Clinical experience in answering questions about demonic
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
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.
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.
- The patient may not seek the traditional healing, if he/she
does not wish to do so on relatives' advice.
- The patient should not discontinue the biopsychological
treatment, even if instructed by the traditional healer to do
- 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.
- El-Islam, Some cultural aspects of the Arab patient-doctor
relationship, International Psychiatry, 2005
- Incawar et al, Psychiatrists and traditional healers unwitting
partners in global mental health, WPA Transcultural Psychiatry,
- Personal communication with Dr El-Islam, 2013
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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