Psychodynamic Psychotherapy in South Africa

Contexts, Theories And Applications

Giada Fabbro, Gillian Eagle, Yvette Esprey, Vanessa Hemp, Gavin Ivey, Tina Sideris, Sally Swartz, Michael O'Loughlin, Glenys Lobban, Cora Smith, Michael O'Loughlin, Glenys Lobban, Cora Smith, Giada Del Fabbro, Glenys Lobban, Michael O'Loughlin, Giada Del Fabbro, Gillian Eagle

• Publisher: Wits University Press
• Year: 2013
• ISBN:
  9781868148035
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Psychoanalysis as a long term modality is inaccessible to the average South African. In this book the authors describe how psychoanalytically orientated or psychodynamic psychotherapy can be practiced as a short-term endeavour and applied to contemporary issues facing the country. Psychodynamic work is currently undertaken by clinical psychologists, therapists, clinicians, trainers, teachers, clinical supervisors, consultants and researchers working in university settings, state hospitals, community projects, private practice and research. The debates, clinical issues, therapeutic practice and nature of research covered in the book are widely representative of the work being done in the country. The need for shorter term therapy models and evidence-based interventions is as acute in global practice as it is locally. The lessons learned in South Africa have broader implications for international practitioners, and the authors stress the potential inherent in psychoanalytic theory and technique to tackle the complex problems faced in all places and settings characterised by increasing globalisation and dislocation. The book is structured in three main sections. Psychodynamic Psychotherapy in South Africa is aimed at local and international practitioners and students, while non-specialist readers will find the text informative and accessible.

PSYCHODYNAMIC PSYCHOTHERAPY

SECTION III

SOCIAL ISSUES

CHAPTER 6

UNCONSCIOUS MEANING AND MAGIC: Comparing psychoanalysis and African indigenous healing

Gavin lvey

Nearly two decades after the transition to democracy in South Africa, the mental health field has revealed itself to be a fascinating attractor for a range of cultural, political, legal and philosophical debates, inevitably shaped by the country’s turbulent past and questions about its future. Two recent events establish the context for this chapter. In 2009 the South African Psychoanalytic Association was accredited as an official International Psychoanalytical Association study group, with the ultimate aim of training psychoanalysts in accordance with international standards. Five years earlier the South African parliament passed the Traditional Health Practitioners Act (No. 35 of 2004), aimed at recognising and integrating traditional healers into the country’s official healthcare system. The historical juxtaposition of these two events invites a consideration of the relationship between psychoanalysis and indigenous African healing.

The existing meagre comparative local literature focuses more generally on biomedicine and indigenous healing, the politics of mental health, or on the role of indigenous beliefs in the context of integrative trauma therapy (Eagle, 2004; Straker, 1994). Few authors (I know only of Buhrmann, 1986, and Maiello, 1999) have published comparative work on psychoanalysis and traditional healing in the South African context. The aim of this chapter is to extend and sharpen the comparative discussion of these two healing systems. In the course of doing so I will not simply examine traditional healing from the perspective of psychoanalysis, but also highlight the peculiarities of psychoanalysis and consider its ‘place’ in the South African context.

My interest in comparing psychoanalysis and indigenous healing has three professional tributaries. Firstly, my role in training South African clinical psychologists in psychoanalytic psychotherapy has exposed me to the tensions between traditional African belief systems and those informing the psychoanalytic world-view. Many African trainee psychologists, particularly those raised in rural communities, have consulted indigenous healers and been raised in cultures imbued with these healing practices and their attendant philosophies. Comparisons between psychoanalytic and indigenous healing thus arise regularly in seminar discussions about the nature of the therapeutic enterprise. These discussions have required that I, a white psychoanalytically oriented therapist, acquaint myself with the culturally embedded healing traditions familiar to my students. Secondly, a recent requirement for professional registration as a clinical psychologist in South Africa is a year of post-qualification community service. Many recently qualified psychologists find themselves in remote rural clinics, where they frequently encounter patients concurrently treated by indigenous healers. These psychologists are forced to negotiate potentially fraught professional dilemmas arising from the collision of differing belief system healing modalities. An example of this is presented later in the chapter. In such circumstances a considered awareness of the commonalities and differences between these modalities is a prerequisite for ethically informed professional action. Thirdly, as noted in the legislation referred to above, formerly suppressed and marginalised traditional healing has been accorded new respect and legal recognition. This behoves Western psychotherapists to reflectively engage indigenous healing practices, both out of respect for these ‘new’ professional colleagues (who, ironically, pre-date psychotherapy practitioners by centuries) and because some formal cooperation between psychotherapists and indigenous healers may well arise in future. The form such cooperation may assume is currently being debated and I will offer my perspective on this toward the end of the chapter.

