Review

Effectiveness of traditional healers in treating mental

disorders: a systematic review
Gareth Nortje, Bibilola Oladeji, Oye Gureje, Soraya Seedat

Lancet Psychiatry 2016: Traditional healers form a major part of the mental health workforce worldwide. Despite this, little systematic
3: 154–70 examination has been done of their effectiveness in treating mental illness or alleviating psychological distress. In this
See Online for podcast interview Review, we aim to fill this gap, with a focus on quantitative outcomes. We searched four databases and reference lists
with Gareth Nortje
for papers that explicitly measured the effectiveness of traditional healers on mental illness and psychological distress.
Department of Psychiatry, Eligible papers were assessed for quality, and outcomes and other details were extracted with the use of a standardised
Stellenbosch University,
Cape Town, South Africa
template. 32 eligible papers from 20 countries were included. The published literature on this topic is heterogeneous
(G Nortje FCPsych [SA], and studies are generally of poor quality, although some findings emerge more consistently. Some evidence suggests
Prof S Seedat PhD); and that traditional healers can provide an effective psychosocial intervention. Their interventions might help to relieve
Department of Psychiatry,
distress and improve mild symptoms in common mental disorders such as depression and anxiety. However, little
University of Ibadan, Ibadan,
Nigeria (B Oladeji FWACP, evidence exists to suggest that they change the course of severe mental illnesses such as bipolar and psychotic
Prof O Gureje DSc) disorders. Nevertheless, qualitative changes that are captured poorly by conventional rating scales might be as
Correspondence to: important as the quantitative changes reviewed here. We conclude by outlining the challenges involved in assessing
Dr Gareth Nortje, Department of the effectiveness of traditional healers.
Psychiatry, Stellenbosch
University,Francie van Zyl
Avenue, Cape Town, 7505,
Introduction (as is occurring in Indonesia, South Africa, Bali,
South Africa Traditional healers form a major part of the global Uganda, Papua New Guinea, New Zealand, Canada, and
g.nortje@gmail.com mental health workforce. A large amount of published the USA7,12,32–35).
literature spanning the past 50 years suggests that many Despite this widespread use of traditional healers,
people in developing countries seek out traditional their effectiveness in treating mental illness has never
healers for mental health complaints, sometimes in been systematically reviewed. Effectiveness is often
addition to using conventional psychiatric services.1–14 tacitly assumed, and only a few studies explicitly attempt
Traditional healers are appealing because they share a to quantify it.36 This Review aims to systematically
common perspective with their clients, and make use of collate and analyse the published literature measuring
knowledge, beliefs, and practices indigenous to the local the effectiveness of traditional healers in improving
culture.15 In developing countries in particular, these mental health.
shared beliefs typically include spiritual and religious This task is complicated by the fact that conceptions of
models of illness causation, which affect patterns of mental illness differ greatly between cultures, and it is not
help-seeking.16 In areas where formal psychiatric services always clear that psychiatric labels and outcomes are
are scarce or unaffordable, traditional healers are universally valid. The mind–body distinction implicit in
especially well used and provide a potentially valuable mental illness is not present in many other healing
source of mental health care.9,17,18 traditions, which make little distinction between physical
In addition to populations from developing countries, and emotional illness, spiritual problems, and the obstacles
notable minority populations in high-income and of daily living.37 For example, depression is often not
developed countries continue to use their own traditional viewed as a mental illness, and the strange behaviours of
healing systems. High rates of traditional healer psychosis are often explained in spiritual terms such as
attendance for mental health problems have been possession or bewitchment.16,31 Notions of wellness are
documented in North American Indians,19–21 Chinese linked to social and spiritual harmony and balance rather
immigrants in Canada,22 Pakistanis in Britain,23 than psychopathology.31,38 Consequently, concepts of
Bangladeshis in London,24 Turkish people in Germany,25 healing and the assessment of its efficacy are much
Hispanics in the USA,26 southeast Asian refugees in the broader and more nuanced in traditional healing than in
USA,27 and Muslims in the UK.28 conventional psychiatry. Application of the standard
Since patients with serious mental illnesses in criteria to assess outcomes would miss important
developing countries seldom receive formal psychiatric qualitative changes in meaning, attitude, relationships,
treatment,29 traditional healers will continue to have a self-image, and sick role.39,40 For example, the rituals of
substantial role in mental health-care delivery.30 symbolic healing used by traditional healers might work
Although the debate regarding the legitimacy and status on many levels, from catharsis and cognitive restructuring,
of traditional healers within existing health systems is to change in family structures, restoration of community
ongoing,31 many countries acknowledge the potential identity, and social cohesion.41 That said, patients do
usefulness of traditional healers for treating mental present to traditional healers with many psychosocial
health problems, and are attempting to incorporate complaints, and their symptoms often meet criteria for
these healers into their own formal health-care systems psychiatric caseness.31,42,43 Despite a myriad of culturally

154 www.thelancet.com/psychiatry Vol 3 February 2016


specific idioms of distress, the prevailing view in psychiatry
suggests that many disorders are present and recognisable
in every culture,16 although standard diagnostic criteria
might not be universally valid.43,44 Additionally, traditional
healers are able to identify patients with putative mental
disorders, although they might name them and explain
them differently.31,45 Therefore, it is reasonable to assume
that patients with psychiatric disorders similar to those
diagnosed and treated by orthodox medicine attend and
are treated by traditional healers. Examination of outcomes
of these patients from the viewpoint of conventional
psychiatry, while acknowledging that this is only part of the
story, is therefore potentially useful.
Methods
Search strategy, definitions, and selection criteria
We aimed to include papers at the intersection of
three broad areas: traditional healing, effectiveness, and
mental disorder. The broad nature of each of these
concepts necessitated the use of several terms for each
concept in the search strategy. For example, in addition
to “traditional healing”, we included “religious healing”,
“indigenous healing”, “diviner”, and ten other related
terms. Similarly, we searched for “mental illness” and
related terms and specific psychiatric diagnoses. We
searched MEDLINE, PsycArticles, Scopus, and the Social
Sciences Citation Index on May 25, 2014 (for full details,
see appendix pp 1–2). We also manually searched the
reference lists of included papers and contacted key
authors for other potentially relevant papers. When
necessary and possible, we requested these papers from
authors in at least two emails sent 1 week apart.
Existing definitions of traditional healers are inadequate
for use as inclusion criteria in a systematic review. For
example, the key criteria in the WHO definition of
traditional medicine is that it should be “based on
experiences indigenous to different cultures” and usually
has a “long history”.46 However, this definition does not
clarify the meaning of “indigenous” or “long history”, and
includes a heterogeneous range of healing methods with
little in common. We preferred to use a criterion based on
qualities inherent to the healing modality, and chose an
operational definition of traditional healers as “healers who
explicitly appeal to spiritual, magical or religious
explanations for disease and distress”. This definition
encapsulates a core feature underlying the meanings and
rituals of the healing modalities of interest, and was derived
by the authors after reading the published literature.
Notably, healing modalities that fit this criterion tend to be
very culturally specific and have a long history, as per the
WHO definitions. This definition includes those healing
practices that typically make use of sacred rituals,
ceremonies, talismans, divination, and prayer during
diagnosis or treatment. Traditional healers who use physical
treatments such as herbs or massage to complement
spiritual treatments are also included, since these physical
treatments often have a notable magical or religious
www.thelancet.com/psychiatry Vol 3 February 2016
Review
meaning. However, the definition excludes healing methods
that rely mainly on physical, humoral, or quasi-mechanical
explanations for illness, such as acupuncture, chiropractic,
herbalism, homeopathy, traditional Chinese medicine,
Ayurveda, Qi-gong, Reiki, and Western medicine. We also
exclude the effects of personal religiosity and spirituality,
so-called distant healing where the patient is not directly
involved in the intervention, and western psychotherapies
that incorporate religious elements.
Papers were selected for inclusion by two authors (GN
and BO) independently. We included papers written in
English that explicitly assessed the effectiveness of a
traditional healer on mental illness or psychological
distress. Traditional healers rarely use western psychiatric
diagnoses, and this absence of diagnostic rigour is reflected
in the published literature. We therefore included papers
that used both psychiatric diagnoses and non-specific
psychological or behavioural complaints. Furthermore,
since traditional healers make little distinction between
mind and body, and many somatic complaints brought to
healers have psychological origins,7,47 we accepted studies
that assessed mixed complaints as long as they also
reported a psychological outcome. Studies of traditional
healing often use measures of effectiveness that are more
holistic and subjective than those used in conventional
psychiatric research. These quantitative ratings, such as
“perceived improvement”, “effectiveness”, or “satisfaction”,
are less objective than formal rating scales, but could not See Online for appendix
be ignored48 because they are personally and socially
relevant outcomes that can be quantified. Therefore, to be
as inclusive as possible, we accepted a broad range of
outcome measures, ranging from validated psychiatric
rating scales, through non-validated custom rating scales,
to the aforementioned subjective measures. However, we
excluded papers that discussed only qualitative changes
attributed to the healing experience, such as personal
transformation or spiritual growth. We also excluded
anecdotes and case reports.
Data extraction
Data were extracted from eligible papers by two authors
independently (GN and BO) using a fixed template, and
any differences were decided by consensus. The quality of
included studies was assessed through the use of
six operationalised criteria: adequacy of controls, sampling
methods, diagnostic rigour, follow-up procedures,
outcome assessment method, and reporting of results (see
appendix p 3). When samples included patients with both
physical and psychological complaints, we reported on the
outcome for the psychological complaints only, or we
reported the psychological outcomes for the whole sample.
We anticipated that too much heterogeneity would exist
between studies to allow for any statistical generalisations.
Since the effectiveness of traditional healing might depend
on the severity of the complaint, we report the main
findings stratified by the severity of the mental illnesses
treated, where possible.
155
 Review

