Proofs - Personal Webspace for QMUL - Queen Mary, University of ...

categories was performed very carefully and the categories
were revised within the process of analysis through feedback
loops [24].
3. In a third step, we built “supercodes” by creating “families”
to reduce the material by grouping meaningful codes and
quotations into a single meaningful concept. This process was
accompanied by the use of the function “query tools” in the
ATLAS.ti programme.
4. Finally the programme ATLAS.ti lists the most meaningful
concepts, which can then be interpreted by the researcher.
To support this process, network analyses where built within
the programme ATLAS.ti to formulate theoretical models. The
network is defi ned by a set of nodes and links, which allows us
to specify the relationship between the codes and to present
a theoretical construct of our data at the end of the research
process (Handbook, Atlas.ti 5.0, 2010).
4. Results
The results consisting of 454 created codes and their relation
suggest that psychosocial factors like the break of taboos and
family confl icts are seen by patients and experts as playing an
important role in causing schizophrenia in Mali.
We noticed that:
1. The interviewed patients often assumed external causes
for their disease (like the “evil eye”). In all our interviews,
patients never blamed themselves (except in terms of an
occidental migration experience in the patient’s biography).
Experts suggested that the externalized explanatory models
appear to play an important role for the resilience of the
patients.
2. Psychopathologically, patients reported key symptoms of
schizophrenia [3] such as thought insertion and thought control
by jinn’s or witches, coenaesthesia and commanding voices, as
evidenced by the following patient interview: How would you
describe your problem/illness/disease?
“I just got here for a treatment reasons, because I have problems
with the family… regardless I am ill.”
“There are witches, they are in my stomach and my throat and
they are also in my whole body. … Someone of the family sent the
witches to destroy everything…they creep into my body and want
to eat me.”
“The witches are also in my organs and they control me and
my thoughts.”
“They control my connections with other people, with the people
I keep company with…When I intend to read a book, they try to
disturb me. Therefore I am reading very loud, thus they cannot
prevent me from reading.”
Furthermore, local concepts such as “Hakili bana” played an
important role in patients’explanatory models of their suffering;
this term denotes loosing one’s soul, mind, spirit and (control
of) thinking.
The interviews suggest that the company of a family member
during hospitalisation reduces aggression and stigmatisation and
increases the patient’s compliance. Also the reintegration process
of the patient after the psychiatric hospitalisation appears
to be facilitated.
F. Napo et al. / European Psychiatry 27 (2012) / supplement n°2 / S44-S49 S47
We observed that:
1) Patients and experts report that the expected and preferred
treatment includes modern medicine (psychotherapy,
medication, etc.) and utilisation of traditional treatment by
patients and families (plants, Koteba, etc.).
2) The Koteba, the traditional African theatre, plays an important
role in the struggle against stigmatisation. Here, typical
confl ict situations are enacted by patients in front of the whole
therapeutic village, i.e. other patients, their relatives and the
professionals. Patients and their social environment are thus
on the same level and no one can easily distinguish between
“illness” or “health”. The Koteba has a social function and supports
the resilience by reminding the patients of their integrity,
self- respect, importance for the community, responsibility for
others, etc. The Koteba breaks taboos and leads the individual
to concentrate on his ressources.
5. Discussion
Our study confi rms the eminent role of individually and
culturally infl uenced explanatory models on patients’ symptom
presentation, social interactions and expectations towards
therapy [4,21,25,30]. In spite of such cultural and religious
differences in the explanation of psychotic symptoms, patients
described “classical” fi rst rank symptoms of schizophrenia [35]
such as thought insertion, which they explained in terms of
local beliefs in witches or jinns (spirits). The Malian experts also
emphasized that in a Westernised psychiatric setting, psychiatric
professionals diagnose a symptom of schizophrenia (for example
when a person believes that he is able “to talk to the witches in
his body”), while West Africans can have alternative concepts of
the “self” or the”ego” infl uenced by cultural, ethnical norms and
traditions, which often include beliefs of magical interference.
However, if such local beliefs in spirits and witches exist, how
can experts distinguish between common beliefs and psychotic
symptoms? The experts as well as the patients’ relatives told us
that in this part of Africa, possession by evil spirits is supposed
to cause bad luck but not thought insertion or imperative voices.
Therefore, it is necessary to involve family and community
members in the diagnostic process, which helps to distinguish
between commonly shared beliefs and idiosyncratic explanations
of psychotic experiences. For example, family members of
one psychotic patients who experienced “thought insertion by
witches” clearly labelled his report as an unusual and alarming
experience, which indicates a state of illness. They emphasized
that this experience cannot be understood within traditional
concepts of spiritual interference, as spirit possession may cause
suffering and misfortune but not “insertion” of thoughts. These
considerations highlight the fact that the symbolisation and
language of the patients shape their presentation of symptoms
and the interpretation of these symptoms within diagnostic
contexts. The specifi c way how patients and relatives describe
psychic and somatised symptoms and syndromes thus play a
decisive role for a cultural sensitive diagnosis and can help to
reduce false diagnoses [12,7,24,25,21,33].
Professional treatment in Pont G actively involved family
members and public display of typical confl ict situations in the
Koteba theatre. Strengthening family bonds can thus counteract
Proofs
08_Napo.indd S47 14/06/2012 14:44:50