A BRIEF OVERVIEW OF AFRICAN INDIGENOUS HEALING

There has been a recent increase in the amount of literature on African cosmology and indigenous healing in South Africa, driven largely by two post-apartheid imperatives. The first involves efforts to restore the dignity of African philosophies and cultural practices following their marginalisation by hegemonic Western biomedical ideology and decades of racist stigmatisation (Holdstock, 2000; Kruger et al., 2007; Mkhize, 2004). The second concerns attempts to establish collaborative relationships between Western biomedical and allied practitioners (including psychologists) and traditional healers. This is aimed at addressing the pressing mental health needs of a country where a large percentage of the population consults both Western practitioners and indigenous healers (Campbell-Hall et al., 2010; Mkize, 2009).

The first initiative typically endorses the culturally embedded differences between African indigenous healing practices and Western therapeutic modalities, but does so proudly, countering the latter colonising ideologies by asserting the legitimacy of African cultural realities. The second is aimed at reconciling racial divisions evident in the biomedical–indigenous healing schism, not merely to redress historical ideological injustice, but also to build bridges between contrasting healing frameworks in order to improve health service delivery. However, the question of where to locate psychoanalytic theory and practice in all of this is seldom addressed in the literature referred to. Before discussing this matter, it is necessary to describe indigenous African healing and to locate it in the context of traditional African culture.

Indigenous healing refers to traditional therapeutic practices that tend to share four characteristics (Tseng, 2001). These practices are (1) embedded in local cultural traditions, (2) magico-religious in terms of mobilising supernatural forces, (3) tend to function independently of official healthcare systems, and (4) are validated in terms of subjectively experienced benefits rather than scientific procedures.

While a variety of indigenous healers exists in South Africa (e.g. herbalists and spiritual healers), it is the isangoma’s (isiZulu term for ‘diviner’ or ‘witchdoctor’) work that most invites comparisons with psychoanalytic therapy. The term ‘diviner’ refers to the central activity of divining the cause of the person’s misfortune or suffering. The nature of these causes is embedded in the traditional ‘African worldview’, a ‘psychological reality referring to shared constructs, shared patterns of belief, feeling and knowledge… which members of the group carry in their minds as a guide for conduct and definition of reality’ (Makwe, 1985: 4). This worldview is expressly supernatural as magical and spiritual figures and forces are believed to exert both benevolent and malign influence. Of foremost importance are the ancestors – omnipresent spirits of significant deceased relatives who continue to play a life-preservative role in the activities of the living (Mbiti, 1990; Ngubane, 1977). Ritual contact with and adherence to the wishes of the ancestors is considered imperative for continued well-being. Withdrawal of ancestral protection leaves the individual spiritually alienated and vulnerable to misfortune, whether opportunistic or intended by the ancestors to teach the ‘victim’ a lesson.

The sangoma’s ancestors are particularly significant as it is they who summon the individual to the diviner’s vocation and confer upon him or her healing powers. Becoming a sangoma is not a matter of individual choice, but rather an ancestral decree made evident in the individual’s experience of thwasa sickness. This ‘syndrome’, while varied in its manifestations, is typically characterised by alarming physical and psychological symptoms, often including psychotic states. Only a sangoma can diagnose thwasa sickness and the symptoms will persist until the afflicted person accepts the calling. The sangoma’s training is protracted and arduous, requiring a long period of apprenticeship to a senior sangoma who instructs the neophyte in medicinal preparation, purification rituals, animal sacrifice, dream interpretation, ceremonial dancing, diagnosis and divination. All these interventions require the sangoma to be a conduit for the ancestral spirits – both the sangoma’s and the patient’s – as it is the ancestors who ultimately restore the patient to health (Buhrmann, 1986).

Misfortune is never accidental but is usually the consequence of ‘pollution’ or witchcraft. Pollution refers to a contaminating mystical force that may afflict a person who comes into contact with persons or objects considered taboo, such as menstruating women, meat from a diseased animal, or a foetus that has not been properly buried (Hammond-Tooke, 1989). Ritual purification is required to remove the polluted state.

While good magic involves the use of supernatural power to positive ends, witchcraft – typically motivated by envy, jealousy and malice – involves the intentional deployment of malignant spirits or magical substances to harm others. The latter substances are collectively referred to as muti, an ambiguous term denoting supernaturally imbued objects or potions capable of magically healing or harming, depending on their application and the intentions of their user (Ngubane, 1977). Sangomas typically use good muti to counteract bad muti and heal afflictions, whereas witches only use bad muti to destructive ends. They concoct this from symbolically poisonous substances such as ground-up ants that have eaten meat deposited in graveyards, thereby capturing vengeful spirits of the dead (Niehaus, 2000) or ‘bodily exuviae, such as nail parings and hair clippings, or even the earth from footprints’ (Hammond-Tooke, 1989: 78). Muti exerts its influence through contact with the victim or being unknowingly imbibed, thereby ‘poisoning’ them.