one case-control study,68 and nine retrospective

4128 records identified from database searches surveys.7,10,18,69–74 The studies varied substantially in terms of
1485 from MedLine
140 from PsycArticles the type and uniformity of interventions, patient
864 from Scopus recruitment and sampling methods, diagnostic spread,
1639 from Social Sciences Citation Index
follow-up protocols, and assessment methods. Most
interventions were administered to outpatients, in single
327 duplicates removed or repeated sessions. However, five studies52,59,63–65 report on
outcomes after extended admissions to traditional healing
shrines. Roughly a third of the papers reviewed used rating
3801 records after duplicates removed
scales to assess symptomatic improvement. Two-thirds of
the papers asked patients to rate the subjective effectiveness
2763 records rejected because about non-traditional healing modalities of the healing on a one-dimensional scale assessing
(eg, mindfulness, homoeopathy), about physical interventions, about a effectiveness, satisfaction, helpfulness, improvement, or a
physical illness (eg, cancer), non-empirical papers (eg, historical reviews),
or non-health related (political, economic) similar descriptive term.

1038 abstracts considered
827 papers rejected from abstracts
or article skimming
211 papers for full-text 142 papers from reference
examination chaining
353 papers for full-text
consideration
321 not eligible because contained only descriptive or qualitative data,
about personal religiosity, about exclusively physical illness or
substance addiction, or non-empirical (eg, reviews, opinion,
theoretical)
32 eligible papers
Figure: Search strategy
Results
Literature search
Our initial literature search found 3801 unique records
(figure). This number was reduced to 211 potentially
eligible papers, which were combined with a further
142 papers identified by reference chaining. Of these
353 papers that needed detailed full-text examination,
64 (mostly published pre-1995) were unavailable through
our university. We requested copies of 32 of the
unavailable papers from the authors, of whom 16 supplied
copies for consideration. Many insightful and excellent
papers about the qualitative effects of traditional healing
on mental health were excluded because they did not
provide any quantitative data.
Eligible papers
The 32 eligible papers from 20 countries consisted of
two randomised controlled follow-up studies,49,50 six
non-randomised controlled follow-up studies,42,51–55
14 uncontrolled naturalistic follow-up studies,12,40,56–67
Quality of papers
The methodological quality of the papers was generally
poor. Many aspects fell short of the standards usually
needed to assess the effectiveness of a psychiatric
intervention (table 1). Convenience sampling used in
many papers is vulnerable to selection bias.12,51–53,56–58,69
Study designs lacked randomisation and control groups.
Many papers used informal or unclear diagnostic
procedures7,12,42,49,54,57–60,70,75 or omitted diagnoses altogether
and listed only patient complaints.40,55,61,62,76 Few papers
provided adequate descriptions of the procedures used
for outcome assessment or provided a complete report of
results. Many papers did not account for the large
numbers of patients lost to follow-up.49,55,59,61,76
Severe mental illness
Eight papers reported outcomes of mainly patients with
psychosis (table 2). The most rigorous of these, by Abbo
and colleagues63 and Sorketti and colleagues64 used
validated rating scales to measure the change in psychotic
symptoms of patients treated by traditional healers in
Uganda and Sudan, respectively. Both studies reported a
significant reduction in psychotic or manic symptoms
over the course of 3–6 months. Abbo and colleagues63
noted that 80% of their sample attended local primary
health clinics concurrently and probably received some
form of conventional care. Sorketti and colleagues64
reported that many harmful treatments, such as beating
and chaining, were sometimes used. Harding and
colleagues’ 1973 study65 of patients with psychosis
admitted to a traditional healer’s compound in Nigeria
reported significant rates of improvement that were
similar to those achieved with the psychiatric treatment
of the time. However, these studies are naturalistic and
uncontrolled studies, so comparison with other
treatments or the normal course of illness is impossible.
In a controlled study, Halliburton52 compared outcomes
of severe mental disorder when treated by conventional
psychiatric care, religious healing, or Ayurveda in India,
and found a modest improvement that was similar across
all three treatments. He suggested that different
treatments might be suitable for different patients, and

156 www.thelancet.com/psychiatry Vol 3 February 2016

 Review

Country Study design Controls Sampling Diagnostic Assessment Outcome Reporting of Sample homogeneity
rigour procedures measures results
Controlled follow-up studies
Kleinman and Gale Taiwan Controlled follow-up study Adequate Adequate Poor Poor Adequate Complete Mixed physical and
(1982)54 psychological diagnoses
Koss (1987)55 Puerto Rico Controlled follow-up study Adequate Adequate Very poor Adequate Poor Complete Mixed social, emotional, and
behavioural complaints
Patel et al (1998)42 Zimbabwe Controlled follow-up study Adequate Adequate Poor Good Good Complete Mixed psychiatric disorders
Dixon (1998)49 UK Randomised controlled Good Adequate Poor, unclear Adequate Good Selective, Mixed physical and
follow-up study unclear psychological complaints
Mehl-Madrona USA Controlled follow-up study Poor Unclear Unclear Poor, unclear Poor, unclear Incomplete Mixed physical and
(1999)51 psychological complaints
Halliburton (2004)52 India Controlled follow-up study Adequate Poor Very poor Poor Adequate Incomplete Mixed severe psychiatric
disorders
Hurst et al (2008)53 USA Controlled follow-up study Poor Very poor Very poor Poor Poor Incomplete Mixed psychological complaints
Boelens et al (2009)50 USA Randomised controlled Good Adequate Unclear Adequate Good Complete Single psychiatric diagnosis
follow-up study
Case–control study
Salib et al (2001)68 Egypt Case–control study Adequate Adequate Adequate Unclear Adequate Complete Single psychiatric diagnosis
Uncontrolled naturalistic cohort studies
Harding (1973)65 Nigeria Prospective follow-up study None Adequate Poor Adequate Poor Complete Mixed psychiatric diagnoses, all
psychotic
Kleinman and Sung Taiwan Ethnographic follow-up None Adequate Very poor Poor Adequate Partial Mixed physical and
(1979)61 study psychological complaints
Finkler (1980)40 Mexico Ethnographic follow-up None Poor Very poor Adequate Adequate Partial, Mixed physical and
study selective psychological complaints
Salan et al (1983)12 Indonesia Ethnographic follow-up None Very poor Poor Poor Adequate Partial Mixed physical and
study psychological complaints
Peltzer and Machleidt Malawi Ethnographic follow-up None Poor Poor Poor, unclear Poor Partial, Mixed psychosocial and
(1992)59 study selective psychiatric complaints
Wirth (1995)60 USA Naturalistic prospective None Adequate Very poor, Poor Good Complete Mixed physical and
cohort unclear psychological complaints
Lemelson (2004)67 Indonesia Ethnographic follow-up None Very poor Good Poor Poor Partial Specific psychiatric diagnosis
study
Zacharias (2006)57 Mexico Naturalistic prospective None Very poor Poor Poor Poor Partial, Mixed psychiatric disorders
cohort selective
Schiff and Moore Canada Follow-up study None Poor Not applicable Poor Adequate Complete Unclear
(2006)56
Lee et al (2010)62 Singapore Ethnographic follow-up None Poor Very poor Poor Poor Partial Mixed physical and
study psychological
Boelens et al (2012)66 USA Prospective crossover None Poor Unclear Poor Good Complete Specific psychiatric diagnosis
follow-up study
Abbo et al (2012)63 Uganda Naturalistic prospective None Adequate Good Good Good Complete Specific psychiatric diagnoses
cohort
Sorketti et al (2012)64 Sudan Naturalistic prospective None Adequate Good Good Good Complete Specific psychiatric diagnoses
cohort
Mainguy et al (2013)58 Canada Naturalistic follow-up study Poor Very poor Very poor Poor Poor Incomplete Mixed physical and
psychological complaints
(Table 1 continues on next page)

argued that a greater availability of distinct forms of
treatment could improve mental health outcomes at the
population level. Although controlled, the study had a
small sample size, substantial loss to follow-up, unclear
standards of conventional treatment, and an absence of
rigour in diagnosis and assessment. The Egyptian case–
control study by Salib and Youakim68 showed that elderly
patients with schizophrenia relapsed more frequently if
they engaged in religious healing during remission than
if they did not, independently of the presence of religious
beliefs or religious delusions. However, reverse
causality—the possibility that early relapse led to
increased use of religious healing—could explain this
association. Increased relapse rates were most
pronounced for patients who had attended a religious
healer for exorcism or witchcraft rituals. Three
retrospective surveys of patients with mainly severe
mental illnesses reported previous experiences of

