Spirituality has been regarded as central to sense making for many people living with disabilities (Claasens, Shaikh, & Swartz, 2018). Viewed as an umbrella concept under which one finds religion, spirituality may be defined as faith in the "sacred" and finding a personal relationship with God or a supreme power…whereas religion can denote a state of adherence to specific institutional beliefs and practices (Sango & Forrester-Jones, 2018).
Recently, several studies have shown the importance of spirituality in mental health care and interventions (Garssen et al., 2020). The role of personal and communal spiritual connection has been shown to support well-being and recovery for people with lived experiences of psychosocial disability (Rosmarin & Koenig, 2020). A challenge for the study of spirituality in relation to disability, including psychosocial disability, is understanding the role of spirituality in mental health care and other forms of support. This is partly because the literature, as with other fields, is dominated by research conducted in wealthy countries in the Global North (Meekosha, 2011; Nguyen, 2018). The vast majority of people with disabilities live in low and middle-income countries, many of them in contexts in which beliefs and practices do not necessarily accord with those in wealthier contexts (WHO & World Bank, 2011).
As African scholars working in Africa, we use case material in this article to demonstrate the importance of including an African Indigenous worldview for understanding disability issues. In line with discursive practices in other fields, there has been a dominance of Western discourses often at the expense of Indigenous knowledges and the experiences of African people. Consequently, mainstream theorization is formulated, constructed, and developed outside of the frame of reference of Indigenous African people.
To contribute to the discourse about Indigenous notions of disability, we will reflect on experiences of conducting research with Indigenous communities in two regions in Africa – Ghana, in West Africa, and South Africa in Southern Africa. The reflections are drawn from two authors' doctoral studies and highlight the intersection of spirituality and psychosocial disability as theorized within specific African Indigenous worldviews and belief systems. We discuss pertinent components of these worldviews by delineating commonalities and differences in the two contexts.
We acknowledge that use and understanding of the term "Indigenous" remains contested (Peters & Mika, 2017) and we recognise the multiple ways in which this term can be applied. The United Nations (UN, 2002:2) states that:
Indigenous peoples are the holders of unique languages, knowledge systems and beliefs and possess invaluable knowledge of practices for the sustainable management of natural resources. They have a special relation to and use of their traditional land. Their ancestral land has a fundamental importance for their collective physical and cultural survival as peoples. Indigenous peoples hold their own diverse concepts of development, based on their traditional values, visions, needs and priorities.
However, it is worth noting that there are significant differences in Indigenous peoples' circumstances in various parts of the world, as shaped by varying degrees of dispossession, different health and education experiences, and diverse political relationships (Kunitz, 1994). For purposes of this paper, we are guided by, and draw from Indigenous scholars such as Semali & Kincheloe (1999) and Smith (1999) who speak about Indigenous people "within the context of people's colonial relations with European conquerors and modern attempts at economic, political and cultural restructuring" (Smith, 1999:7). We speak about a dynamic construct that includes networks of people who have been subjected to colonisation of their lands and cultures (Smith 1999), thus leading to their cultural identities being shaped and reshaped by colonisation (Semali & Kincheloe, 1999). This colonisation of lands and cultures has prevented Indigenous people from living according to their own practices. Work by Ohajunwa (2019) with a focus on expressions of spirituality and health and Ned (2019) with a focus on education and health clearly provide evidence of such daily struggles of hegemony. However, Smith (1999) also notes that neither colonisation nor socio-economic disadvantage is the most defining element of Indigeneity. Rather, as Durie (2004) writes, the most significant characteristic for defining indigeneity stems from the strong sense of unity with the environment.
Acknowledging our positionality
The narratives presented here are based on research undertaken as part of doctoral studies for two authors, Lily Kpobi and Chioma Ohajunwa.
Lily Kpobi is a Ghanaian who worked as a clinical psychologist for several years in a teaching hospital in Ghana's capital, Accra. Her training has been in Western psychological approaches. Through clinical work experiences over the years, she recognized the pluralistic approach to help-seeking that several service users applied. It was not uncommon to hear of clients seeking simultaneous or consecutive help from other non-clinical practitioners (such as Indigenous healers, neo-prophetic pastors, or traditional herbalists). Such experiences led Lily, through her doctoral studies, to examine the beliefs and methods of Indigenous and faith healers in Ghana, with an emphasis on understanding the cultural value of Indigenous approaches to mental health and wellbeing.
