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The Royal College of Psychiatrists Improving the lives of people with mental illness

Questions about demonic possession

Clinical experience in answering questions about demonic possession

In daily practice in psychiatry in Egypt, various forms of mental illness are commonly attributed to magic spells or demonic possession. These illnesses are usually manifested by overt motor behavioural disturbances. Top of the list of these disorders are epilepsy and schizophrenia. Unusual ideas and actions found mythical explanations in witchcraft and demonic aetiology by patients and relatives in this traditional community. Symptoms that are typical of obsessions are intrusive, unacceptable thoughts which many patients attribute to a demonic agent known as the devil. It's not uncommon for patients and carers to enquire whether this is due to demons or supernatural agents known as jinn. The psychiatrist tries to find culturally acceptable answers to patients' questions about demonic and jinn possession. The basic essence in answering this questions can be summarised as doctors can adopt an empathic subjective (emic) approach to understand supernatural beliefs and attitudes within this culturally shared context (1).

It is recommended to ask explicitly in the drug and treatment history about non-medical interventions such as therapy offered by a traditional/religious healer, as some patients or relatives may not volunteer this information on their own. One cannot tell for sure why, but some relatives expressed their embarrassment from the experience, especially that some rituals may include physical harm, animal sacrifice, or an emotionally charged ceremony known as 'Zaar'. Others assume the doctor may be critical of such notions. Some think it is not relevant to the psychiatrist. Conversely, some patients are referred from traditional healers who confirm that what they suffer is mental illness.
 
When the patient or the carers ask about whether their illness is caused by demonic or jinn possession, some doctors may answer that the clinical picture presented is a usual or typical presentation of mental illness, implicitly ruling out the supernatural explanation, and explicitly stating the role of biopsychosocial treatments in managing the condition. Restating the symptoms as psychiatric syndromes offers the medical point of view. Avoiding plain Yes or No answers may be a culturally sensitive choice to avoid implicit notions that the doctor claims knowledge about the supernatural which is beyond the scope of medical practice. Some doctors may explicitly express the medical limits of their role. Aal-e Yassin,1995 (2) found that patients who adhered to their religious code seemed to benefit more from religious therapy (e.g. obsessional disorder). He further stated that patients may seem to possess 'religious receptors' which accept religious advice by others. Some psychiatrists would state that illnesses have precipitating factors that could be either as natural as bereavement or divorce, or supernatural as demons or jinn.

Fig 1

El-Islam offered the following framework to answer these questions (Figure 1). Some people believe that supernatural precipitating factors could evoke the biochemical mechanisms involved in symptoms formation e.g. neurotransmitter and transporter mechanisms. It is through these mechanisms that biomedical treatments act irrespective of the nature of the precipitating factors. The effect is the stirring up of the chemical imbalance that may have caused the mental health problem. Many relatives of patients who have psychiatric treatment would like to negotiate the option of traditional healing in order to deal with their demono-dynamics. Approval of involving a traditional healer may be sought from the clinician. El-Islam (3), proposed that three conditions should be fulfilled explicitly by the patient in order to have traditional healing.

  1. The patient may not seek the traditional healing, if he/she does not wish to do so on relatives' advice.
  2. The patient should not discontinue the biopsychological treatment, even if instructed by the traditional healer to do so.
  3. The patient should not let anybody harm him/her physically or by use of herbs. Some herbs are poisonous, or may not work well with medication.

Alternatively, recitation of religious verses can be done by the patient for himself/herself as 'autoreligious therapy' i.e. self-help. Occasionally, a direct question to the doctor tries to find out whether the treating doctor shared their belief in demonic or jinn possession. It may be helpful to say 'I've never encountered something like that'. A direct answer about personal privacy of the clinician may be perceived as 'offensive' by the patient. Equally, collusion with the patient and relatives' cultural explanation may trigger role confusion. Some patients who attribute their illness to supernatural forces expressed their scepticism that natural elements as medication can offer a cure, however, they expressed that it helped them to become calmer.

Despite the diversity of the explanatory models to mental health problems, phenomenological description, empathic reflection, respect of cultural beliefs and genuine attitude of care from the clinician's side seem to help bridging or even aborting an anticipated clash of explanatory paradigms.

When I started practising psychiatry these questions seemed quite awkward to answer especially, I could not find ready made answers about this in handbooks of psychiatry and textbooks seemed to provide a comprehensive overview about culture-bound syndromes, that I could not directly translate to daily clinical work. I tried asking senior doctors and I found an array of different answers. I tried to present the answers that seemed more comprehensive. During this journey of understanding, I learned that the role of the doctor is basically to help people get better with their illness.  Maintaining the focus may be hard as there is the temptation to wonder about cultural beliefs and even a frank invitation to offer answers. I learned that it is best to resist the temptation to advocate a certain explanatory model of mental illness, collude or collide with cultural beliefs.

References

  1. El-Islam, Some cultural aspects of the Arab patient-doctor relationship, International Psychiatry, 2005
  2. Incawar et al, Psychiatrists and traditional healers unwitting partners in global mental health, WPA Transcultural Psychiatry, Wiley-Blackwell 2009
  3. Personal communication with Dr El-Islam, 2013

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Comments

Really very nice article, Dr Emad. 

It strikes a very sensitive point in our practice . It is a usual dilemma to find a suitable ,culturally sensitive , method to explain to our patients what is behind their suffering . Also , Prof. Dr Y.T .Elrakhawy has a very nice contribution to this issue , we can discuss later.
Again , thanks for your nice article.

 

Dr Mohamed Elshazly

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Dr Emad Sidhom

 

Dr Emad Sidhom, is a psychiatrist working in an old age psychiatry department in a private hospital in Cairo, Egypt. He is board certified by the Arab Board of Psychiatry.