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Country Study design Controls Sampling Diagnostic Assessment Outcome Reporting of Sample homogeneity
rigour procedures measures results
(Continued from previous page)
Retrospective surveys
Bhana (1986)71 South Africa Retrospective survey None Poor Adequate Adequate Adequate Complete Mixed psychiatric disorders
Campion and Bhugra South India Retrospective survey None Poor Adequate Good Adequate Complete Mixed psychiatric disorders
(1997)73
Gadit (1998)18 Pakistan Retrospective survey None Poor, Poor, unclear Poor, unclear Unclear Partial Mixed psychiatric disorders
unclear
Ensink and Robertson South Africa Retrospective survey None Poor Unclear Good Adequate Partial Mixed psychiatric disorders
(1999)70
Mirza et al (2006)69 Pakistan Retrospective survey None Very poor Poor Poor Poor Complete Mixed psychiatric disorders
Kurihara et al (2006)7 Indonesia Retrospective survey None Poor Adequate Adequate Poor Partial Mixed psychiatric disorders
MacLaren et al Solomon Retrospective survey None Poor Poor Poor Poor Partial Single culture-bound syndrome
(2009)72 Islands
Salem et al (2009)74 United Arab Retrospective survey None Poor Adequate Adequate Poor Complete Mixed psychiatric disorders
Emirates
Mbwayo et al (2013)10 Kenya Retrospective survey None Unclear Adequate Adequate Poor Partial Mixed physical and psychiatric
disorders

Table 1: Included studies with quality assessments

attending a traditional healer for mental illness. In these
surveys, patients were generally dissatisfied with
traditional healing,70 which they found to be less effective
than conventional treatment.71 However, in a survey from
Bali7 two-thirds of patients reported at least an
improvement after seeing religious healers, although
non-psychotic patients reported more improvement than
those with psychosis. Notably, recruitment at
conventional psychiatric services in these studies
probably excludes patients who were helped the most by
traditional healers.
In general therefore, the studies of major mental
illness suggest that acute psychotic episodes might
improve somewhat over time under the care of traditional
healers. Studies that assessed outcome at least 6 months
after the healing show that initial modest improvements
are often maintained.52,63,65 However, little evidence exists
to suggest that this improvement is different from the
natural course of the illness. The only study using
conventional psychiatric care as a control showed a
non-significant trend towards a worse outcome for the
traditional healer patients.52 Somewhat alarmingly,
attending religious healers might increase the risk of
relapse in chronic schizophrenia.68
Common mental disorders
13 studies analysed outcomes of mainly common mental
disorders (eg, depression and anxiety) and other
psychosocial complaints treated by traditional healers. In a
controlled study, Kleinman and Gale54 reported that
Taiwanese patients attending a tang-ki shrine mostly with
somatic complaints owing to psychiatric or psychosocial
problems (ie, somatisation) were less satisfied with their
treatment and outcome than were patients attending
western medical services matched for demographic and
illness variables. However, they noted that dissatisfaction
with the shamans was largely attributable to a single healer
and that research nurses were overtly ambivalent to
traditional healing, both of which could have potentially
skewed results. In Zimbabwe, Patel and colleagues42
compared outcomes between traditional medical
practitioners, primary health-care clinics, and private
general practitioners, using a validated questionnaire at 1
and 12 months, and reported generally high rates of
improvement in symptoms of common mental disorders
irrespective of the type of treatment. Although the
differences between practitioners did not reach significance,
patients attending traditional healers tended to report more
improvement than those attending primary health-care
clinics. In Puerto Rico, Koss55 asked patients with similar
complaints attending either spiritist healers or receiving
psychotherapy in primary care to rate their expected degree
of problem resolution or symptom alleviation before the
session. After the sessions, patients attending spiritist
healers rated outcomes significantly higher than those
attending psychotherapists, with the difference largely
being explained by pre-existing expectations. These three
controlled studies suggest that traditional healers might be
as helpful as conventional primary care services for
psychosocial and neurotic complaints, although the results
vary by culture and comparison group. In uncontrolled
studies, small samples of patients with mainly neurotic
disorders were followed up after attending dang-ki
shamans in Taiwan61 and Singapore,62 and curanderos in
Mexico.57 Patients reported generally high rates of perceived
“effectiveness”, “helpfulness”, or “improvement”,
respectively. Interestingly, two of these studies showed that
subjective reports did not necessarily correlate with
symptomatic improvement or problem resolution.61,62 In
the Taiwanese study, patients reported reluctance to criticise
the treatment in case they prejudice the gods against
them,61 while the Mexican study suggested that less severe

158 www.thelancet.com/psychiatry Vol 3 February 2016

 Review

complaints improved more than did severe ones.57 depression and anxiety ratings in depressed patients,
A controlled study of repeated individual prayer sessions in although the study had poor sampling, unclear diagnosis,
the USA50,66 reported significant improvements in and poor follow-up procedures.

Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
Controlled follow-up studies
Kleinman Tapei, Shamanic treatment Consecutive patients 112 shaman patients Clinical interview by Semi-structured For somatisation Results possibly biased
and Gale Taiwan at tang-ki shrines with first attendance (28 with psychiatrist. interviews done complaints, TAU in favour of physicians.
(1982)54 (no details given) vs for current illness. somatisation) and Somatisation 3–4 weeks after more satisfactory Dissatisfaction with
TAU at private Controls matched by 118 physician patients category included treatment. Patients than shamanic shamans was largely
physician or general socioeconomic and (25 with mainly depression, subjectively assessed treatment (81% vs due to only one of
hospital clinic illness variables somatisation), mostly anxiety, chronic pain, satisfaction with 58% were at least three shamans studied
lower-middle or and conversion treatment and change satisfied)
upper-lower class disorders in symptoms
Koss Puerto Spiritist healers First new patients of 46 therapist patients No diagnoses listed. Patients rated pre- Spiritists were rated Higher expectations of
(1987)55 Rico working with the day attending and 54 spiritist Patient complaints treatment outcome as more effective spiritist patients were
individuals or groups trained therapists or patients. Spiritist included nervousness, expectations and than therapists associated with better
vs supportive and spiritist healers patients younger. family problems, subsequent outcome (p<0·05), but became outcomes. Almost half
problem-solving Similar occupational visions, and insomnia on a Likert scale non-significant after of patients did not rate
psychotherapy at and socioeconomic correction for their outcome, which
community clinics status in pre-treatment is a potential source
and a psychiatric the two treatment expectations of bias
hospital groups
Patel et al Zimbabwe Traditional medical Consecutive patients Traditional medical Nurses and GPs Shona Symptom Caseness at baseline, Traditional medical
(1998)42 practitioners vs scoring >8 on Shona practitioners: n=67; confirmed caseness Questionnaire 2 months, and practitioners’ diagnosis
primary health care Symptom primary health care: for common mental administered at 12 months was of kufungisisa (roughly
clinics and GPs in Questionnaire were n=72; general disorders (depressive baseline, 2 months 100%, 38%, and 41%, equivalent to common
urban Harare eligible “cases” practitioner: n=60. and anxiety disorders, and 12 months to respectively. No mental disorders) was
35% male, 46% not details not given) assess caseness significant difference significantly related to
formally employed, between treatment improved outcome.
mean age 34·5 years groups Belief in witchcraft
associated with poorer
outcome
Dixon UK Semi-rural general Consenting patients Healer: n=30; Chronic symptoms Patient interview with Median symptom Research nurse not
(1998)49 practice. 10 weekly were divided controls: n=27. for >6 months, research nurse (not rating and HADS masked. Possible
40-min sessions of alternately to healing 32% male, diagnostic procedure masked to group scores at 3 and difference in ages of
brief discussion, or control group by modal ages: not specified. allocation) assessing 6 months decreased controls and
application of healing the research nurse healer group Depression and stress overall symptoms significantly more intervention
hands over body >65 years, accounted for 20% of (1–10) and HADS, at (p<0·05) in healing participants. Unusual
while visualising with controls 45–54 years complaints baseline and at 3 and group than in control choice of summary
music vs conventional 6 months group statistics. High loss to
care from GP follow-up. Selective
reporting of results
Mehl- USA Intensive Native Intervention patients Intensive Diagnostic procedure 5-year follow-up by Perceived Control results not
Madrona American healing contacted author to intervention: n=107; not specified. semi-structured improvement of the reported. Methods
(1999)51 experience lasting request Native emergency room: Diagnoses: depression telephone interview 11 depression and unclear. Small sample
7–21 days, with healing. n=100; modal age: or bipolar disorder in of 76% of intervention bipolar disorder size. Possibility of social
follow-up phone calls Matching of controls 30–49 years 11 patients group. Follow-up of patients: “cure” 7, desirability and
vs patients with not described controls not described “better” 3, “no expectancy bias
equivalent diagnoses change” 1, “worse” 0
attending a hospital
emergency room for
TAU
Halliburton Kerala, 3 religious healing Random or Religious healing: Diagnoses of severe Interviewed at healing All three groups Substantial loss to
(2004)52 India centres (Hindu, convenience n=33; allopathic: mental disorders such centres (or postal showed modest follow-up. Small
Muslim, and sampling of n=35; Ayurvedic: as schizophrenia was questionnaire if improvements, no sample sizes. Diagnoses
Christian) with inpatients n=32. Of these assumed, on the basis discharged), at significant differences and assessment
reputations for 100 patients, 53 were of patients being baseline (n=53), and procedures informal
healing mental inpatients and the treated as inpatients 6–9 months later and poorly described.
disorders vs focus of this paper at the healing centres (n=16). Psychiatric standard of
2 allopathic Researcher rated care not outlined. High
psychiatric hospitals “degree of decline or risk of rater bias
and an Ayurvedic improvement” on
hospital 7-point scale
(Table 2 continues on next page)

