Black Magic: Symptom relief with contemporary collaborative psychotherapy
Combining an understanding of clients’ cultural beliefs with a contemporary therapeutic approach can help people who believe their symptoms have supernatural causes.
People migrating from their country of birth to their newly adopted country tend to carry their culture with them, effecting a cross-cultural mingling of values, traditions and religious beliefs. This is of significant clinical relevance in psychotherapy, since different cultural idioms of distress and understandings of illness can include spiritual, mystical and cosmic factors. Thus cultural psychiatry has attracted increasing traction in recent times (Bhugra and Bhui 2007).
For a majority of people from the Middle East, Africa and the Indian subcontinent, notions of cosmic influences, sorcery and black magic are deeply rooted in their culture and psyche, pervading all aspects of life including health and healing practices (Khalif et al 2011; Littlewood 2004; Mullick 2013; Neki et al 1986; Rathod 2017). Illnesses attributed to black magic, commonly noted amongst migrants from these countries, are surfacing in clinical practice in Western countries (Aidone 2018; Ally and Laher 2008; Betty 2005; Dein and Illalee 2013).
As a result of their cultural beliefs, and a feeling that psychotherapists do not comprehend their holistic concepts of illness, their phenomenology, or their subjective experiences well enough to treat them in a culturally sensitive manner (Bhugra and Bhui 2007), many migrants from the aforementioned countries initially seek advice from holy men, priests, astrologers or palmists. For example, they perform religious rituals and wear taweez (amulets) to ward off evil influences believed to cause mental illnesses (Bhugra and Bhui 2007; Juthani 2007; Kakar and Kakar 2007; Tariq 2003; Thacore & Gupta 1978).
Traditional healing practices may provide solace and hope, but relief from symptoms is not always achieved. Consequently, as a last resort, some patients consult mental health clinicians or pursue traditional and modern therapies concurrently (Bhargava et al 2017; Bhatt 2015; Khalifa et al 2011; Moodley, Sutherland and Oulanova 2008). This provides an opportunity for clinicians to engage them in a collaborative and contemporary psychotherapeutic process to attain lasting relief from their symptoms. Providing culturally appropriate interventions means clinicians must understand patients as individuals, including their understanding of the causes of their illness, their idioms of distress and healing traditions (Bhugra and Bhui 2007; Kirmayer 1989; Lu, Lim and Mezzich 1995). These factors, until recently, were not explored in the biopsychosocial model of illness which focused mainly on symptomatology and symptom relief (Sim 1994).
Black magic is defined as the use of occult energy by its perpetrator to cause distress and ill health in people (Neki et al. 1986). It provides a cultural explanation of mental disorders (Lu, Lim and Mezzich 1995) caused by agencies outside one’s control, and can thus induce extreme fear. Given that literature on contemporary psychotherapy with patients who understand themselves to be afflicted with black magic is sparse, this article aims to provide insights into the factors clinicians need to consider when engaging in therapy with patients presenting with spirit affliction. To this end, a clinical example of a patient afflicted with black magic is presented to highlight the psychodynamics and psychosocial functions of black magic, the symptomatology, and phenomenology. The name of the patient has been changed and particulars of the case have been altered to ensure anonymity.
Alima, a 40 year-old Muslim woman, was referred with symptoms of neck pain, episodes of confusion and acute psychosis. Employed as a teacher, her husband ran a small business. They had two sons. During a brief hospital admission, investigations including ECG, CT scan cervical spine, lumber puncture, CT brain scan and EEG had returned normal, prompting the referral. Alima was seen at a private psychiatric hospital and followed up as an outpatient. She related spontaneously in the therapeutic situation, switching between English and her native language, Urdu. Her narrative of events and history are summarised. To convey the nuances of her feelings, some idioms and expressions in Urdu are included in quotes in italic, and translated in brackets. Symptoms associated with black magic are underlined.
Alima gave a three-week history of recurring episodes of palpitation, panic, loss of memory, “feeling scared of everything” and feeling like “mar gayae” (dead). She feared going to the mosque. She expressed a yearning to be with her mother and “be held” and was “crying like a child”. She revealed that her mother-in-law had given her a hard time, usinbg the phrase “ khoon chooce leya” (sucked all my blood, energy), when she lived with her for a few months prior to joining her husband in Australia.