Chioma Ohajunwa is originally from Nigeria but undertook her doctoral studies in South Africa. She is trained as a special educator, and has practiced in Nigeria, Liberia, and South Africa, exposing her to the different perceptions of disability within these contexts. One commonality she experienced within these contexts is the medico-spiritual plurality that exists as related to wellbeing. Working in Nigeria and South Africa, the author observed that whenever people encounter health challenges, especially issues of mental wellbeing, they go home to their families to identify the cause and seek interventions. The collective, communal spiritual belief systems (Indigenous or otherwise) often inform the interpretation given to mental illness and interventions sought. This informed her interest to study spirituality and its influence on physical and mental wellbeing within the South African context.
Lieketseng Ned is a South African occupational therapist who specialized in disability studies and health sciences rehabilitation for her postgraduate studies. She undertook her doctoral studies (as did Chioma) with AmaBomvane in the Eastern Cape province of South Africa, focusing on the link between health and education from an Indigenous lens. A common issue she shares with AmaBomvane is the disconnect, conflict, and tensions often experienced as a result of power relations that have been instituted within colonial practices of education and health. This informed her doctoral research and current post-doctoral work.
In the sections below, we discuss notions of mental health and wellbeing through narratives from Indigenous leaders (which includes church leaders, such as pastors, priests, bishops, Apostles, and community knowledge holders, such as the headmen and chiefs), as well as Western medical practitioners from Madwaleni, a rural South African community in the Eastern Cape Province. We also include insights from Indigenous healers from the Greater Accra Region in Ghana. The context of the South African study is a rural community called Madwaleni, in Mbhashe municipality, which has a population of about 277,251, in the Eastern Cape Province of South Africa. The people are part of the Nguni group that speaks isiXhosa, which is a Bantu language. The people considered Indigenous to this location are known as AmaBomvane. The Greater Accra region, while geographically small, has a highly diverse population due to in-migration of people from other parts of the country to the capital, Accra. The people considered Indigenous to this region are the Ga people, who make up approximately ten percent of the region's population.
The Imbalance of Psychosocial Disability
In our research, South African and Ghanaian leaders emphasized balance as an important indicator of wellbeing. In the Ghanaian context (as is likely the case in other Indigenous African communities), spirituality forms a central part of social relations and this is reflected in approaches to care and support. Although interventions such as biopsychosocial therapy could include helping clients to recognize and harness spiritual strengths that were important to them, Indigenous ideas of wellbeing emphasized the importance of looking beyond enhancing personal spiritual wellbeing to include a return to a balanced spiritual life. Therefore, they saw mental health issues as a disruption in spiritual and communal balance.
Persons living with psychosocial disabilities (and often their families) typically sought to restore balance to their sense of spiritual connectedness with their social networks—a balance they reportedly found from Indigenous healing processes. Indigenous healing processes center on interconnectedness through enhanced compatibility with others, with the spiritual world, and with the social structure. Thus, Indigenous health interventions often encompass not only individual care, but also activities aimed at restoring social and spiritual balance.
The Necessity of Mental Health as Holistic
It was also evident that mental health was constructed as necessarily holistic in nature. While this is a growing understanding in the Western biomedical perspective, Indigenous interventions necessitate the inclusion of physiological, spiritual, and social factors in treatment approaches. According to the Ghanaian Indigenous healers for example, ill-health is considered a disruption of the physical, spiritual, and social worlds. To repair this disruption, all domains of the person must be addressed. In that sense, Western biomedicine alone cannot achieve this. As explained by one diviner: "…what I have noticed is that your methods only take care of the symptoms; you do not connect with the spiritual side of the person… if you don't take care of the person's spirit, they will never be well" (Indigenous healer, Ghana). The notion of spirituality for Indigenous healers is therefore not simply an asset which may aid recovery in mental health, but a core factor which clients and caregivers seek to enhance in order to achieve wellbeing.