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Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
(Continued from previous page)
Hurst et al USA Prayer sessions lasting Conference attendees Participants: n=78 No formal diagnoses Custom questionnaire Intervention group Substantial loss to
(2008)53 6–7 h as part of “Steps were invited for selected for inclusion; made. before and after reported deductions follow-up. Control
to Freedom in Christ” interview, then controls: n=40 Selected for inclusion healing session in symptom scores of group and assessment
at a conference vs selected if reported if “significant (n=78). Repeat 42–49% (p<0·005) procedures not
controls who psychological depression (including questionnaires and improvements in described. Unclear if
volunteered at problems suicidality), anxiety or returned by functioning of controls had any
church, had not other typical self-addressed 14–45% (p<0·05). psychological
attended conference, presenting problems” envelope 7 days and Controls had complaints
and had no 3–4 months later non-significant
intervention (n=33) changes
Boelens USA Six prayer sessions Recruited from Prayer intervention: Diagnosed in HAM-D, HAM-A, Significant reduction Unusual effect sizes for
et al lasting 60 min over medical physicians n=27; controls: n=36 outpatient setting LOT6, and DSES7 (p<0·01) in HAM-D, prayer group: HAM-D
(2009)50 6 weeks, conducted through posters, (no intervention) with DSM-IV before, after, and at HAM-A, DSES and effect size 3·0, HAM-A
by lay-preacher with some directly from depressive disorder 1 month following significant increase in effect size 4·1. Beliefs
participant. community (most also with intervention LOT after and expectations of
No explicit anxiety). No further intervention and at participants not stated.
psychotherapy or details provided 1 month follow-up in Self-selection bias likely.
touch involved prayer group. No Control condition
changes in control poorly matched
group
Case–control studies
Salib and Egypt Private psychiatric Patients with 20 cases and Clinical diagnosis of Outcome was acute Cases: 85% relapsed Cases were defined by
Youakim hospital. Cases schizophrenia drawn 20 controls. All on schizophrenia by relapse of and required hospital increased and excessive
(2001)68 received religious from register of maintenance hospital psychiatrist schizophrenia admission; controls: personal religious
healing before study psychiatric hospital, antipsychotics. satisfying ICD-10 necessitating hospital 60% relapsed and activity and religious
and during follow-up. age >60 years Matched for age, sex, criteria. Mean admission following required admission healing such as
Controls received no and illness duration duration of illness stable remission (p<0·05) attendance at healing
spiritual healing and 21 years (SD 8) period, over rituals including
had TAU 18-month period witchcraft or exorcism.
Reverse causality might
bias results
Uncontrolled naturalistic cohort studies
Harding Nigeria Traditional healer’s All patients with 24 patients. 50% Researcher interview Assessed during the At 3-month and Outcomes compared
(1973)65 compound in western psychosis who were male, mean age and observation. No admission, and 6-month follow-ups, favourably to outcomes
Nigeria. Treatments unwell enough to 33 years diagnostic schedule followed up with at least a third were in Western psychiatric
included need admission to specified. informal interview at fully recovered, at hospitals in
confinement, the healer’s Schizophrenic 42%, patients’ homes least a third had slight contemporaneous
chaining (for compound during a manic 33%, depressed 3 months and incapacity, and less reports
violence), herbal period of 6 months 21%, other 4% 6-months after than a third were
remedies, divination, discharge. No details severely incapacitated
chanting, communal of outcome
work. Modal stay assessments provided
6–10 weeks
Kleinman Taiwan Shamanic treatment Consecutive clients 19 patients, of whom No formal diagnoses Semi-structured Mixed results. Some patients followed
and Sung at tang-ki shrine. Brief attending a tang-ki 6 had psychological made. Patient interview at clients’ 5/6 rated treatment shaman’s assuredness
(1979)61 shamanic rituals, shrine over 3 days problems: women complaints labelled by homes 2 months after “effective” or of effectiveness, or
followed by aged 22, 25, 54, and researchers as initial visit, exploring “partially effective”. feared prejudicing the
meditating or 61 years; man aged somatisation (n=3), perceived Patients’ evaluation gods. Incomplete
praying. Other cult 31 years; and boy aged anxiety (n=1), bad effectiveness of of effectiveness and reporting of results.
members assist in 10 years behaviour (n=1), and healing and perceived symptom change Loss to follow-up might
healing depression or symptom change. sometimes differed bias findings towards
personality (n=1) 7 clients lost to better outcomes
follow-up
Finkler Mexico Brief ritual interaction Every fifth patient 107 patients. No formal diagnoses Initial assessment at Failures 35·5%, Only successful
(1980)40 with a curer at was eligible. 15% male and 27% made. A third of temple by researcher, successes 25·3%, outcomes reported in
Spiritualist temple in Follow-up sample children complaints had with home follow-up inconclusive 20%, detail, unclear how
rural Mexico. Ritual lived nearby, overtly psychological 7–13 days and other 19%. Cornell many unsuccessful
includes light touch, consented, and were component 30–45 days later. Medical Index scores psychological
blessing, symbolic not regular attenders (eg, nerves, Cornell Medical Index1 improved to similar outcomes. Some
cleansing, brief nightmares, feeling and subjective degrees in both patients reported
history taking, angry, seeing dead assessment of the perceived successes success despite
healer’s trance, people, “cerebro”) treatment received and failures continuing symptoms
and herbs
(Table 2 continues on next page)

