Becoming a Xhosa traditional healer : The calling , illness

The widespread use of traditional healers (THs) for the treatment of common mental disorders, especially amongst low-income groups, underscores the importance of exploring their self-identification, training and practices. In sub-Saharan Africa, belief systems that centre on supernatural aetiologies of mental illness are well established. These belief systems include explanatory models alluding to spiritual phenomena, spirit possession and mystical causes.1,2,3 These beliefs have implications for help-seeking and utilisation within the formal mental health sector. This has particular relevance for sub-Saharan Africa (comprising lowand middle-income countries) where mental health resources are scarce, the treatment gap approaches 80%, and there is a dire need to improve access to care.4,5 More recently, several studies focused on exploring pathways to care for persons with mental illness in sub-Saharan Africa; including the prominence of THs as the first point of contact.6,7,8,9 A better understanding of THs and their self-perceived roles as providers within their communities is warranted.


Introduction
The widespread use of traditional healers (THs) for the treatment of common mental disorders, especially amongst low-income groups, underscores the importance of exploring their self-identification, training and practices. In sub-Saharan Africa, belief systems that centre on supernatural aetiologies of mental illness are well established. These belief systems include explanatory models alluding to spiritual phenomena, spirit possession and mystical causes. 1,2,3 These beliefs have implications for help-seeking and utilisation within the formal mental health sector. This has particular relevance for sub-Saharan Africa (comprising low-and middle-income countries) where mental health resources are scarce, the treatment gap approaches 80%, and there is a dire need to improve access to care. 4,5 More recently, several studies focused on exploring pathways to care for persons with mental illness in sub-Saharan Africa; including the prominence of THs as the first point of contact. 6,7,8,9 A better understanding of THs and their self-perceived roles as providers within their communities is warranted.
Topical areas of research regarding the role of THs in mental healthcare provision include aspects of mental health, such as perceived illness severity, treatment practices and perceived outcomes of persons with mental illness who receive care from THs. 10,11,12,13 Additionally, the research focuses on knowledge and attitudes of THs towards established signs and symptoms of mental illness, quality of life and their effectiveness as healers. 14,15,16 In one study, about 60% of the patients seen by THs met criteria for a diagnosable mental illness, whilst over a third met the criteria for either moderate or severe levels of illness. 14 Furthermore, a recent quantitative review suggests that THs can provide effective psychosocial interventions by helping to relieve distress and improve mild symptoms in common mental disorders, such as depression and anxiety. 15 Additionally, a qualitative systematic review found traditional and faith healing for mental illness was perceived as effective. 17 Moreover, some authors explored collaborative partnerships between THs and formal mental health services and have found that these have been met with varying degrees of success. 18,19,20,21,22 Whilst the controversies, pitfalls and abusive practices (which occur within some TH settings) are recognised, the potential merits of working partnerships have also been documented and explored. 18,19,20,21,22 However, whilst a significant proportion of the population affected by mental illness in sub-Saharan Africa continue to seek help and are treated by THs, 6,7,8,9 a workable model of collaboration between medical health providers and THs remains elusive. 18,19,20,21,22 A systematic review indicated that a poor understanding between different healthcare providers (such as between physicians and nurse practitioners) of each other's educational training and background was a key barrier to effective collaboration. 23

Xhosa cultural context in South Africa
South Africa has approximately 8 million inhabitants of Xhosa descent and the Xhosa language is South Africa's second-most popular official language. 24 Traditional beliefs are common amongst the Xhosa and use of the traditional healthcare system is a regular and frequent occurrence. 25 However, the experience of accepting the calling -that is, being called by the ancestors to become a healer -and becoming a Xhosa TH, is not well studied. Literature from the 1970s describes the phenomenon of Thwasa/Intwaso, a state which has been defined as a 'crisis in living … [and a] creative illness', 26 as a first step to becoming a Xhosa TH. i, 30 This may present as a period of disintegration where the person no longer perceives him/herself as a whole and experiences some form of communication with his/her ancestors. Dreams and visions are often accompanied by diverse somatic symptoms. These symptoms can appear so extreme that western psychiatrists may interpret them as manifestations of psychotic illness. 31 However, the Xhosa see this as a gift: This is the disease of the Igqira which is in me. This type of disease, the thwasa disease, is a gift one receives from one's ancestors, one's grandfathers, whom one does not know but from which one has inherited one's surname. 30 Such phenomena are described at the beginning of the process of becoming a TH. 32 However, besides three studies from the 1970s and 1980s, 26,30,31 only one recent case description exists on these phenomena in the Xhosa culture. 32