Indigenous healers in South Africa (Sangoma) agree with this understanding of mental health and wellbeing as holistic. One Indigenous healer discussed the relevance of using holistic approach to address mental illness:
"there are sicknesses that they don't know and are suitable for Sangomas and traditional healers. There are things called amanxeba or amadliwo eenyoka, they don't know them, only Sangomas do. For example, a person gets mad they give him tablets and inject him and he gets better. After that injection, they wake up and go very mad again"(Indigenous healer, South Africa).
Another Bomvane 2 Indigenous knowledge holder in South Africa affirmed this further by stating, "No the medicines work in two ways, there is something in a human that will need a Xhosa medicine and there is also that will need the English medicine. One can get sick and be cured with a Xhosa herb, or one can get sick and be cured by the medicine from [hospital] doctors. It is like that."(Indigenous Elder and Knowledge holder, South Africa)
Healing and Social Interconnectedness within Mental Illness
Within ideas of personhood among Indigenous communities in Ghana is the central belief that all people are spiritually connected through their bloodline. From the day of birth, a person is viewed to be connected through unifying social networks, ancestrally as well as in the present. As a result, ill-health (including psychosocial disability) is often viewed as an imbalance in some aspect of the person's life that affects all others with whom they are spiritually connected.
Health and illness therefore function as a means of identifying threats to the spiritual wellbeing of the social group. As one healer explained:
"…you know that everything we do has a spiritual [component]; because your human body is not only about what you can see… so we have to make sure that whatever is wrong spiritually is solved… if we don't look at every side of the matter, the person will not be well and then the whole family suffers" (Indigenous healer, Ghana).
It was therefore common for Indigenous interventions to be structured around activities which are targeted at making restitution for perceived social slights or confessions of wrongdoing which needed to be righted.
Similar to the Ghanaian context, in the South African context, a balanced spiritual relationship (Ukulungisa) is a foundational concept within the understanding of wellbeing. This spiritual connection is maintained through Indigenous healing ceremonies that are performed throughout the life cycle of a person. One of the male community leaders referred to the importance of ensuring that the right spirit occupies a person's mind:
"First of all, take note, now I say the right spirit should control you first and your understanding, your mind and sense should understand that this is the right spirit to control my wellbeing" (Church leader, South Africa: 2017).
When we draw from both the Ghanaian and AmaBomvane healers' knowledges asserted above, we begin to see what Indigenous practitioners bring to healthcare practice. The Indigenous practitioner does not approach the individual as an isolated entity but rather as rooted within relationships that can be impacted by actions taken by the individual, or others around them. Indigenous health seekers and Indigenous caregivers also understand the interconnectedness of their actions and approach interventions with this social lens. In many ways, the narrow, individually-focused approach is arguably more typical of western practice. Further, within former colonialized contexts, Western medicine and their related practices have tended to be ordered and classified as superior, at the expense of Indigenous medicines and related practices.
Mental illness is often considered to be one of the most prominent signs that reflect the ancestral calling to start the process to become a traditional healer (Ukuthwasa) within the Indigenous South African context. Traditional healers assert that human beings possess both biological and spiritual DNA, which is a person's identity. An alignment between this identity is important for mental health and wellbeing. Ithwasa (an initiate in the process of Ukuthwasa) with mental illness will be shown in a dream which Sangoma to approach for healing and training, and to make restitution on their behalf as they are becoming a Sangoma in their own right. Many of the healing ceremonies linked to this process are performed as a collective, with the family and community involved, because of their shared spiritual relationship and characteristically employ music and dance. As one Sangoma said:
"We also do Intlombe (Ceremonial dance) for our well-being, we sing and dance in the name of well-being, I will invite all the Sangomas in the community to come and support me; when making requests from my ancestors we sing, dance and clap hands." (Traditional healer, South Africa).
While Western medicine places less emphasis on dance and music as part of treatment (with only a latent and uneven recognition of music therapy), Indigenous ways of healing encompass an assortment of care practices from herbs to cover the medicinal aspect of illness to song and dance to cover the spiritual and physical aspects.