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 Review

Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
(Continued from previous page)
Salan and Indonesia Ritual healing in Patients selected 90 patients with an Clinical assessment by Semi-structured Improvement Diagnoses were unclear
Maretzki 9 healers’ offices or “somewhat even age distribution physician. No interviews and Cornell reported in 60% and and not rigorous.
(1983)12 houses. Various arbitrarily” if willing from <20 years to schedule. 61% had Medical Index1 57% of psychological Incomplete reporting of
methods including to participate in 60 years. 38% male, psychological or immediately after the and major disorders results. Possible
holy water, Koranic interviews and fill in and all lower or psychiatric problems, healing session, and at respectively, although response bias due to
talismans, herbs, questionnaires lower-middle class 15% had major home 2–4 weeks later, half were regarded as influence of
palpation, exorcising mental disorders especially “views self-limiting. Great Western-trained
rituals, divination, (mean duration concerning the variation between clinicians. Possible bias
and trance 4·7 years) outcome of individual healers due to convenience
treatment” sampling
Peltzer and Malawi Traditional healing Patients selected if 51 patients. No details Diagnostic procedure Unstructured 51% “improved”, Unclear and incomplete
Machleidt community for semi-structured given not described. interview including 28% “not improved”, data reporting, text
(1992)59 inpatients. Daily tasks interview revealed Neurotic and subjective 22% “no follow-up” does not agree with
included chores, mental disorder. No personality disorders improvement rated by tables. Possibility of
prayer, music, dance, details of selection 35%, psychosocial patients and relatives investigator bias
possession, rituals, procedure given disorders 33%, at next visit to healing
ancestor veneration, schizophrenia 28%, centre or elsewhere
sacrifices. Mean affective disorder 4% within 1 year.
duration 8 months 11 patients lost to
follow-up
Wirth USA Multiple 15–30 min Consecutive new 48 patients, of whom Independent medical General Well Being Significant No clinician ratings.
(1995)60 healing sessions over patients attending 6 had mental diagnoses were used Questionnaire,2 Health improvement on all Choice of non-
3 weeks in Espiritista Espiritista healer disorders. 64% white. “when available”. Perceptions measures (p<0·05) dominant healing
healer’s office. 38% Christian, 15% Mostly chronic Questionnaire,3 with including worry/ paradigm could lead to
Idiosyncratic methods Jewish, and 15% physical disease. postal questionnaire concern, sickness self-selection bias. 31%
based on spiritual Atheist Mental disorders follow-up 18–25 days orientation, anxiety used other treatment
power, laying on of included anorexia, later. Patient and depression. concurrently. Perceived
hands, and religious depression, and expectations assessed Improvement cure 12·5%, significant
icons manic depression with 3-item correlated with Improvement 52%,
questionnaire expectations slight improvement
(no details) 25%, no change 10%
Lemelson Bali, Treatment by Muslim Patients with 22 patients. Obsessive Diagnoses of Subjective 1 patient noticed Potential reporting bias
(2004)67 Indonesia dukuns, including obsessive-compulsive compulsive disorder obsessive-compulsive improvement, improvement in since no rating scales
religious ceremonies, disorder and/or mean age 39·9 years disorder and/or assessed by interviews symptoms, which were used. Potential
massage, incense, Tourette’s syndrome (SD 16). Tourette’s Tourette’s syndrome over 20-month was temporary. No sampling bias skewed
sorcery, charms, and recruited from syndrome mean age made by psychiatrist duration of study. other improvements towards protracted and
sacrifices. Some psychiatrists and not reported according to DSM-IV No details provided. noted severe cases recruited
patients attended neurologists in Bali and ICD-10 No Y-BOCS outcomes from specialists
several times definitions, using reported
items from the CIDI
and Y-BOCS
Zacharias Mexico Curanderos Inclusion required 8 patients. 37% male. ICD-10 criteria. Semi-structured Improvement after Patient selection and
(2006)57 diagnosed and presence of 7 adults (mean age Procedure not interview treatment: rating procedures
treated by divination, psychological 30 years), 1 child (age described. pre-treatment and 4 complete, 3 partial, poorly described,
tactile contact, disorder, degree of 9 years) Adjustment disorders post-treatment and 1 no data. At potential for selection
symbolic rituals, self-reflection, n=4, chronic pain n=1, 6 months’ follow-up, 6 months: and rater bias. 6-month
spiritual practices, and availability, and panic n=1 (both with including rating of 6 complete follow-up not
occasional catharsis. consent anxiety/depression), degrees of improvement, 2 no described. Long
Multiple sessions over substance improvement from data. Less severe follow-up and mostly
weeks to months dependence n=1, “deteriorated” to disorders improved self-limiting conditions
schizophrenia n=1 “fully or very more than did
improved” schizophrenia
Schiff and North Sweat lodge All participants who 42 patients. 59% No diagnoses or Health screening No significant No diagnoses
Moore American ceremony as practised arrived early to fill in indigenous First complaints noted questionnaire (SF-364) changes in mental or mentioned
(2006)56 Native by First Nation’s baseline Nation people, and Heroic Myth physical health scores (self-selected sample
healing People of Canada. questionnaire were 41% not indigenous. Index5 immediately on SF-36, probably who may have
(USA) Lasts up to 3 h and invited to take part 75% had attended a before and after because of ceiling attended for general
culminates in a feast. ceremony before ceremony (including effect and small wellbeing). Ratings
Ceremony not feast). Long-term sample size. Innocent, done 3 h apart,
described out of outcomes not tested Sage and Warrior potential for
respect to elders scales increased expectancy bias
significantly on
Heroic Myth Index
(Table 2 continues on next page)

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Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
(Continued from previous page)
Lee et al Singapore Chinese dang-ki Patients in lobby of 21 patients, of whom No formal diagnoses Three ethnographic Post-treatment: Inconsistent reporting,
(2010)62 healers in three shrine who gave 9 had psychosocial made. Presenting interviews at the 5 helpful, 3 not sure no details of 1 month
selected shrines. consent and issues (reported here). problems included shrine immediately but hopeful, and outcomes. Only 3 of
Healing involved presented with health Mean age 44 years, anxiety, depression, before and after the 1 unhelpful. At 9 patients thought
trance, divination, or psychosocial 33% with a nightmares, bad luck, healing, and by phone 1 month, “as a whole their problems were
advice, divine writings problems high-school unemployment, and 1 month later. the consultations solved. Worry of
and symbols, and education, and interpersonal Focused on research were considered offending the gods
talismans 66% employed problems questions including helpful” might bias ratings at
perceived helpfulness shrine
of dang-ki
Boelens USA This study is the Initial recruitment as 63 initially enrolled, Diagnosed in HAM-D, HAM-A, Decreases in HAM-D, Adjunctive
et al one-year follow-up of for the 2009 study. 48 of whom received outpatient setting LOT6, and DSES7 HAM-A, and DSES psychotropic
(2012)66 Boelens and Control participants prayer intervention. with DSM-IV repeated 1 year maintained at 1 year medication was
colleagues’ 2009 could choose to enter Mean age 48 years, depressive disorder following (p<0·01). Increase in allowed before and
study50 (described prayer intervention all women (most also with intervention. LOT maintained at during study. Beliefs
above). The prayer anxiety). No further 4 participants lost to 1 year (p<0·01) and expectations of
group and crossover details provided follow-up participants not stated.
prayer group received Self-selection bias likely
no further
interventions during
the year
Abbo et al Uganda Traditional healers at Patients attending 115 patients aged SRQ-25 and MINI. All Assessment at >20% improvement Ratings were blinded.
(2012)63 their shrines in two traditional healer >18 years, mean age had psychosis baseline, 3 months, in all scales at 3 and 80% of patients
districts of eastern shrines who 34·5 years (SD 8), (psychotic depression and 6 months 6 months, all attended local
Uganda. Treatment answered yes to any 56% male patients 40%, mania 36%, (follow-up rates of significant. Greatest psychiatric clinics
not specified screening questions schizophrenia 24%) 87% and 78% improvement for concurrently. Clinic
for psychosis were respectively) using mania, smallest in attendance decreased
included PANSS, YMRS, schizophrenia caseness at 3 months
MADRS, CGI, GAF, and but increased caseness
COMPASS at 6 months, compared
with non-attendance
Sorketti Sudan 10 randomly selected All inpatients 129 patients, mean Schizophrenia PANSS assessed on Reduction in PANSS Potentially harmful
et al traditional healing receiving treatment age 29 years (range diagnosed on MINI. admission and from 118·36 on interventions included
(2012)64 shrines. Treatments in the shrines with a 16–55), 71% male, Mean duration of discharge. Mean admission to food restriction,
included admission, diagnosis of 25% with secondary untreated psychosis duration of admission 69·36 on discharge. chaining, isolation,
reciting holy verses, schizophrenia education or higher, 15·8 months 4·5 months, median Reduction in total beating, and stopping
inhaling holy smoke, 54% not working <2 months and all subscales was psychiatric treatment
and holy water (see statistically (in 20%)
also the Comments significant
column)
Mainguy Canada Canadian Aboriginal Participants 155, of whom 35 had Diagnostic procedure Phone contact at 5-year outcomes of Unclear if all
et al healing, including contacted author psychiatric not specified. regular intervals psychiatric 155 patients were
(2013)58 sweat lodge requesting traditional complaints. Diagnoses: anxiety (usually every complaints: cured 15, followed up over
ceremony, Aboriginal healing Participants were disorders 12%, mood 6 months for 5 years). better 12, the same 7, 5 years. Loss to
storytelling, daily non-Aboriginal, disorders 8%, other Medical outcomes worse 1, dead 0 follow-up not
prayer ceremonies, median age psychiatric disorders rated on 5-point Likert mentioned
and sacred pipe, 40–49 years 2% scale from +2 (cured)
followed by to 0 (no different) to
debriefing −2 (dead).
(Table 2 continues on next page)