Alima acknowledged that she harboured “unbearable anger” at being married under the false pretence that her husband had a big business in Australia. She said that her husband had poor business acumen, that they were in financial strife and she feared losing her house. She resented him sending money to his parents. Her husband had proposed selling the house and returning to India, which she refused to do. She said that her mother-in-law had continued to be abrasive towards her, pushed her children around and that “pricked” her. From time to time she felt restless; a sense of impending disaster; as if her “head will burst open” (indicating extreme stress); udaas (depressed) and “dead inside”. She felt “so angry” that her husband denied any problems, including that she was sick.
She felt treated as if she was “no entity”, with “no rights”, “like my father treated my mother”. Her parents had separated on account of her father’s excessive drinking. She mentioned her father as a “very self-centred” and “controlling” person; “not a good man”; a “typical man”. She said her “mother was denied any rights and suffered much”. She emphasised, “I will not let anyone treat me like that”. I acknowledged her feelings as understandable.
From time to time Alima had angry outbursts, hit her husband and claimed amnesia thereafter. She was told that she had a “fit”. She said, “I have no feelings for my husband”; “something’s going wrong”; “nothing happening as I would like”. Feeling somewhat desperate, she asked, “tell me what to do doctor saheb?”. Taking the opportunity to bring about a therapeutic shift, I suggested that it may be worthwhile for her to address her feelings of insecurity and anger and to develop assertive skills as well as the ability to control the angry outbursts which were causing concern. This appealed to her and with her concurrence, therapy was directed towards anger management and enhancing her self-confidence and self-esteem, which she acknowledged she lacked.
In time, Alima developed insight into her behaviour. She described herself as an obsessive, controlling and stubborn person with a quick temper and poor self-worth. She admitted that she had felt “suppressed” all these years and was “rebelling”. A few months later she presented feeling anxious about her mother-in-law’s impending visit. She said that she would not let her mother-in-law into her house; “she will kill me”; “what will happen to my children?" Exploring her reasons for such intense fear of her mother-in-law, Alima confided, “to tell you the truth, doctor saheb, she does jadu tona (black magic)”, a belief which she revealed had been haunting her for some time.
After some thought, I suggested, “in that case you will need to obtain a taweez (amulet) to protect yourself”. “Do you believe in it, doctor saheb?” she quizzed, seeming quite surprised. “I am aware that a lot of people feel protected by it”, I replied. Loosening her hijab she revealed wearing a taweez round her neck saying, “I have one”. “Obviously it is not working”, I said, “you need to get a more effective one”. She said that the maulana (Muslim religious scholar) who gave her the taweez has passed away. Seeing an opportunity here, I suggested, “in that case you will need to become strong and protect yourself, like wearing a steel armour so that the arrows (black magic) of your enemy do not pierce through”. She took cognizance of the metaphor and committed herself to continue working on her personal development and inherent strengths.
She continued to feel unsettled however, and said she was not getting better; “as if someone has nazar lagaa dee (put a spell or evil eye on me). But I am not entertaining any bad thoughts (towards her mother-in-law and husband), which is a function of the shaitan (devil)”. Following one of her visits to India, I saw Alima jointly with her husband. He had returned from work and found Alima hiding in a cupboard fearing that her mother-in-law was in the house and would take everything from her, but she claimed amnesia after the event. She went on to say that her mother-in-law was doing jadu tona on her and questioned, “ham paagal hain kya” (am I mad or what?), a manner of speech seeking reassurance and implying that she was not paagal (mad) and was really experiencing the effects of black magic. She said, “every Id (festival) I get insulted by my mother-in-law and sisters-in-law”; “I find my clothes torn and remain sick throughout Ramazan”.
On enquiring about the taweez, she said that she had consulted a prominent maulana during her last visit to India who confirmed that there was “someone there who is not letting you sit comfortably” and advised her not to feel frightened. He gave her holy water to drink after namaaz (prayers) and instructed her to keep praying, read the Quran and ignore her mother-in-law. Thereafter, her relationship with her husband improved as she felt peaceful and safe regarding her children. She said, “I am changing myself; I don’t want to be a bewakoof ( fool), a yes person any longer”. She felt she was empowering herself and being more independent. She said that she will not let her mother-in-law come into her house, saying “this is my country not hers”, implying that she was now in a different cultural territory. She said that she will visit her family with her own money and that “all women should work” to be independent.