These are examples of how mental wellbeing is perceived within African Indigenous healing. Generally, in both Ghana and South Africa, although the individual is acknowledged at a personal and biological level, healing is located within the social and spiritual level done by and for the collective. Both contexts reflect the importance of balanced spiritual relationships as vital to wellbeing. Therefore, a key difference to the approach of mental health between Western biomedical and Indigenous views of wellbeing is that Western biomedical practitioners aim to heal the body and expect total healing, while African Indigenous healers believe in healing the spirit for the body and mind to get healed. What is evident is that subscribing to all knowledge systems with their embedded healing paradigms may be a way of providing a complementary system of a plural mental healthcare that offers users authentic holistic and comprehensive care. This requires that we reimagine a system that acknowledges limitations of each knowledge system, and that we let go of knowledge absolutism in order to embrace diverse worldviews and co-existence of multiple healing approaches.
Based on the case examples we have shown above, we argue that to understand mental health and spirituality within Indigenous African experiences, there are two essential ideas that must be given prominence. The first is that using an Indigenous lens to understand how Indigenous people conceptualize mental health and spirituality is crucial in order to develop culturally appropriate services. The second point is the need to address the global politics of knowledge about disability.
The first issue is particularly important because Western conceptualizations have been dominant in shaping disability service provisions, disability research, and in addressing perceived needs. The current situation continues to maintain the hierarchy wherein Western ideologies of biomedicine are seen as normative and universal in disability studies while Indigenous knowledges and voices remain disregarded, undermined, and therefore excluded from informing service systems. However, a central and important feature of how both disability and Indigeneity are experienced globally has to do with social exclusion and disavowal. If we continue to impose a Western lens on people's experiences, we add to that layer of exclusion and are complicit in the oppression.
In narrating some of our own experiences as researchers, we are (inter)woven into this permeating tapestry of collectivist worldviews that we exist in as Africans. We are not separate from, but are a part of, African existentialism. The South African moral philosophy of Ubuntu situates all as a part of the collective, which means that what we believe and practice as researchers influence the lives of others and vice versa. Therefore, even in the presentation of these studies, we carry the values instilled in us by this moral ethic, to ensure that we represent the stories and the people who shared these knowledges with us in a responsible and authentic manner. We recognize that we have been made custodians of this knowledge within this space and for this time and must engage on behalf of—and with—the larger discourse beyond African borders.
Decolonizing theorist Frantz Fanon's work on colonial oppression's damage to the Black psyche becomes crucial and relatable here. For Fanon, and for us, the cumulative experience of being treated as inferior both by ableist ideologies and colonial oppression are central to the creation of mental distress, such that the colonised begin to internalise these negative representations and poison one's sense of self. Both Fanon (1967;1963) and South African Occupational Therapist and decolonial scholar Elelwani Ramugondo (2015) advocate for efforts to raise consciousness, as the way out with an aim to bolster identity, build pride and improve self-esteem. A clear example of such an alternative practice is seen from the transformative psychiatry work by Fanon at Blida hospital in Algeria during the Algerian war for liberation (1954-1962). In the act of decolonisation, Fanon and his colleagues set out to sensitize themselves to the culture of the North African Arabs under their care instead of continuing with imposing an imperialistic Western worldview on them. Fanon realised that opportunities within the hospital spaces needed to be culturally appropriate. These practices facilitated re-socialization amongst both patients (on the Algerian and French sides) and clinicians through healing that is embedded in community-building and self/collective determination (Fanon, 1967;1963; Menozzi, 2015).