Three retrospective surveys recruited patients with
mainly neurotic disorders from the shrines of healers or
directly from the community.10,18,69 In these surveys,
treatments by shamans and religious healers for mainly
depression in Pakistan achieved only modest ratings of
satisfaction,18,69 by contrast with a Kenyan survey that
indicated that 95% of patients were satisfied with the
traditional healing they had received.10 The wide variation
in results could represent real differences in effectiveness
of the respective healers, or might be caused by the
sensitivity of subjective ratings to procedural aspects of the
studies, such as the timing, location, and the wording of
questions. Lemelson67 noted that traditional healing is
often thought to help individuals to reframe and make
sense of their illnesses, but that this highly subjective
process might not necessarily improve underlying
neuropsychiatric symptoms. He therefore studied the
effectiveness of Balinese traditional healers in treating the
symptoms of obsessive compulsive disorder or Tourette’s
disorder, which are less responsive to non-specific
therapies than common psychosocial problems. Of
22 patients with these disorders who had repeatedly

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 Review

Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
(Continued from previous page)
Retrospective surveys
Campion South Psychiatric outpatient Consecutive patients 198, of whom 89 had ICD-10 diagnoses by Semi-structured “Subjective 90% of patients had
and Bhugra India clinic. Previous attending during a previously consulted researcher: mood interview with improvement in stopped religious
(1997)73 religious healing 3-month period religious healers. disorder 27%, patients and relatives symptoms” rated by treatment by the time
included chanting 81% Hindu, 9% neurotic or stress at the outpatient 33% of Muslim of psychiatric
mantras, thayath Muslim, 10% Christian disorder 23%, clinic, including patients, 35% of consultation. Hospital
(amulets), ingestion psychotic disorders questions about the Christian patients, sampling might
or sprinkling of ash or 23%, substance use patients’ contact with and 23% of Hindu introduce bias
holy water, 12%, other 15% religious healers patients
take-home objects,
and sacrifices
Bhana South Psychiatric outpatient Indian patients who 86, all of whom had Diagnosis from Semi-structured Doctors: effective Timing of previous
(1986)71 Africa facility. Previous had previously first consulted hospital notes: interview by 70%, not effective healer contact not
spiritual healing attended a spiritual spiritual healers schizophrenia 56%, psychologist with 26%; healers: specified. Hospital
included application healer depression 22%, patient and family effective 53%, sampling might
of ashes, cloves, lime, epilepsy 14%, member, including not effective 40%; introduce bias.
amulets or holy water, behaviour patients’ perceptions only the doctors 40% believed that both
prayer or fasting, and problems 7% of “effectiveness” helped 26%; only the doctors and healers had
other rituals and healers helped 8% helped
sacrifices
Gadit Pakistan Shrines, mosques or Patients visiting “About 400”. No other Diagnosed by Semi-structured Patient reports: 30% Timing of interview
(1998)18 residences of shamans. Selection details given psychiatrist using interview by “entirely satisfied” and treatment not
100 shamans in not described DSM-IIIR criteria. psychiatrist in with shamanic specified
Karachi districts. Diagnoses: depression shamanic place of treatment; 70%
Treatments included 80%, psychosomatic healing (details not “mixed feelings”
amulets and disorders 5%, epilepsy given). Patient
talismans, holy water, 7%, psychosis 6%, interviewed at time of
recitations, and rituals no disorder 2% visit to shaman (no
details given)
Ensink and South Two psychiatric Random sample of 62, of whom 36 had Diagnoses by Semi-structured For diviners and faith Generally low
Robertson Africa hospitals in Cape first admission consulted diviners or psychiatric services questionnaire healers: carers satisfaction with
(1999)70 Town. Details of African patients faith healers in the (no details given). exploring 30% satisfied, traditional healing.
previous healing past 12 months Most had acute “satisfaction” with all 70% uncertain or Diviners in particular
interventions not psychosis, organic services used. Main dissatisfied; patients criticised harshly.
described syndromes, caregiver and patient 47% satisfied, Psychiatric services
parasuicide, or mood interviewed at 53% uncertain or rated as more
disorder. No details patient’s home. dissatisfied satisfactory. Hospital
given Timing of interview sampling could bias
unclear selection
Mirza et al Pakistan Mental health Convenience sample 150, of whom 72 had Diagnosed by Semi-structured For religious or faith GPs received highest
(2006)69 consultation day in of attending villagers consulted religious or registrar-grade interview, including healers: 20–23% ratings of effectiveness.
village in rural who had faith healers psychiatrist or higher. rating of effectiveness response for Ratings were
Pakistan. Healers seen psychological Depression 68%, of previous depression, 22% retrospective, with no
included religious complaints and gave other 27% (mainly treatments on 4-point response for other apparent time limit on
healers (use Islamic consent epilepsy) Likert scale, then complaints when previous healers
teachings) and faith collapsed to “response were consulted
healers (for removing or not”
black magic or
harmful spells)
(Table 2 continues on next page)

consulted dukuns (Indonesian shamans), only one patient
noted a temporary improvement. He suggests that the
psychosocial techniques used by traditional healers are
ineffective in treating neuropsychiatric symptoms.
Although wide variation exists, traditional healers in
general could be modestly helpful in the treatment of
common mental or neurotic disorders that are most
amenable to psychosocial interventions. In particular,
patients with mild depression and anxiety tend to
respond favourably to repeated, regular, intense
contact with a traditional or spiritual healer.49,51,57,58,66
By contrast, less malleable symptoms such as obsessions
or tics might be less amenable to such support.67
Culture-bound syndromes
Surprisingly, the only study to assess the outcomes of
culture-bound syndromes as diagnosed by traditional
healers is a retrospective survey by MacLaren and
colleagues.72 They recruited patients in remote hamlets
in the Solomon Islands who had been treated by

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 Review

Study Setting and Patient selection Sample size and Diagnostic Assessment Results Comments
location intervention* characteristics procedure and procedures and
diagnoses* outcome measures
(Continued from previous page)
Kurihara Bali, Sampling at Consecutive new 54, of whom 47 had Diagnosed by Once psychiatrically 29·8% “much Treatments included
et al Indonesia psychiatric hospital, patients at psychiatric attended traditional psychiatrist using stable in own home, improved”, sprinkling or ingesting
(2006)7 interview in patients’ hospital healers ICD-10 criteria. 80% patients rated 38·3% “improved”. of holy water, chanting
home. Previous with psychotic “treatment effect” of (No data reported for mantras, advice,
healing interventions symptoms, 57% the traditional healer other outcomes). religious ceremonies,
by Hindu (95%) or admitted to hospital. on 5-point Likert Non-psychotic use of oil, herbal
Muslim (5%) healers 40 schizophreniform, scale: “much complaints rated medicine, and massage.
17 with mood, stress, improved”, significantly more Hospital sampling
or other disorders “improved”, “no improved than could introduce bias.
change”, “worse”, or psychotic complaints Ratings were
“much worse” retrospective
MacLaren Solomon Treatment by Patients who had 20 patients, 30 family Patients were Single discussion with 50% reported Buru possession
et al Islands community been possessed in the members diagnosed by patients and family complete cure, symptoms include
(2009)72 traditional healers in past and their family traditional healers members, rating 30% reported mutism or
five remote hamlets members. Selection with buru possession subjective temporary relief with over-talkativeness,
of the Solomon process not described (culture-bound improvement. later relapse, and 20% suicidal ideas, delusions,
Islands. Includes: food syndrome, see No details given reported no relief aggression, or social
taboos, divination, Comments column). isolation, lasting 1 day
and ritual smearing Psychiatric diagnoses to several weeks, rarely
with crushed lime and not given becoming permanent
leaves
Salem et al United Psychiatric outpatient Consecutive new 106, of whom 45% Consultant Semi-structured Of those who Patients with psychosis
(2009)74 Arab department and outpatients and all had consulted faith psychiatrist made interview with consulted faith visited faith healers
Emirates inpatient unit. admissions over healers before diagnosis using patients after seeing healers, 45% reported more frequently and
Interventions by 9 months in 2003 attending psychiatric ICD-10. Psychotic psychiatrist. Custom some improvement made more
Islamic faith healers services disorders 23%, questionnaire but symptoms supernatural
included prayers and depression 25%, included details of recurred later, 47% no attributions of illness
herbs anxiety 26%, other previous contact with improvement, and than depressed or
non-psychotic healers and views on 8% got worse anxious patients.
disorders 26% outcome. No further Hospital sampling
details given could introduce bias.
Ratings were
retrospective
Mbwayo Kenya 59 traditional healers Selection of patients 305, of whom 196 MINI-plus Nursing students did 95% responded Traditional healers
et al in 3 districts around attending healers not had a mental disorder administered by “in-depth interviews” reported satisfaction diagnosed only
(2013)10 Nairobi. Treatments specified diagnosed using trained lay with patients with traditional 27 patients with mental
included counselling, MINI-plus interviewers. Major including “patients’ healer services illness (mostly
herbs for ingesting, depressive disorder satisfaction with psychosis) and 15 with
washing or inhaling, 20%, post-traumatic services offered by witchcraft or
divination, and stress disorder 15%, traditional healers”. possession, compared
removal of bewitched generalised anxiety No further details with 196 diagnosed
items disorder 10%, other given using MINI
anxiety disorders
10%, alcohol misuse
9%, schizophrenia 7%