Theoretical framework
Social constructionists believe that knowledge is connected to power relations which prescribes what people are allowed to do and know. 33 Thus, what we know and can do, for example in terms of mental illness, is prescribed by those in power. Feminist social constructionists and post-modern i. It should be noted that thwasa is not unique to the Xhosa culture but also occurs amongst other African ethnic groups, for example, Nguni, 27 Zulu 28 and Sotho 29 cultures.
feminists highlight the way in which knowledge, especially psychiatric knowledge, is derived from a western patriarchal society 34 which repeatedly asserts power over other societies. As such, knowledge which is different to the dominant construction is often not acknowledged 35 In much the same way, traditional healing of mental illness is often not acknowledged as valid by proponents of the biomedical paradigm. 36,37 This lack of acknowledgement pervades despite the evidence suggesting that THs can provide effective psychosocial interventions. 15,17 In this study, we include the perspectives of the other, the THs, in knowledge making. 38 Specifically, we use their understanding and experiences of accepting the calling and becoming a TH to generate knowledge.

Study aims
To our knowledge, the experience of the calling as an illness has not been explored amongst Xhosa THs in the Western Cape. To develop a workable model of collaboration in the future, it is crucial that mental health care providers develop a better understanding of the experiences of THs in becoming care providers. This study aims to explore the experience of becoming a TH, including accepting the calling, and sheds light on how the experience is conceptualised within the cultural and communitarian ii context of THs.

Participants
Four participants (Xhosa-speaking THs, born and raised in South Africa, and practicing as healers in the Western Cape province) were purposefully selected for more focused interviews from a sample of 50 participants (80% = female) iii who participated in a descriptive, quantitative study of the training and practices of THs. 39 During the aforementioned index study, it became evident that the healers were reluctant to share detailed descriptions of their experiences. We were interested in exploring this further and selected four participants who were willing to participate in this sub-study.

Interviews
In-depth qualitative interviews, lasting between 54 and 85 minutes, were conducted between July and September 2017 and audio recorded. To assist with the flow of the interviews, the interviewers used an interview schedule containing three open-ended questions: (1) Describe how you knew you had to become a healer; (2) Describe the process and your experience of becoming a healer and (3) Describe the work ii.Communitarianism is the philosophy that a person's (in this case the TH's) social identity and personality are largely moulded by community relationships, with less development being placed on individualism. This is in line with collectivistic 40 and Ubuntu culture of the Xhosa people. 41 iii.Fifty (N = 50) IsiXhosa THs, aged 21 and older, born and raised in South Africa and practicing as THs, were purposefully recruited using snowball sampling. Two members of the research team, who are also members of the Xhosa community from which participants were recruited, discussed the study with the THs and invited them to participate in the study. Participants were encouraged to refer other interested THs to the study.
that you do as a healer from the first time a client comes to see you. The questions were specifically broad and open-ended so that the participants had sufficient opportunity to extensively express their view point. 42 In addition to the interview schedule, interviewers prepared for the interviews by reading through the case files from the index study of these four participants. iv This provided context for the interviewers and an opportunity for interviewers to prepare any additional, specific questions (e.g. if a participant mentioned a specific dream during the index study they had about becoming a healer, this could be elaborated on in the in-depth qualitative interview). Probing questions were used where more detail and richness were required regarding participants' experience of becoming THs. Thus, we first obtained a description of the experience, followed by probing questions to elicit the meaning and more detail of what was described. 43 Two interviews were conducted in Xhosa by a clinical psychologist at her office at a government hospital and two interviews were conducted by the first author (a research assistant), in English, at the participants' local church. Xhosa interviews were translated and transcribed by a professional language, translation and copywriting services company. English interviews were transcribed by an MSc student and checked by the first author for accuracy.

Data analysis
Data were analysed using Giorgi's descriptive pretranscendental Husserlian phenomenological analysis 44 research method. Phenomenology develops a deeper understanding of subjective human experiences (Rose 1990 as cited in Van der Watt 45 ) whilst the pre-transcendental Husserlian research aims to scientifically study consciousness. 46 As a combination, Giorgi's descriptive pre-transcendental Husserlian phenomenological analysis method holds that psychological realities can only be understood through rigorous procedures that are rooted in phenomenological philosophy. 47 Thus, we processed and analysed individual THs' experiences with the final goal of distilling a psychological experience that is common to all 46 the participants. This process can be grouped into six steps: (1) grasping a sense of the whole and the context of each interview; (2) extracting units of meaning; (3) clustering of units of meaning to form units of significance; (4) summarising each interview; (5) combining all the interviews into a coherent whole and (6) providing a synopsis of research findings. Through this process, a collective experience of the phenomena 44 of accepting the calling and becoming a TH was derived.

