Examining the Etiology and Treatment of Mental Illness Among Vodou Priests in Northern Haiti.

This study assesses the perspectives and experiences of Vodou priests (ougan) in the treatment of mental illness in northern Haiti. Our goal is to explore the etiology and popular nosologies of mental illness in the context of Haitian Vodou, through understandings of illness and misfortune which are often viewed as a result of sent spirits-or spirits sent supernaturally by others with the intent to cause harm. Using a qualitative approach, this study conducted semi-structured in-depth interviews with 20 ougan living near the city of Cap-Haïtien. Interviews highlight a sample of healers with little formal training who maintain beliefs and practices that differ significantly from current biomedical models. Ougan treat mental illness through a variety of means including prayer and conjuring of spirits, leaves for teas and baths, as well as combinations of perfumes, rum, human remains, and other powdered concoctions that are either imbibed or rubbed on the skin. The primary purpose of these treatments is to expel the spirit causing harm, yet they can often result in additional harm to the patient. Findings suggest that while ougan are willing to collaborate with biomedical practitioners, significant barriers remain preventing cooperation between these two groups.

Introduction

Just as mental illness has existed throughout human history, traditional healing practices too have developed and endured over millennia resulting in a myriad of explanatory models, treatment methods and rituals, adapted to different topographies, climates, religions, cultures, and political systems (Wampold 2001). Today, concepts of what constitutes “mental illness,” presumed etiology, and preferred treatment options can vary considerably from one cultural context to another (Ventevogel 2016).

With its unique history, Haitian Vodou is often described in relation to its strong links to traditional religious systems from Africa—particularly West Africa—with many of the same spirits and divinities maintained on both sides of the Atlantic (Métraux 1958). Similar to explanatory models of mental illness in Haiti, studies of traditional beliefs in sub-Saharan Africa often portray etiologies based in spirit possession and sorcery (Okello and Musisi 2015; Falen 2018). Central in these forms of treatment is the understanding that indigenous African categories of misfortune often do not consider mental illness a separate, or distinct, category from other “nonmedical forms of misfortune” (Ventevogel 2016:69). As another study describes,

In Africa, mental disorders are often perceived as a source of misfortune; ancestors and witches are believed to have a crucial role in bringing them about. Such disorders may be viewed in terms of magical, social, physical and religious causes, but rarely as diseases within the Western biomedical paradigm (Ngoma, Prince and Mann 2003).

Other in-depth studies from sub-Saharan Africa have exhibited similar explanatory models of mental illness and forms of traditional healing (Umoren 1990; Ovuga, Boardman and Oluka 1999; Crawford and Lipsedge 2004; Graeber 2007; Atindanbila and Thompson 2011; Kajawu et al. 2016; Falen 2018).

While little research exists on traditional methods for treating mental illness historically, in recent years, an increasing number of studies in low- and middle-income countries (LMICs) have tried to systematically assess the practices of traditional healers for mental health treatment (Abbo et al. 2008, 2012; Burns and Tomita 2015; Gureje et al. 2015; Nortje et al. 2016). Many studies examining traditional approaches to treating mental illness utilize qualitative approaches including grounded theory, developing theories that are connected to the data collection and analysis process (Glaser, Strauss and Strutzel 1967). In particular, these methods emphasized participant observation, in-depth interviews, and collecting artifacts or texts to better understand subjects being studied. Additionally, many studies also use an iterative approach through the constant comparative method, in which researchers move in and out of the data collection and analysis process and emphasize inductive reasoning.

As in many places around the globe where traditional healing in the treatment of medical ailments is widespread, understanding the methods of traditional practices and how the traditional healers—and their communities—perceive illness is important for public health programming in Haiti. Traditional healing practices for mental illness in central and southern Haiti have been documented by several studies (Meudec 2007; Pierre et al. 2010; Fils-Aimé 2016). However, some aspects of ougan practices have not been investigated before. In addition, no known studies have examined traditional healing practices in the north of the country. While similar to southern Haiti, past research has documented many distinctions between the north and the south as relates to traditional healing practices (Métraux 1958). As Haiti has few mental health services outside of the capital and in the southern half of the country, the vast majority of Haitians in northern Haiti have little choice but to go to traditional healers for mental health concerns. While some research shows that Haitians would prefer biomedical services if they were available (Khoury et al. 2012), there is debate as to whether improved access to allopathic services alone would significantly change local health behaviors (Meudec 2007). To date, few studies have examined the perspective of traditional healers—and the activities they engage in with regards to treating mental illness—in addition to the possibilities for coordination between traditional and biomedical practitioners in Haiti (Fils-Aimé 2016).