TAU=treatment as usual. GP=general practitioner. HADS=Hospital Anxiety and Depression Scale. HAM-A=Hamilton Rating Scale for Anxiety. HAM-D=Hamilton Rating Scale for Depression. LOT=Life Orientation
Test. DSES=Daily Spiritual Experiences Scale. ICD-10=International Classification of Diseases 10th edition. CIDI=Comprehensive International Diagnostic Interview. Y-BOCS=Yale–Brown Obsessive Compulsive
Scale. SQR-25=Self Reporting Questionnaire 25.10 MINI=Mini International Neuropsychiatric Interview. PANSS=Positive And Negative Symptoms Scale. YMRS=Young Mania Rating Scale.
MADRS=Montgomery-Asberg Depression Rating Scale. CGI=Clinical Global Impression. GAF=Global Assessment of Functioning. COMPASS=COMPASS Mental Health Index.9 CGI=Clinical Global Impression.
MDD=major depressive dsorder. MINI=Mini International Neuropsychiatric Interview. *Treatments or diagnoses are ordered from most to least common.

Table 2: Studies assessing the effectiveness of traditional healers—summary of findings

traditional healers for buru (possession; symptoms
listed in table 1). Subjective rates of permanent cure
were 50%, with 30% finding temporary relief and 20%
reporting no improvement.
Mixed diagnoses
Several earlier studies adopted an ethnographic approach,
which typically has a greater focus on qualitative than
quantitative outcomes and uses a less rigorous
experimental design.77 In an ethnographic study, the
researcher, usually an anthropologist, embeds herself
within the social context of an interaction to explore its
meaning and social function in an open and unstructured
manner.78 Diagnoses are necessarily often unclear or
mixed. Despite the different emphasis, some ethnographic
studies report quantitative outcomes. Finkler40 in Mexico
critically assessed the success rates of spiritualist healers.
Her sample with mixed physical and psychological

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complaints reported more perceived failures (36%) than
successes (25%), although incomplete reporting of
outcomes prevents a detailed analysis. Salan and
Maretzki’s12 sample of patients attending Indonesian
traditional healers with a wide variety of complaints
reported high rates of improvement (60%) for psychological
and psychiatric problems. They also found some healers
performed consistently better or worse than others.
However, poor reporting and vague diagnoses make
detailed analysis difficult. Peltzer and Machleidt59 followed
up patients with mixed psychiatric disorders who had been
admitted to a traditional healing centre in Malawi.
Follow-up within the year after discharge showed that half
of the patients and their relatives felt that the patient’s
condition had improved, although almost a third denied
any improvement, with the rest of the sample lost to
follow-up. A follow-up study by Wirth60 that recruited
mainly non-indigenous white patients attending an
Espiritista healer in California, USA, used a validated scale
to show improvements in general wellbeing, which were
predicted by the patients’ pre-healing expectations.
Two controlled studies of spiritual healing in the UK49 and
a Native American healing ceremony51 recorded significant
improvement in depression ratings and subjective
improvement, respectively, compared with controls.
However, both studies had notable flaws, including control
conditions that were poorly matched to the intensity of the
active interventions.
In four retrospective surveys,70,71,73,74 patients with mixed
psychiatric disorders were recruited from psychiatric
clinics or hospitals and asked about their experiences of
traditional healing. Perhaps unsurprisingly, these
patients typically reported some ambivalence or frank
dissatisfaction with their previous traditional healing,
although sampling and assessment factors might have
biased these findings.
Discussion
We found 32 studies that reported quantitatively about
the effectiveness of traditional healers in treating
mental disorders and psychological distress. Although
substantial shortcomings exist in the published literature,
some generalisations can be made. Acute relapses of
major mental illnesses such as schizophrenia and bipolar
disorder tend to improve with time under the care of
traditional healers, although improvements might
represent the natural course of the illness. The small
amount of available evidence suggests that traditional
healing methods have little effect on the long-term
course of chronic illnesses such as schizophrenia and
obsessive-compulsive disorder. Common mental
disorders, such as depression, anxiety, and somatisation,
and interpersonal and social difficulties, seem to be more
likely to respond to traditional healing interventions,
which might be at least as effective as primary psychiatric
care in the countries studied. These findings are
consistent with modern psychiatric guidelines that
www.thelancet.com/psychiatry Vol 3 February 2016
Review
recommend psychosocial interventions as first-line
treatment for common mental disorders, but only as
adjunct therapy for major psychiatric disorders such as
psychoses and mania.79
The reviewed studies provide some insights into the
mechanisms that enable positive outcomes for traditional
healing. Two studies55,60 reported a significant effect for
patient expectancy and belief on outcome. Similarly,
two studies12,54 showed that individual healers can differ
substantially in their effectiveness. Indeed, positive client
expectations and the personal qualities of the healer are
core ingredients of traditional healing and Western
psychotherapy alike, suggesting that these disciplines
might share some therapeutic mechanisms.80–82 In
traditional healing especially, ritual and ceremony can
encourage successful outcomes by increasing expectancy
and the belief in the authority of the healer.83 Interestingly,
belief in the power of the ceremony and the healer’s
authority might be helpful even in the absence of a
shared cultural heritage, as shown in the two studies that
report favourable outcomes for non-indigenous
patients.58,60 Going further, a German study showed that a
contrived spiritual ceremony with no overt meaning was
found to improve participants’ mental, spiritual, and
physical quality of life.76 The role of ritual, metaphor, and
meaning in traditional healing is described well
elsewhere.36,41,83
Limitations of the published literature
Overall, the quality of studies is poor when viewed
through the lens of rigorous psychiatric research. Most
trials do not include a control group, and therefore to
assess whether any changes over time differ from the
natural course of the illness is difficult. This situation is
particularly problematic for psychiatric illnesses in
which the natural course of symptoms can wax and
wane. Spontaneous improvement might therefore be
wrongly attributed to the healing intervention. In many
studies, patients attending traditional healers are a self-
selected group with high expectations, which limits the
generalisability of the results to the general
population.40,50,51,53,56–58,60,66 For example, in Mehl-Madrona
and colleagues’ controlled follow-up study of
Native-American healing,51 patients actively sought
alternative healing and elected to travel from out-of-
state for the intervention, whereas control patients
merely attended local hospitals. Patient diagnoses are
often vague and subjective, and diverse psychiatric
diagnoses are frequently grouped together, sometimes
with physical complaints. Outcome assessments often
use non-validated rating scales or interviews. Ill-defined
subjective measures (eg, “satisfaction” or “helpfulness”),
although useful, are prone to different interpretations
by patients and researchers and are especially
vulnerable to response and expectancy biases. Patients
might attempt to produce socially desirable responses
in their interactions with both researchers7,12,42,54,70 and
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 Review
traditional healers.54,61,62 Researchers themselves might
give biased ratings in studies without masked control
interventions.49,51,59,67,75 Many studies do not adequately
describe their assessment procedures and might not
sufficiently acknowledge and minimise these sources
of bias. Data reporting across studies is inconsistent
and patchy, with studies often omitting actual scores
from assessment scales and not providing reasons for
loss to follow-up. Finally, the healing interventions
themselves are heterogeneous and not standardised—
both between and within studies—making it difficult to
tease out which components of the intervention
contribute to effectiveness. Notably, the most
methodologically flawed studies often find the most
unambiguous and impressive effects.49,53,58,84
Limitations of this Review
Other limitations of this Review include the wide
heterogeneity of studies, which allows only broad
generalisations to be made. Despite some commonalities
across different healing modalities, such as a shared
spiritual perspective, cultural endorsement, and
extensive use of rituals and ceremony, substantial
differences in practice remain. For example, healing
interventions might be brief or long, personal or
impersonal, inpatient or outpatient, and involve private
ritual or public ceremony. A review cannot do justice to
each study, and interested readers are referred to the
individual studies. Second, our literature search,
although extensive, might not be exhaustive since this
topic extends across several disciplines and is not well
defined. Older studies in particular might not be
indexed in electronic databases and are more often
unavailable for potential inclusion. Finally, this Review
does not discuss the potential harms of traditional
healing, which would normally form part of a review of
effectiveness. Although numerous case reports exist
describing harms such as beating, deprivation, and
chaining, the studies included here did not report on
these harms.
Challenges of assessing outcomes of traditional healers
Assessment of the outcomes of traditional healing is
fraught with difficulties, and some have argued that
non-western healing should not be subjected to western
standards of scientific evidence at all.85,86 Traditional
healing is an extreme example of a complex intervention,
which does not submit easily to the standard models of
evidence-based medicine even in relatively well-resourced
ideal settings.87–89 Therefore, it is not surprising that the
studies reviewed here often fall short of rigorous
standards of acceptable evidence. Nevertheless, in the
interest of evidence-based practice, evaluations must be
made, however problematic they might be. Moreover,
assessment of traditional healing presents particular and
unique challenges related to trial design, implementation,
and evaluation.
166
Design
Control groups are essential, but to identify a suitable
control to compare with traditional healing is difficult.
Traditional healing is embedded in culture, and
evaluations of its effectiveness are only likely to be valid
for people within that particular culture. Culturally
foreign control interventions, such as a waitlist group,
psychotherapy, medication, or non-specific support,
suffer the disadvantage of not meeting important
cultural needs and expectations. Withholding culturally
expected treatment for the sake of a control condition is
also likely to increase distress and might not be viewed
as ethical.63,90 Some studies in this review42,52,54,55 therefore
forego randomisation and give patients the choice of
allocation to traditional healing or a control condition of
conventional treatment. Although this approach
introduces selection bias, these studies usefully assess
the effectiveness of traditional healers, for those who
choose them, compared with conventional treatments,
for those who choose them. This finding can inform
clinicians about whether an intervention works for
patients who choose it.90,91 Since patient expectations and
beliefs are not easily changed or controlled for, these
patient factors should be incorporated into evaluations
of treatment effectiveness as treatment–patient
interactions.55,60 This concept is not new: treatment–
genotype–phenotype interactions are increasingly
important considerations in clinical psychiatry.92
Standardisation of treatment is similarly poor when
studying traditional healing. An empathic traditional
healer, like a good psychotherapist, will adjust and tune
their approach to the nuances of the client’s problem,
rather than applying a standard treatment dictated by the
symptoms.89,93 In addition to this within-session
variability, treatment styles and techniques differ from
region to region, and even from healer to healer within
the same village.12,94 Indeed, as is the case for studies of
psychotherapy, different healers working within the
same paradigm can achieve very different results.12,15,54
Manualisation of an intervention, or indeed placing most
forms of constraint on it, would probably interfere with
the process and outcome, and is strongly resisted by
traditional healers themselves.84 Therefore, we should in
principle extend our analysis to treatment–patient–healer
interactions to obtain optimum predictive value.
Implementation
Patients routinely use both conventional medical services
and traditional healing when both are available, and to
prevent such an approach would be both impractical and
unethical, which makes it difficult to distinguish
traditional from conventional healing effects.63,66 Language
and cultural barriers might be substantial for non-native
investigators.39,75 The choice of dialect and style of
translated questionnaires could prime nuances of status
and hierarchy which can affect results,67 and to ask
participants about certain demographic variables, such as
www.thelancet.com/psychiatry Vol 3 February 2016