Ethical consideration
Ethical approval was obtained from the Chicago School of Professional Psychology (IRB16-01-0056) and Stellenbosch iv.This file contained four sections: (1) demographic information; (2) becoming a healer (e.g. when they started training, who trained them, how long they trained, how they knew they had to become healers and so forth; 39 (3) traditional healing as occupation and (4) client and diagnoses/treatment information.
University (N/16/05/059). Prior to data collection, participants provided informed consent. All files with identifiable information were password protected and kept in a locked office. Participants were reasonably compensated for their time and expenses. 65

Results and discussion
Three units of significance emerged from the data: (1) the gift of healing as an illness; (2) the experience of conflict and (3) the experience of belonging. The results (using Xhosa pseudonyms: Nombeko, Nolindo, Nosimo and Ntando) and discussion are presented concurrently.

Case descriptions
Four female participants consented to the in-depth phenomenological interviews. Male participants were not intentionally excluded. However, the participants in the index study were predominantly female (80%) which likely contributed to why all four participants in the current study were female. We present a case description of each participant.
Her highest formal education level is Grade 10. She attends the Methodist church and says her religious orientation did not change when she became a TH. Her paternal grandmother practices as a TH. Nombeko knew she received the calling when she was 17 years old. She started her training at the age of 21 and started to work as a TH when she was 46 years old. Nombeko self-identifies as a traditional doctor and treats mental and physical illnesses. She states that God reveals to her what is wrong with her clients (mode of diagnosis). She mainly uses prayer, herbs and sacrificing animals to treat clients.
Her highest formal education level is Grade 6. She attends the Old Apostolic church and says her religious orientation did not change when she became a TH. Her grandmother used to practice as a TH but has since passed. Nolindo knew she received the calling when she was 23 years old. She is not sure how old she was when her training started, but she estimates she was around 40 years old. She reckons that she trained for 5 years before she started to work as a TH. Nolindo self-identifies as a sangoma and says she only treats physical illnesses. She states that she 'just knows' what is wrong with a client, or that the ancestors will reveal the diagnosis to her. She mainly uses candles, herbs, incantations and sacrificing animals to treat clients.
Her highest formal education level is a diploma in Travelling and Tourism. She used to attend the Anglican Church but changed to the New Apostolic church after she received the calling. Both her parents practice as THs. She continued to explain how she was: '[V]ery sick as a child I used to have a stomach ache. I used to get very sick and have cramps and even bend. In the long run I suffered from headaches.' v.Hospital medicine was interpreted as any medication (e.g. Disprin, Panado) which may be prescribed by a medical doctor. Thus, the healer will tell the client to go and buy Panado, for example. Some would also write a script that the client can take with them to the hospital or pharmacy to obtain hospital medication (unpublished data).
Her illness continued to become worse, because: 'I was not even wearing beads. I was still young then and when I wear the beads the other kids will make fun of me, so I decided not to wear them. I became very sick…' From the above, it is evident that receiving and accepting the calling is experienced individually and that it manifests in a variety of ways, including that of a perceptual phenomenon such as hearing voices. In a western medical paradigm, such phenomena may be considered as a psychotic symptom (e.g. hallucination). However, describing the experience of receiving and accepting the calling to become a TH as an illness does not take into account the understanding of THs and their experiences. As such, we might postulate that the experience of receiving the calling might be better understood not in terms of an illness, but in terms of a developmental crisis. As part of development, a succession of differentiated phases of http://www.sajpsychiatry.org Open Access transitional periods are characterised by cognitive and affective changes which form an integral part of growth. 48,49,50 This provides opportunities for the development of healthy adaptive reactions. 50 Accordingly, in the first stage of this process, the calling might be negatively experienced as it alters individual homeostasis, creating the need for a transition. However, as indicated in previous research, 51 whilst the individual makes this transition, the process of accepting the calling and becoming a healer brings healing. Mlisa (2020) describes this as constructing healing identities that are created and manifested in different socio-cultural, physical and spiritually-abundant sacred spaces travelled by an initiate. 52 This finding highlights the importance of obtaining a better understanding of the training process of THs. Receiving the calling and answering it is culturally, and often socially, deemed more acceptable than being diagnosed with a mental illness. Indeed, mental illness is often stigmatised in many African cultures. 53,54,55 It is possible that people with psychiatric symptoms because of mental illness would rather approach THs in the hope that these symptoms are a sign of receiving the calling. Thus, it may be beneficial for biomedical care providers to collaborate with THs to provide them with the necessary resources and knowledge to recognise some trainees with mental illness who could benefit from biomedical treatment.