Methods

Setting

This descriptive study examines the practices of ougan in Haiti relative to mental health. This research was conducted in northern Haiti between 2019 and 2020 in the context of a doctoral dissertation at Sant Sante Mantal Mòn Pele (or SSMMP), the first mental health clinic in northern Haiti. Founded in 2016 by a local psychologist, this clinic quickly developed into a reference for mental health treatment throughout Haiti (Galvin and Michel 2020). Formative research and initial focus group interviews were conducted with clinic psychologists in May and June of 2019. Formal in-depth interviews were conducted with 20 ougan—15 male Vodou priests referred to as ougan or bòkò and 5 female Vodou priestesses referred to as manbo—that live and work in the municipalities immediately surrounding SSMMP between August and November 2020. Other studies which interviewed traditional healers similarly found that 20 was an appropriate sample size for achieving saturation while ensuring validity (Guest, Bunce and Johnson 2006; Akol et al. 2018). Even though ougan is a term reserved for male Vodou priests—with females referred to as manbo—for simplicity sake this study will refer to them collectively as ougan. SSMMP is located in a rural area just east of Haiti’s second largest city Cap-Haïtien. All interviews were conducted solely in Haitian Creole (or Kreyòl) and lasted between 30 min and 1 h. Ten additional informal interviews were conducted with other key informants including medical professionals, ougan from southern Haiti, civic leaders, and university students for the purpose of this research. All names used in this study are pseudonyms to protect the identity of participants.

In this article, we will be using terms in Kreyòl as written in Valdman’s Ann Pale Kreyòl (1988), thus writing the commonly termed “Voodoo” in English as “Vodou,” etc. Words in Kreyòl are written the same in singular and plural so the designation ougan represents both. Though largely derived from French, Kreyòl is a unique language that is unintelligible to a French speaker. Though both French and Kreyòl are official languages in Haiti, a small minority of Haitians speaks fluent French (Etienne 2006). As there are few French-speaking countries in the Western hemisphere—and even fewer that speak French-derived Kreyòl—Haitians have been historically insulated from many outside influences (Métraux 1958). Additionally, in 1804, Haiti earned its independence decades and even centuries before many of its neighbors, allowing a local culture largely inspired by former African slaves to dominate the country (Pierre et al. 2010). Several experts have examined the African origins of Haitian beliefs with regards to traditional medicine (Métraux 1958; Hurbon 1987; Hoffman 1990; Meudec 2007; Régulus 2012).

Study Design

Institutional Review Board (IRB) approval was obtained from Washington University in St. Louis for both the focus groups conducted in 2019 (IRB #201905029) and in-depth interviews with traditional healers in 2020 (IRB #202005009), as well as with the Haiti National IRB—or Comité National de Bioéthique—in 2020 (IRB #1920-51). In the context of a larger mixed-methods study on mental health in northern Haiti, this research used grounded theory to examine the perspectives and experiences of ougan, particularly in relation to their treatment of mental illness, in the areas surrounding SSMMP. Through participant observation and semi-structured in-depth interviews, this study also sought to examine their past collaboration with biomedical service providers as well as their openness to future collaborations. Researchers used an inductive approach in which data informed the development of theories and hypotheses rather than vice versa. This is primarily due to the fact that there are few theories developed surrounding these practices.

