate Psychology student).
The translations were then reviewed by two other native Amharic-speakers (an
Amharic language instructor and a research consultant) who compared them to the
original English version. If either of the reviewers noticed any discrepancy in the
original translations, they discussed them with the investigator and then decided how
to correct any mistakes or differences. The questionnaire was pilot-tested on a small
sample before final revisions were made. All translators were fluent in written and
spoken English and Amharic.

Reliability
Reliability was established through inter-rater analysis the categories used to code
the interview responses. Two independent coders (research assistants) used the
 International Journal of Culture and Mental Health 7

coding categories developed by the investigator, to code 10% of the interviews. Their
individual coding was compared to each other’s and to the investigator’s coding.
Changes were made to the coding categories based on discrepancies that were
observed.

Validity
To establish content validity, information about the social, cultural and political
history of Ethiopia was referenced to support the appropriateness of the coding
scheme and to incorporate an emic understanding of Ethiopian society into the
analysis of response categories. Face validity was established by examining the
presence and extent of inappropriate responses, which would indicate that the
questions did not make sense or were not understood. The occurrence of such
responses was very low.
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Procedures
Ethical approval and a research permit were obtained from the Ministry of Health in
Ethiopia. The questionnaire was administered in both face-to-face verbal and pen-
and-paper written format. A research assistant, fluent in Amharic and English,
administered the questionnaire under the principal investigator’s supervision.
Approximately one-third of the surveys were administered by oral interview. The
research assistant both asked the questions and recorded subjects’ responses in
Amharic while the investigator was present. The remaining two-thirds of the surveys
were administered in written format in Amharic, with subjects reading the
questionnaires themselves and writing the answers. Administration took 30
45
minutes.

Analysis of interview data

The data were analyzed using open coding to identify salient themes in the interview
responses. The coding occurred in several phases. The first step was breaking down
the interview questionnaire into conceptual domains: (1) defining mental illness and
its symptoms, (2) explaining its causative factors, (3) identifying preferred treatment
practices and (4) identifying the most common and most severe mental illnesses in
the society. Each domain included at least three questions pertaining to an
explanation of depression, anxiety and psychosis. Next, all of the questionnaire
interviews were reviewed, by domain, to identify and record each core idea contained
in the responses. An individual response could, and often did, contain more than one
idea. Similar response ideas within each domain were grouped together.

Revising categories and themes

After each category was identified, the first draft of the coding scheme was complete
and was then used to code 50% of the interview responses. Categories were then
revised, including aggregating some categories, splitting others and creating new
categories. Then, all of the data were coded using the revised coding scheme.
Finally, two independent coders checked the reliability of the codes and
determined, along with the investigator, any further revisions that were needed by
 8 N.M. Monteiro and S. Kolawole Balogun

coding 10% of the responses. As a result, there was one final revision of categories.
All of the data were then recoded with the new coding categories.

Results
Responses were broadly classified as focusing on spiritual, psycho-cultural or socio-
economic explanations of mental illness. Spiritual concepts are those that relate to
supernatural indicators, causation or treatment practices, such as spirit possession,
evil eye (buda), use of holy water, prayer, traditional practices etc. Psycho-cultural
concepts are those that are related to Ethiopian cultural values and standards of
personal character, behavior and psychological appropriateness that the society
expects its members to uphold. Socio-economic responses are those that mention
financial, employment or other economically-based environmental deficiencies, such
as loss or property or damage due to societal catastrophes. Responses from at least
one of these categories were included in almost all respondents’ answers. For many of
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the questions, healthcare workers were the least likely to use spiritual responses in
their answers.
Nine themes were identified in response to the questions of how to identify and
what causes mental illness: Psychocultural appropriateness, Religious/spiritual,
Social difficulty, Behavioral disturbance, Cognitive-emotional impairment, Disaster
and economic deprivation, Adaptive functioning, Substance abuse and Physical/
medical.