The experience of conflict
Participants described becoming a healer as a 'lengthy and tedious passage' (Nolindo) which often resulted in familial conflict and conflict with the church. In turn, this generated self-conflict and confusion.

Familial conflict
Participants described experiencing conflict with their families for various reasons linked to being, or becoming, THs. For example, Ntando explained how her grandmother was the 'only person who could understand me', whilst the rest of her family 'never wanted anything to do with this thing [the calling] because in their [family] mind they were thinking of their money….' Indeed, as was indicated by participants of the index study, becoming a TH can be a very expensive undertaking, considering the various animals (including chickens, goats and oxen) which must be purchased for specific rituals. 39 Additionally, it is a lengthy procedure during which time trainees do not receive remuneration. In a country with an unemployment rate of 29.8%, and 41.2% amongst black women, 24 it is not surprising that the expensive and lengthy process of becoming a TH can lead to familial conflict.
In addition to the financial strain, a lack of understanding caused familial conflict. For example, Nosimo explained that her family did not understand her illness and perceived her as simply being 'silly': Participants' experiences of the lack of understanding from their families about their situation resonate with the experiences of many individuals with mental illness who feel misunderstood by their families. 46,47 The excerpts above also suggest that participants wanted their families to understand them and to resolve the conflict. It might be beneficial for family members of TH-trainees to receive culturally appropriate psychoeducation when they exhibit abnormal behaviour, whether this is interpreted as a mental illness, or the receipt of the calling to become a TH. Familial support 56,57 is important and prolonged familial conflict may have negative consequences. 52,53 Alleviating the burdens that contribute to familial conflict might be important for improving the quality of life of THs and their families.

Conflict with the church
Some of the familial conflicts appeared to be related to the church that the family was attending. For example, Nosimo explained: 'We grew up as church goers so my mother does not like healers. When asked why it took her so long to seek help from a healer for her illness and to accept the calling, Ntando simply answered: 'Because I was a church-goer…' However, Ntando, who was very close to her grandmother who was also a TH, had since decided: Indeed, despite their experienced rejection from the church, participants appeared to continuously integrate worshipping ancestors and God, or working as healers for God. For example, Nosimo explained: 'Because I always beg the ancestors and God so that [pause] I mix them all, that's the way I work, I mix religion and the ancestors because to me they go along together. … that day [at church] was a ministry day and they did not like the fact that I'm a healer, they were against it. But I told myself I did not come to any of the pastors I'm only here for God. … I will never get rid of my ancestors, it's either I come to church or I stay home that's it. I love religion, I love going to church … there is no need for me to struggle if God is with me because he has been there all the time. And [I] also trust my ancestors because they helped me when I was sick and unable to walk, now I'm able to walk because of them.' Even though she appeared unsure, Nombeko believed the ancestors were sent by God: 'I don't know if I am fooling myself but I think I am not fooling myself telling myself the truth, God, the God will send them [ancestors] sometimes will send my uh, uh, uh ancestors to come and save me.' From the above, it is clear that the relationship between religious beliefs and traditional beliefs is a complex and conflicting issue for participants, with no simple explanation. In South Africa, belonging to a Christian church does not necessarily imply a break from traditional beliefs, 58 especially if one is part of an African Independent church. 59 Indeed, faith healers are embedded within these churches and are seen as 'outstanding persons with clairvoyant and healing powers, operating from within African church[es].' 58 However, different types of African Independent Churches exist and differ in terms of their following of the 'so-called mainline churches, founded and influenced by missionary colonialism.' 60 Consequently, some churchgoers, such as the families of participants, may still adhere to colonialist religious views of THs as going against the church's beliefs and dogma, consequently resulting in conflict.