If the desire is to be socially responsible in resisting all forms of oppression and disadvantage in mental healthcare, then there is a case to be made for the inclusion and integration of African notions of spirituality as a valid way of understanding mental healthcare. This conception and practice from an African perspective needs to be at the center of disability inclusion efforts within Africa. Our approach here begins this process by intentionally taking the position that all human beings are born into valid and legitimate knowledge systems grounded in their language and culture—an approach that differs from the more conventional practices in (Global North) disability studies. The influence of Western bias, which erroneously position these conventional knowledge systems as universal even though they are natal to Western ways of sense-making, limits broader insights and transformative applications. Conventional approaches, as critical disability studies scholar Helen Meekosha (2011) puts it, usually come with methodological projection that frames data using metropolitan concepts, debates, and research strategies. We acknowledge the clearly complex interplay between congenital/biological and the socio-political context within which mental distress is formed. It is therefore necessary for mental healthcare as a practice to be actively resistant to the political oppression of Indigenous people; mental healthcare practices must also reflect greater awareness of the involved power and domination within the hegemonic mental healthcare systems as with the general relationship between knowledge and power (Foucault, 1991). A particular focus needs to be given to issues of epistemic injustice and the violence ingrained within the dominant Western biomedical system.
Linked to the above is the second issue of the politics of knowledge about disability in a global context. As African scholars, we often find ourselves in conflicting situations as a result of straddling an intersectional world with a hierarchy of knowledges. Discursively, it also seems that there is a split which has authors either saying that African spirituality is "all good and wonderful" or those who, like psychologist D.L. Lamptey (2019), for example, dismiss everything as "just superstition." These case studies demonstrate that Lamptey's assumption is another case of Western dominance in the documentation and interpretation of the world and that part of the audience for knowledge in the literature are people from the Global North thus making knowledge a monologue within the North to be presented to Africans as a receptive audience and therefore excluding African writers 3.
What we need is a production of more rigorous knowledge, which necessitates that we open up to ecologies of knowledges and mosaic epistemologies to include the knowledge that encompasses Indigeneity across the world. This would encourage situated scholarship that respectively acknowledges its locale. In this way, collective knowledge is generated out of an appreciation of the different particulars and resists the eclipsing influence of Western-based ideas and practices (Cesaire, 2010).
Bringing in ecologies of knowledges to theorize disability from the Global South would address some of the current form of scholarly colonialism that has become entrenched within the southern academe, such as data projections based on Global North values. Specifically, we argue for critical, contextually relevant, and focused research on the sincere engagement between disability and spirituality and possible solutions to challenges experienced within the Global South-North tensions with consideration for the interconnectedness of these worlds even when entrenched by Euro-modernity (Mignolo, 2007).
A related issue is that many articles written about mental health in the South are often written and published in spaces that are inaccessible to the communities who need to work with these outcomes, including policy outcomes. However, it is relevant to note here that there are multiple factors that influence African Indigenous perspectives of disability. We do not only position knowledge co-creation as situated between the North and South, but rather we also advocate for increased transfer of knowledge ecologies between South-South communities. The production of North-South, as well as South-South situated scholarship has the potential to allow for the development of diverse writing styles and Indigenous modes of narratives that are more inclusive of persons with disabilities and their families within their different contexts. We contend that this is key to building a robust, critical global discourse on disability.
The issue of spirituality within mental healthcare is not new. Although many African contexts have been recognised as emphasising spiritual ideas of illness, African Indigenous praxis about spirituality and disability have been conspicuously missing from the discourse. There is a dominance of a hegemonic Westernised lens as a way of understanding healthcare and this includes how spirituality is understood. Such a hegemonic lens suggests that disability is universal and can thus be studied from the same point of view. This type of discourse influences practice and has implications for how disability interventions are experienced by Indigenous people. As we have illustrated above, for many Indigenous African communities, spirituality extends beyond individual experience (even individual participation in socio-religious activities) to include an emphasis on social spiritual wholeness. Given that people seek help and inclusion through local resources and frameworks and this is how they live their lives, is it our role to convince local resources that they do not know what they are doing? As researchers invested in Indigenous and decolonizing practices, we challenge the primacy of Western ways of knowing in training or practices that marginalize African experiences, reinforce existing epistemic violence, or increase the vulnerability of Africans with physical and mental disabilities. We need more disability research from the frame of reference of those most excluded—not only in Africa but across the world.