“ Psychocultural appropriateness: Many respondents discussed culturally in-

appropriate behaviors or social responses as prominent signs. These included
behaving outside of cultural boundaries, breaking taboos, lacking balance and
a negative attitude. Causes included: failing to achieve culturally expected
goals, having a moral or personality weakness and having too much
knowledge.
“ Religious/spiritual: Spiritual responses included possession by evil spirits or
demons, magic spells, Satan and lack of belief in God.
“ Social difficulty: This category included social discomfort, withdrawal and
conflict with family or community members. Loss of romantic relationship
and death of a loved one were cited by respondent as social causes of mental
illness.
“ Behavioral disturbance: In this category, participants listed bizarre, abnormal
behaviors, aggressiveness and angry outbursts.
“ Cognitive-emotional impairment: Participants said that incoherent thought
processes and impaired communication were significant cognitive-emotional
symptoms of mental illness, while excessive worry and negative emotions were
seen as causes.
“ Disaster/economic problems: Displacement, war, unemployment and poverty
were reported as causes of mental illness.
“ Adaptive functioning: Participants discussed difficulty adapting to different
environments and poor hygiene and personal care as symptomatic of mental
illness.
“ Substance abuse: Use of alcohol, marijuana or khat (a commonly used herbal
stimulant that is native to the region) was cited both as an indication and
cause of mental illness.
 International Journal of Culture and Mental Health 9

“ Physical/medical: Physical defects and somatic complaints were discussed as

symptoms and genetic or medical illnesses as causes.

Table 2 shows the most common responses to each question by occupational

category.

Most common and serious illnesses and preferred treatments

The most common mental illness cited was anxiety and the most serious was
madness. Respondents also listed loss of love, family problems, infectious diseases
(HIV, typhoid), epilepsy, blindness, psychiatric diagnoses (bipolar disorder and
schizophrenia), poverty, having too much knowledge, impaired thinking and
substance abuse in their answers. Preferred treatments included psychological
approaches (minimizing the problem, distraction with pleasurable activities), social
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Table 2. Most frequently cited response category for each question by occupational
classification.

Community member Healthcare worker Traditional healer

Question n 75 n 35 n 5

How would you describe Anxiety / Excessive Impairment in Bizarre / Abnormal

mental illness? thinking and thinking and behavior
worrying communication
How would you know if Bizarre / Abnormal Bizarre / Abnormal Bizarre / Abnormal
someone is mentally behavior behavior behavior
ill?
How would you know if Negative affect / Negative affect / Negative affect /
someone is depressed? Emotions Emotions Emotions
How would you know if Bizarre / Abnormal Negative affect / Bizarre / Abnormal
someone is anxious? behavior Emotions behavior
How would you know if Bizarre / Abnormal Bizarre / Abnormal Bizarre / Abnormal
someone is psychotic? behavior behavior behavior
What causes people to Loss of loved one / Loss of loved one / Loss of loved one /
become depressed? Death Death Death
What causes people to Excessive thinking Excessive thinking and Excessive thinking
become anxious? and worrying / Fear worrying / Fear and worrying / Fear
What causes people to Excessive thinking Excessive thinking and Excessive thinking
become psychotic? and worrying / Fear worrying / Fear and worrying / Fear
What is best way to deal Advise and Advise and counseling Traditional
with (treat) counseling / Social / Social support spiritual / Cultural
depression? support treatment
What is best way to deal Advise and Modern / Psychiatric Religious practice
with (treat) anxiety? counseling / Social treatment
support
What is best way to deal Modern / psychiatric Modern / Psychiatric Modern /
with (treat) psychosis? treatment treatment Psychiatric
treatment
What are the most Anxiety / Excessive Psychiatric illness
Madness / Bizarre
common mental worry and fear schizophrenia, mania and abnormal
illnesses in this behaviors
society?
What is the most severe Madness / Bizarre Psychiatric illness
Madness / Bizarre
mental illness a person and abnormal schizophrenia, mania and abnormal
can have? behaviors behaviors
 10 N.M. Monteiro and S. Kolawole Balogun

Table 3. Crosstabs
treatment preference by occupational classification.

Preferred modern Preferred traditional Preferred both types of

crosstab crosstab crosstab
n (%) n (%) n (%)

Community member 34 (45.9) 17 (23) 19 (25.7)

(n 74)
Healthcare worker 17 (48.6) 0 17 (48.6)
(n 35)
Traditional healer 1 (20) 1 (20) 3 (60)
(n 5)

support (spending time with family, counseling), modern medical treatment

(psychiatrist, medication, improve healthcare system) and spiritual methods (prayer,
holy water, religious rituals).
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Depression, anxiety and psychosis

The most frequent response for how to identify depression and anxiety was negative
emotions, while the most frequent answer for recognizing psychosis was bizarre or
unusual behavior. Loss of a loved one was the most common answer to the question
‘What causes depression?’, while excessive thinking and worrying were most
frequently cited as the cause for both anxiety and psychosis. Medical psychiatric
treatment was seen as the best treatment for psychosis, as opposed to advice and
social support for depression and anxiety.