age, might be a spiritual taboo.95 Other investigators have
found that to gain access to the private and sacred rituals
of traditional healing can be difficult for outsiders.38,56,96,97
More importantly, once trust and confidence are gained,
the presence of the researchers might affect the process
and outcome of treatment.54 The healing experience of
sacred and private rituals could be undermined by
outside scrutiny, and scientific researchers might bias
responses.39,56,57 These effects are likely to be significant in
traditional healing, which mainly relies on more malleable
psychological and social processes.38
Profoundly different understandings of health and
illness between traditional healers and modern medicine
confound attempts to create a patient group that conforms
to both psychiatric and traditional diagnostic categories.
Traditional diagnosis aims to find the ultimate meta-
physical cause of a disturbance, such as spiritual neglect or
witchcraft, whereas psychiatric diagnosis focuses on the
symptoms and behaviour, remaining steadfastly agnostic
regarding the ultimate cause. There is at best a tenuous
link between diagnoses generated by these different
systems.37,98,99 This tension is evident in the reviewed
studies, which generally made little attempt to single out a
psychiatric diagnosis for study and often grouped physical
and mental presenting complaints together.
Acknowledging this, we cast a wide net in this Review and
included studies with heterogeneous diagnoses or
complaints. We believe that our approach is justified
because a high proportion of complaints brought to
traditional healers are psychological in nature47 and many
patients with psychiatric problems present to traditional
healers with somatised physical complaints.55,98,100
Evaluation
Evaluation of the effectiveness of an intervention depends
critically on the concept of effectiveness. Modern
psychiatry typically interprets effectiveness in terms of
symptom improvement as measured on a validated rating
scale. This simplification strives for specificity, objectivity,
and quantifiability, removing ambiguity and clutter while
focusing on what are believed to be the core features. It
focuses on malfunctioning biological or psychological
processes—the disease—rather than the personal and
social experience that constitutes the illness (using
Kleinman’s distinction101). Although undoubtedly
powerful, this view makes particular culture-specific
assumptions about what is most important. In doing so,
it might ignore aspects of effectiveness that are especially
valuable and relevant in other cultures.41 Less specific and
more subjective outcomes, such as “satisfaction” or
“helpfulness”, as assessed by some of the reviewed
studies, might capture other aspects of effectiveness that
are important to the patient. These outcomes could be
useful indicators of the patient’s self-perceived health
status and ability to function, which are important social
and economic outcomes.40 The distinction between illness
and disease is shown in some of the reviewed studies that
www.thelancet.com/psychiatry Vol 3 February 2016
Review
showed that subjective impressions of effectiveness do
not necessarily correlate with symptomatic
improvement.55,61,62,102 Clearly, patients’ assessments of
effectiveness do not necessarily align with scores on
psychiatric rating scales. Patients also judge success
according to a healing system’s ability to provide internally
consistent and satisfying explanations for sickness and
misfortune,55,103 or by the ability to maintain social
connections and social structure.102 Implicit in the
psychiatric approach is the assumption that successful
treatment involves a restoration to a previous level of
wellbeing or functioning.104 Waldram makes the useful
observation that many traditional healing paradigms,
however, facilitate transformation of the person from
illness to wellness, which might not involve curing the
disease.104 Although the degree of restoration can be
quantified in principle, transformation implies a
qualitative change that is difficult to measure (although
this has been attempted105). Such transformation from
illness to wellness, or from one state of illness to another,
is a crucial aspect of the so-called performative efficacy of
traditional healing, by contrast with the fastidious efficacy
of medicine that demands specific biological changes.106
The performance of symbolic rituals rich in meaning and
metaphor facilitate the patient’s transition, independent
of any change in symptoms.41,83 The healer’s ritualised
divination and explanation, followed by the prescribed
ceremonies, might substantially relieve distress and
prime positive expectations. Similarly, of course, the
conventional doctor’s ritualised examination and
explanation, followed by the prescribed remedy, might
considerably relieve distress and prime positive
expectations long before any medication is swallowed.
Conclusions
Despite the limitations of the published literature, it
seems reasonable to conclude that many people,
especially those with less severe complaints and positive
expectations, derive subjective benefit from attending
their chosen traditional or spiritual healers. Value seems
to exist in attending a traditional healer for those who
choose to do so and who find the process meaningful.
This benefit might occur without a concomitant
improvement in symptoms. The effective component of
healing is often unclear, although intensive regular social
interventions generally achieve superior outcomes to
brief single interventions. That said, little evidence is
available to suggest that traditional healers are effective
in changing the course of major psychiatric illnesses
such as schizophrenia or obsessive-compulsive disorder.
Additionally, harms could be associated with traditional
healing, which we have not reviewed here. For patients
who have cultural and spiritual beliefs not in line with
those of conventional psychiatry, the possibility exists
for more holistic care, and potential synergies, if
collaboration between healing systems is facilitated. This
topic should be an area of active research.
167
 Review
Contributors
SS and OG conceived the Review. GN wrote the first and final drafts.
GN and BO did the systematic search, selected papers, and extracted
data. SS, OG, and BO contributed comments and suggestions to the
paper. All authors reviewed the paper before submission.
Declaration of interests
OG has received grants from the National Institute of Mental Health to
study collaboration between conventional and alternative medicine and
conventional biomedicine. SS, GN, and BO declare no competing
interests.
Acknowledgments
This Review was supported by the National Institute of Mental Health
grant supporting Partnerships for Mental Health Development in
Sub-Saharan Africa (grant number 1U19MH098718–01), the South
African Research Chair in Post-Traumatic Stress Disorder hosted by
Stellenbosch University and funded by the Department of Science and
Technology, and the National Research Foundation, South Africa. These
funders had no role in the methods, preparation, writing, or decision to
publish the Review. We thank Joan Koss-Chioino for valuable comments
on an early draft of the report.
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