Self-conflict and confusion
Participants described receiving the calling to become a TH as sometimes being in conflict with who they are or who they want to be. The internal conflict, struggle and confusion experienced by participants were evident. This emphasises the difficulty of receiving the calling and becoming a TH. Previous literature also notes experiences of confusion and sometimes denial when receiving the calling. 52 This highlights the importance of trainees (and their families) receiving culturally appropriate support throughout the process.
Nosimo's reference to the gender aspect of becoming a TH is interesting, especially if you take into consideration that receiving the calling is often deemed a 'woman's gift'. 52 Indeed, men undergoing the training often use women's dresses even during ritual performances. 52 Additionally, a study amongst Zulu THs found that female THs have attributes that outclassed their male counterparts 61 and that female THs are at the pinnacle of the hierarchy of Zulu THs. 62 Further research is needed to understand gender norms and roles associated with THs, especially amongst the Xhosa population.

The experience of belonging
Lastly, becoming a TH also meant that participants found a place of belonging. For example, Ntando explained: 'Oh like when I grew up uh I wasn't a, I was a different child to the others, not in the way I was like disabled but I was a different child um people whom they never liked me so much like the other children and even at the home because we have, we were a lot because the aunts and uncles were, everybody was staying at the same house …so it was difficult because I couldn't get everything that I want like the other children every time if they, they, they buy things for the other children but mine [emphasis] …they loved me less than the others …Like now it, I say it was better because I am what I am today because, because at the time I thought they ill-treat me but now I can see they were putting me like for the world …people are respecting me.' Becoming a TH also helped Nolindo to reconnect with her estranged father: ' Furthermore, participants referred to their trainers as 'mother'. It is possible that this sense of belonging contributes to the healing effects of TH training. This sense of belonging can also be linked to the lucrative and respected role in society that THs have. 51

Limitations
The present study is not without limitations. Firstly, whilst the sample size is small and limits generalisability, Giorgi cautions that 'research based upon depth strategies should not be confused with research based upon sampling strategies' 44 and as such does not stipulate the number of participants to be recruited for in-depth phenomenological interviews. However, Giorgi does recommend the inclusion of at least three participants. 45 Additionally, generalisability was not the main purpose of the present study; rather it was exploratory and based on gaining more insight into what it means to become and to be a Xhosa TH. The goal was to derive formative data that could facilitate a larger future study. Thus, for the purpose of descriptive phenomenological research, the current sample size was deemed adequate. However, future research with a larger sample size is likely to improve the depth, richness and generalisability of the present findings.
Secondly, whilst a professional language, translation and copywriting company translated the Xhosa interviews, the interviews were not back-translated for accuracy because of limited financial resources. Additionally, even though two participants indicated that they were comfortable with conducting the in-depth interviews in English, it was not their first language. This may have influenced participants' ability to accurately describe their feelings and experiences.
Lastly, even though an attempt was made to create a power-neutral interview environment, the powerimbalance between interviewer and interviewee cannot be underestimated. As such, the researchers employed reflexivity in order to avoid prejudice, bias and domination of their own personal ideas, 63 partly through bracketing. 44,64 Through bracketing, we brought our own preconceived ideas and perceptions of THs to the foreground to distinguish them from the information provided by the participants. Nonetheless, we recommend that future in-depth interviews be conducted by demographically matched interviewers in a neutral setting.

Conclusion
This study explored the experience of receiving the calling to become a TH and sheds light on how the experience is conceptualised within the cultural and communitarian context of THs. The current findings highlight the importance of obtaining a better understanding of the training process to become THs. Receiving the calling may manifest as a psychiatric illness, 51 or it can be understood in terms of a developmental crisis. Accepting the calling and becoming a TH entails conflict; yet it is also a socio-cultural, physical and spiritual journey resulting in a healing identity 52 and a place to belong. More longitudinal and in-depth phenomenological research is needed to better understand the process from receiving the calling to becoming a skilled TH, especially amongst Xhosa THs. It is important to learn how a TH differentiates between clients that have received the calling versus those who possibly have a mental illness.
It may be beneficial for medical providers to collaborate with THs and their trainees. There is evidence for the importance of familial support 56,57 and the negative effects of prolonged familial conflict. 52,53 Alleviating the burdens that contribute to familial conflict might be important for improving the quality of life of THs and their families. This is underscored by the findings of this study and the relevance of culturally appropriate psychoeducation for the family members of TH trainees, and for the TH trainees themselves. Such culturally appropriate psychoeducation serves the purpose of alleviating both conflict within families, as well as internal struggles and self-conflict experienced by TH trainees. Such training may also result in improved support from family members to TH trainees throughout the difficult process of becoming THs. Research is needed on gender norms and the complex relationship between religious and traditional beliefs to develop culturally appropriate psychoeducation programmes.