powerment vs disempowerment of patient and healer in the therapeutic context. The problems revealed in this study of therapeutic process in Madagascar may bear on similar situations cross-culturally. --Author's Abstract
For the Sakalava of northwest Madagascar, definitions of spirit possession and madness are intertwined, defining a spectrum of symptoms and experiences, each with its distinct set of appropriate therapeutic responses. Possession by royal dead, or tromba spirits, is regarded as sacred and honorable and is a common experience especially among women. Mediums say that they periodically suffer (mijaly) from the actions of these spirits; nevertheless, once a medium instates her spirits, they become a permanent fixture in her life. In contrast, madness is a dangerous--and, hopefully, temporary--state. The kin of the afflicted often travel great distances and may exhaust their resources in their search for cures. A marginal area between these two distinct categories is occupied by various forms of possession sickness, involving dangerous and volatile spirits which must be driven from their victims before they risk permanent harm.
A wide array of indigenous healers--including spirit mediums (tromba, tsigny, kalanoro), herbalists (moasy/ombiasy), and diviners (mpisikidy)--play key roles in diagnosing and treating spirit possession and madness and their associated problems. If the efforts of these practitioners fail to improve the health status of a patient, she, often with her kin, may seek assistance from non-indigenous healers: typically, these are Protestant exorcists or psychiatrists. Either of these options serves as a last choice in a locally-conceived hierarchy of resort 1. Two factors account for this reluctance to consult with Protestants and psychiatrists: ethnic factionalism between local Sakalava and non-Sakalava migrants; and what I will refer to as "conflicting" or "alternative epistemological realities", defined by Malagasy vs western cognitive systems.
Spirit possession has long been a focus of interest for theologians [ 2- 5]. In terms of psychological and psychiatric orientations, there is, likewise, an extensive literature in anthropology addressing the efficacy of indigenous healers in treating mental illness [ 6- 14. Other authors have questioned the validity of applying psychiatric diagnoses cross-culturally. This literature identifies psychiatry as being most effective when applied to western, middle class whites [ 15- 17]. Others suggest that psychiatry can be applied effectively cross-culturally if communication and understanding exist between therapist and patient. Kleinman [ 18, 19], for example, has argued that therapeutic approaches fail when patient and healer embrace different and conflicting "explanatory models" of illness. The value of this approach is that it addresses the impasses encountered as a result of cultural differences or misunderstandings between patient and healer. Its shortcoming, however, is that it assumes that psychiatric approaches can be effective if the therapist is culturally sensitive to the patient's beliefs, yet it fails to acknowl-