Modern versus traditional treatment

The question ‘Where do you believe is the best place to get help with mental illness?’
was analyzed by itself. Responses were categorized as either endorsing modern
psychiatric treatment, traditional treatment or both. In all, 46% said that modern
treatment was best, 16% preferred traditional treatment and 33% said both.
Crosstabs were run to compare laypersons’, healthcare workers’ and traditional
healers’ responses to this question (Table 3).

Discussion
Participant responses emphasized: behavioral, cognitive and emotional disturbance;
impairment in basic functioning and personal care; social/relationship difficulties;
somatic symptoms and biological causes; behaving, thinking and interacting with
others in culturally inappropriate ways; religious, traditional/spiritual and super-
natural themes; and substance abuse. Many of the indicators cited by respondents are
consistent with previous findings, that disorganized behaviour and acting aggres-
sively, excessive worry, economic stress, family loss, medical problems and spiritual
battles are associated with mental illness (Alem et al., 1999; Mulatu, 1999; Patel,
1995; Ulman & Minas, 1977).
Participants responded that excessive thinking, worrying too much or obsessive
fear were either manifestations of or causes of mental illness. This illustrates a
 International Journal of Culture and Mental Health 11

culturally-specific understanding of anxiety neurosis. It is related to the Ethiopian

cultural notion of not doing something unless it has a purpose, meaning or end
goal
hence warnings against too much reading, too much knowledge and too much
thinking and worrying. The preferred treatment for this problem emphasized
cognitive strategies such as to take it easy, take things lightly and to not be too
serious.
Supernatural forces, particularly bad spirits, poisoning or the use of magic to
inflict harm, as well as religious difficulties, such as lack of belief in God and failure
to fulfil religious duties, were mentioned in a number of participants’ responses.
However, non-spiritual responses were often provided along with the supernatural
explanations, indicating that a simplistic model of Ethiopian perceptions of mental
illness being solely supernatural is not sufficient. This range of responses is related to
Mulatu’s (1999) notion of a broad sociocultural context that influences beliefs about
illness. The current findings underscore the significance of various biopsychosocial
determinants of perceptions about mental illness.
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To the question ‘Where is the best place to go for treatment?’ most people
responded that a combination of both modern and traditional treatments were
preferable. Very few people said that only traditional treatment (which includes
religious ceremonies, use of spiritual healers and herbalists) was best. This
corresponds to earlier research, where people said that traditional treatments were
best for spirit possession (Alem et al., 1999). In this study, not many people cited
spirit possession as the primary cause or feature of mental illness, therefore the lack
of preference for traditional treatments only makes sense given that few people
focused solely on spirit possession.
Modern psychiatric treatment is viewed positively as a treatment option. The fact
that such a large percentage of the respondents preferred both traditional and
modern treatment speaks to an integration and willingness to use all available
resources for healthcare (Alem et al., 1999) and that people aren’t opposed to non-
indigenous treatment. Ethiopians may not view the two treatments as mutually
exclusive and seem to willing to integrate these two paradigms. This idea is what
Slikkerveer (1990) refers to as plural medical systems.

Community member, healthcare worker and traditional healer differences

The results showed that there were similarities, as well as several differences,
observed in the responses of community members, healthcare workers and
traditional healers. Where there were differences, healthcare workers emphasized
cognitive/emotional and behavioral disturbances, while community members and
traditional healers focused on bizarre/abnormal behavior. Traditional healers
emphasized traditional/spiritual treatments, while the other two groups did not,
and instead emphasized social support. Finally, healthcare workers highlighted
modern psychiatric treatment and the diagnosis of psychiatric illnesses, and were the
least likely to use spiritual explanations in their responses.
These subtle differences in responses highlight the importance of collaboration
among health providers, traditional healers and patients. Healthcare workers’
emphasis on cognitive and emotional impairment, while other groups focused
more on observable abnormal behavior, indicate different expectations about the
importance of specific symptoms. There may also be subtle differences in meaning
and semantics. Healthcare workers have a specialized post-secondary education in
 12 N.M. Monteiro and S. Kolawole Balogun

which they are primarily trained in Western medical concepts, nosology and
treatment modalities, while traditional healers are immersed in cultural approaches.
Madu and Ohaeri (1989) talked about the importance of fostering increased
communication and acknowledging the similarities in methods used by modern
and traditional healers. Such communication would help to identify the beliefs and
practices effective and those that are harmful and under what circumstances.