Being bewitched may be indicated by a variety of dramatic somatic or psychological symptoms, or simply evident in what westerners attribute to ‘bad luck’ – becoming unemployed, miscarrying, failing in a business venture, and so on. While acknowledging a role for natural causes (particularly in the case of common minor ailments), significant adverse life events are typically attributed to someone’s actions and the diviner’s ‘diagnostic’ task is to ascertain who is responsible.

Another aspect of the African worldview that is important concerns the culturally prevalent form that selfhood assumes. The African conception of self is a collectivist, as opposed to individualist, conception – ‘a being-with-and-for-others’ (Mkhize, 2004: 26). In other words, the self is socially constituted and maintained in terms of a network of interdependent familial and community relationships and identifications. The meaning of one’s life is defined by means of communal recognition and engagement, captured in sayings such as ‘I am because we are, and since we are, therefore I am’ (Mbiti, 1969, quoted in Mkhize, 2004: 24). The implication of this collective self is that individual well-being is subordinate to and contingent upon harmonious relationships with familial and community members, that relational disharmony inevitably produces individual dysfunction, and that the repair of disharmonious familial and community relationships is a central aim of healing interventions.

These three integral aspects of the African worldview – collectivist selfhood, the existence of supernatural entities and forces, and the causal attribution of misfortune to malevolent others – all inform the sangoma’s diagnostic and therapeutic practices.

COMPARING PSYCHOANALYSIS AND INDIGENOUS HEALING

Psychoanalysis and indigenous healing do share some characteristics, features that distinguish them from biomedical interventions. Firstly, in diagnostic terms, both are concerned with the underlying meaning of symptoms, which invariably relates to the life context of the sufferer. Secondly, both are forms of symbolic healing. Rather than resorting to biomedical cures, symbolic healing employs words, rituals or symbolic actions as therapeutic interventions. Thirdly, both analysts and sangomas are ‘wounded healers’ in that their respective apprenticeships require their own personal acquaintance with psychic suffering and their treatment by a senior healer in their respective traditions. Fourthly, both approaches consider the patients’ dreams to be meaningful communications and an important resource in the treatment process.

The search for commonalities between apparently divergent therapeutic approaches appeals to the ‘common factor’ literature that has proven popular for at least six decades in Western psychotherapy. It began with Rosenzweig’s (1936) observation that although psychotherapy in general is effective in the alleviation of psychological distress, no one theory-driven psychotherapy approach is more effective than another across a variety of symptom presentations. This must mean that despite overt theoretical and technical differences, it is the underlying factors common to all psychotherapy treatment contexts that are largely responsible for facilitating psychological change.

Relevant to our purposes is the fact that the common factor literature has also been employed to argue for a cross-cultural theory of psychological healing. Thus, despite radically different cultural assumptions and intervention modalities, traditional healing and psychotherapy are argued to be equally effective in their respective cultural settings because the healing agents responsible for alleviating distress are essentially the same. In the 1960s, Frank and Frank (1991) advanced a model that is still influential today. Arguing that all psychological disturbance is either the cause or the consequence of demoralisation (a state of hopelessness, helplessness and perceived failure to cope with life), they claimed that symbolic healing practices include four interrelated aspects that combine to combat demoralisation: (1) a professional relationship between a socially sanctioned healer and a sufferer, in which the healer inspires belief that positive change can be effected in the sufferer’s life. This creates a hopeful expectancy in the sufferer that the relationship will bring about change; (2) treatment takes place in a designated healing setting demarcated from the rest of the environment; (3) every therapy needs to provide a culturally meaningful explanation for the suffering, thereby making symptoms meaningful; and (4) the sufferer must participate in a task, procedure or ritual that is emotionally arousing, requires some effort or sacrifice and is consistent with the explanation for the symptoms. Successfully accomplishing these tasks enhances the sufferer’s sense of mastery, interpersonal competence or other capability.

This framework democratises diverse healing practices by revealing a common cross-cultural structure that establishes the necessary and sufficient conditions for psychological healing to occur. Fuller Torrey champions this position by asserting, ‘[T]he apparent differences between types of psychotherapy within a culture or between cultures are more illusion than substance and are due to differences in techniques used to enhance the basic components’ (1986: 231).

While other cross-cultural common factor theories of symbolic healing have been advanced (e.g. Dow, 1986; Fuller Torrey, 1986; Kleinman, 1988), these tend to be mere clarifications or elaborations of the model Frank and Frank published 50 years ago. While this healing structure undoubtedly applies to both indigenous healing and psychoanalysis, it is worth noting how the model flattens and obscures the signature f...