However, she continued to feel, “something disturbing me”. She informed me that her mother-in-law was planning to migrate to Australia. She feared going to India and fainted twice before going. All the same, she went to see her father who later passed away. On returning to Australia, she found her clothes torn with a set of four keys not belonging to her in her bag and noticed three nails hammered into the front pillar of her house. Her mother advised her to get rid of the clothes, keys and nails and keep reading the Quran. Alima felt relieved to learn that her father had arranged to divert spells on other articles, like clothes, before he died. As she had done frequently, she cancelled her appointment with me, but requested permission to call if she felt the need. She also informed me that she felt relieved to know that her mother-in-law had been refused a permanent visa to live in Australia.
When I last heard from her, Alima had just returned from pilgrimage with her husband. She said she was well and that giving power to herself was pivotal in her recovery. Her personal development was being reflected in welcome changes in the family ethos. Having listened to a telephone conversation in which his mother had spoken disrespectfully to Alima, her husband was more understanding of her problems with his mother. Alima said black magic was no longer an issue. When I enquired as to how she would have dealt with the situation in India, she responded; “stay in bed”; “run to my mother”; “ghut ghut ke mar jaati” (suffocate and die), “suicided” or “divorce”. I commended her on her courage and persistence with therapy to bring about the desired changes in her life.
Alima felt confident enough to discharge herself, but requested to leave the door open should she feel the need to return. She decided to stop taking the small dose of tranquilisers which she had been prescribed to help allay her anxiety.
Having lived in Australia for the past several years, Alima had imbibed values of egalitarianism and self-expression through her exposure to Australian social norms and her working environment. It sparked a desire to extricate herself from the suppressive and abusive family situation in which she was trapped. However, initially she did not possess the psychological capacity to achieve her goal. With escalating desperation and fear, Alima lost her capacity to mentalize. Her belief in black magic turned into cognitive reality (Neki et al. 1986). She manifested her distress in a dual concept of illness presentation, describing her illness in both contemporary and traditional idioms. She was aware of the source of her problems at a conscious level and enveloped her symptoms as caused by black magic.
Since traditional treatment had failed to resolve her problems, Alima accepted a referral for psychotherapy which she perceived as the rational course to pursue in achieving relief from her distress. Accordingly, she pursued two streams of treatment; contemporary psychotherapy and the traditional ritual of dua taweez (prayer and amulet). Black magic is believed to be effective only in those who are vulnerable, powerless, suffer from poor self-confidence and self-esteem (Dein and Illalee 2013; Neki et al. 1986). This is of clinical significance from the therapy viewpoint. The goal of therapy was thus set to enhance Alima’s self-worth, to neutralise her vulnerability and to facilitate her developing autonomy and the integrity of her personality (Storr 1963), which would enable her to deal with her problems and make life worth living (Patterson 1978).
With an individualised, eclectic, flexible and integrative psychotherapeutic approach (Beitman et al. 1989; Avasthi et al. 2013) Alima was helped to make a cognitive shift in her self-perception. She came to recognise that her lack of self-confidence and self-esteem were a function of her upbringing in a culture which, over the centuries, has devalued women leading to her absorbing feelings of poor self-worth (Kakar and Kakar 2007; Avasthi et al. 2013). This self-perception was reinforced by observing her own mother’s abusive treatment within her family, leaving her with suppressed feelings of anger and resentment. These feelings hardened into a resolve to not allow herself be treated like her mother.
In the therapeutic situation, Alima felt safe to vent her feelings openly, thus obviating the need to dissociate and act out in a self-damaging manner. Her resilience, persistence, contribution to family coffers, motivation and endurance to liberate herself from the toxic family environment were acknowledged and reinforced in the therapy. It enabled Alima to consolidate her strengths, enhance her self-worth and gain a sense of power. She realised her resolve to be treated with respect and attained relief from her symptoms. In the absence of family support, a congenial and empathic therapeutic partnership was crucial and served to maintain rapport and the continuity of therapy, despite her frequent cancelling of appointments.
This article has presented an example of a culturally congruent and collaborative psychotherapeutic approach, which can effectively treat patients presenting with symptoms associated with black magic. A contemporary and collaborative system of psychotherapy (Patterson 2004) involving a blend of Western theoretical understanding and elements of the patient’s particular culture (Ally and Laher 2008), can bring about the relief of symptoms in suitable patients who attribute their problems to supernatural influences (Patterson 1978). This could be relevant to clinicians treating patients from diverse cultures presenting with similar symptomatology.
Vinod Thacore is a Consultant Psychiatrist with Monash Health, Melbourne, Australia. As a regular contributor to Contemporary Psychotherapy he has a profile which can be viewed here.
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