The dominance of Western biomedical approaches to mental healthcare as an accepted means of achieving wellbeing, has also often created a dissonance between expected wellbeing outcomes and actual intervention experiences. However, certain biomedical practitioners are beginning to grapple with the reality of spirituality within their practices (Determeyer and Kutac, 2018). Within a postcolonial era, where Western biomedicine still bears more legitimacy and respect than Indigenous healing methods, there are often high expectations of recovery from serious illness. For many service users however, recovery must include a re-balancing and spiritual harmony of the social network of the individual that was disrupted by illness and restored by a combination of medicine, song, and dance—amongst other rituals . It is clear that a Western biomedical paradigm is distinctly different from Indigenous healing, with the former using a clinical or 'scientific' lens while the latter uses an Indigenous lens (Moshabela et al, 2017), which is no less scientific as far as science pertains to the organization of knowledge. Despite the scientific attribute of both, these are evidently two potentially opposing world views. As we have explicated throughout this article, the strength of Western biomedicine lies in a biological curative approach, while Indigenous healing dominates in a spiritual approach that considers the interconnectedness of the spiritual or mental health aspects as in need of healing.
Most recommendations for navigating the intersectional identity of Indigenous healing within a Western biomedicine-dominated healthcare system has been to encourage training of non-biomedical healthcare practitioners to increase their understanding of psychosocial disability as understood from a biomedical viewpoint. However, this approach has not found much success as it has largely ignored the importance of spirituality in Indigenous healthcare. Additionally, there is often a tendency to use a one-sided western biomedical paradigm to compare the different ways of healing and this is shaped by the hierarchical classification of knowledge. These two have different goals and should therefore not be compared head-to-head. The understanding of disabilities in the global South must carry within it and express the foundational intrinsic value system of the Indigenous contexts from which persons with disabilities in Africa live, and make meaning of their existence from this situated frame of reference. This constitutes a form of ethical disability practice.
Conclusion and Recommendations
We need to challenge the dominant disability theory that has been constituted by the Global North through the marginalisation and subjugation of Global South epistemologies. The Western understanding and perspectives of disability and engagement with mental health, has often been given as the solution and standard for the experience of disability within the global south. This research has shown a foundational difference in the understanding and approaches to disability within the North and South. While the Global North focuses more on healing the individual body, Southern perspectives identify the individual as located within a spiritual communal, sociopolitical system that supports their wellbeing and full participation in their communities. Therefore, the experience of disability within Indigenous African communities is lived within a collective spiritual social system that must be recognized and included within broad disability discourse.
Recognizing that African Indigenous knowledge is a valid framework would begin to create a shift that moves African Indigenous knowledges from the margins where it has been relegated, to the center, especially within its original context and space, where it will begin to equally influence global disability discourse. The generative potential of this approach has purchase across wide-ranging contexts of Indigenous people around the globe.
Persons with disabilities exist within spiritual health belief and knowledge systems alongside their communities. An Indigenous African worldview positions community space and its holistic relationship as a healing space, a space of balanced connection, and a support system for the person with a disability. This understanding encourages collaborative engagement that informs various health plans and interventions, and points towards a more sustainable outcome. After treatment or intervention by a Western biomedical practitioner persons with psychosocial disabilities still go back to their community to be re-integrated and to participate fully in the life of their community. Approaches that value local Indigenous spiritual knowledges and practices offer a much-needed opportunity for robustly inclusive care and wellbeing.
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Acknowledgements: We are grateful to the editors and anonymous reviewers for their thoughtful comments and suggestions which have helped us strengthen this paper. We are also grateful to Professor Leslie Swartz for his comments on earlier drafts of the manuscript. The narratives from Ghana form part of the doctoral dissertation of LK, funded by the Graduate School of the Arts and Social Sciences at Stellenbosch University. The narratives from South Africa form part of a doctoral dissertation of CO, funded by NRF grant-holder linked bursary. LN's writing time is funded by NRF BAAP. The content is the sole responsibility of the authors.
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The people indigenous to Madwaleni are known as AmaBomvane.
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We recognize that gestures of exclusion are also evident in citation practices. African Indigenous scholars are either not cited in disability studies or theorization hardly emerges from formulations informed by praxis from these locations (Meekosha, 2011). Furthermore, we begin to understand some collaboration between African scholars and the Western hegemony that is facilitated by asymmetrical power relations to the favour of Western epistemology.
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