Psychosis/neurosis
These results indicate that psychosis and neurosis are perceived by respondents as
being different, such that neurosis (depression and anxiety) is recognized more as a
socially or situationally-driven phenomenon and psychosis is recognized as a
condition where a person is completely out of touch with reality and out of
character. Another difference is that for treatment of depression healthcare workers
cited social support, but for treatment of anxiety they cited modern psychiatric
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treatment more often. This may be because they see anxiety as more serious or
disruptive than depression, or that depression is seen as a natural human experience
rather than a medical disease. Patel (1995) concluded that in most of the sub-Saharan
Africa studies he reviewed, psychotic, more than neurotic, disorders have the most
recognizable and agreed-upon symptoms.

Implications and limitations

The findings are important for health professionals and policy makers focused on
improving mental health care and infrastructure for the mentally ill in Ethiopia. Such
improvement should include knowledge of the population’s perceptions of mental
illness and understanding of how traditional beliefs inform their awareness of mental
illness. Social support, spiritual approaches and modern medical treatment were all
thought to be essential to effective treatment. This speaks to the necessity of any
future programs incorporating the family and the community into treatment plans. It
also highlights the importance of addressing the impact of the illness on the family as
well as individual patients.
These findings are useful for developing appropriate assessment and screening
measures. The culturally influenced concept that excessive thinking and worrying are
psychologically and emotionally unhealthy should be considered when developing
assessment tools. These findings can be used to help refine culturally appropriate
diagnostic and treatment protocols.
The fact that the research questionnaire had to be translated from English to
Amharic and the responses translated from Amharic to English is a significant
weakness of the study. The possibility of respondents’ perceiving the researcher as an
outsider is also a confounding variable. Some people’s answers may be reflective of
their self-consciousness of that fact, which could have influenced their answers.
However, it is hoped that this study, despite its limitations, will have contributed to the
understanding of mental illness in Ethiopia and encourage more research in this area.

Conclusion
The respondents’ understanding of mental illness and its causation and treatment is
quite nuanced. The most consistent finding is that people’s understanding is broad
 International Journal of Culture and Mental Health 13

enough to accommodate numerous, and what may seem like contradictory,

explanations for mental illness. Traditional beliefs and cultural values should be
seen as contributing valuable information about the perceptions and realities of
mental illness in Ethiopia. Other variables such as religion, ethnicity and geographic
region are significant and should be used in further explorations of mental illness in
Ethiopia.

Notes on contributors
Dr Nicole Monteiro is a clinical psychologist who has a diverse range of international clinical
and research experiences, including work in Bahrain, Liberia, Haiti, Grenada, Peru, Ethiopia
and Senegal. She is currently lecturing in the Department of Psychology at the University of
Botswana and serves as coordinator of the Department’s Psychology Clinic. Dr Monteiro’s
professional interests include cross-cultural research, global mental health policy, psycholo-
gical treatment of trauma, and psychotherapy with ethnic minority populations. She founded
CHAD
Center for Healing and Development, a global health research organization. Dr
Downloaded by [Nicole Monteiro] at 13:16 18 April 2013

Monteiro completed the Harvard Program for Refugee Trauma’s Global Mental Health
Master’s Certificate Program where she obtained in-depth training in research and policy work
with culturally diverse traumatized populations, refugee mental health and post-conflict
recovery.

Professor Shyngle K. Balogun graduated with BS (Hons) in Psychology in 1984 from the
University of Ibadan, Nigeria. After the Compulsory National Service for a year he went back
to the same university for his MSc (1986) and PhD (1991). Balogun, who joined the same
department as a Teaching Assistant in February 1988, specialises in Applied Experimental
Social Psychology. He became a full staff member in November 1988 as an Assistant Lecturer,
and rose through the ranks to become a full professor of Psychology in 2003. Balogun, who
was the Dean of the Faculty of the Social Sciences, University of Ibadan between 2010 and
2012, has published widely in applied social psychology, in local and international outlets. His
inaugural lecture, which he delivered in 2011, was titled ‘‘Dancing in the Social Jungle’’.
Balogun is currently on sabbatical leave with University of Botswana for the year 2013.

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