Data Collection

Participants were selected through purposive sampling based on their proximity to SSMMP. As ougan are largely located in rural areas—often far from main roads and towns—and can be difficult to find, participants were identified either through referrals from clinic staff or local residents who know the area well, such as moto taxi drivers. Participants were provided 250 gourdes ($4) as compensation for their time. This sum was determined in consultation with SSMMP clinic staff. All participants were presented with a form explaining the study and informed consent. As the majority of ougan are illiterate, the form was read to them aloud before they signed. Ten of the twenty interviewed marked with an ‘x’ as they could not sign their name. If an ougan refused informed consent they would not be interviewed, however none refused for the purposes of this study. Interviews were audio-recorded, though four ougan refused recording in which extensive case notes were taken and immediately transcribed following the interview. Transcriptions were translated into English and analyzed using thematic analysis. Analysis was performed using the constant comparative method including inductive coding (Silverman 2005). These codes were consequently operationalized into themes which were reviewed, modified, and agreed upon by both the PI and staff psychologists at SSMMP. Patterns of themes were discussed and elaborated together in monthly meetings to establish new codes, beginning after the first month of completed interviews. By the end of month three, primary themes were established and subthemes were identified; for example, the five different remedies that ougan use to treat mental illness. As little prior research existed on this subject in this setting, it was important to develop these themes through an ongoing and iterative process.

Results

Who are ougan?

The ougan interviewed for this study ranged in age from 23 to 70 years old with an average age of 49. Three ougan gave approximations of their age, and one said he did not know his age at all. The vast majority of ougan had significant work experience ranging from 7 to 46 years, with an average of 23 years working experience among them. There are a large number of ougan working throughout rural Haiti. A 1973 study estimated there was 1 ougan for every 100 Haitians (Merlo 1973). A 2003 study was slightly higher estimating that there were 1.5 ougan for every 100 inhabitants in Haiti, a number that would be significantly higher in rural areas where ougan tend to be concentrated (Clérisme, Antoine and Lyberal 2003). This is compared to an estimate of only 1 doctor for every 40,000 Haitians, with other studies estimating 1 in 100,000 (Meudec 2007; Méance et al. 2014). In interviews with ougan for the purposes of this study, most estimated that there were between 10 to 30 other ougan working in their local area, indicating a high concentration in rural areas surrounding SSMMP.

In addition to serving as religious healers, ougan are generally used as guides to find solutions to different problems in rural Haitian society (Merlo 1973). In this sense, they can act as counselors, judges, social workers in addition to spiritual leaders. However, their primary role is to heal (Méance et al. 2014). The majority are born in the local communities in which they live and work, generally come from poorer classes of society, and are often illiterate (Clérisme et al. 2003). In his seminal 1958 work on Haitian Vodou, Le Vaudou Haïtien, Swiss anthropologist Alfred Métraux described rural Haitians as “confined to a world in which mystical forces are always present” (p. 238). Religion and spirituality are in fact omnipresent in Haiti, as described by Haitian sociologist Laënnec Hurbon (1987), “God is always on the lips of the people, invoked in all circumstances” (p. 173). Yet, Haiti presents a unique case of religious “syncretism”—or mixing—in which local Catholicism is heavily interwoven with African beliefs (Mena 1998). For this reason, it is oftentimes difficult to parse out the African beliefs from Christianity in Haiti, as the two are so tightly melded.

How do they Become ougan?

The knowledge of traditional healers is usually passed down through families with the lwa (or African spirit) “claiming” a new individual in the family after the elder’s death (Deren 1953; Métraux 1958). One study found that there are 401 different lwa, and that they primarily live in local plants and animals, such as trees and snakes (Méance et al. 2014). As described by one manbo interviewed, when the spirits choose a new person in the family it is following the “rites of Guinea” (rit gine) and “ensuring continuity in the name of Africa” (Manbo Manise). A common refrain heard by several different ougan is that they were “called” (se lwa ki relew) or “claimed” (reklame) by a lwa. Three ougan interviewed recounted that they inherited their lwa from grandparents who were ougan, with one saying, “when our grandparents aren’t here anymore, the lwa choose children to inhabit” (Ougan Wilfrid). There are several ways in which this spirit transfer can take place, but most common are either through ceremonies or dreams (Métraux 1958; Kiev 1962). One ougan I spoke with described being possessed with the spirit during a large ceremony on January 2nd or Ancestry Day (Jour des Aïeux)—an important holiday in Haiti—when he was 13 years old: “That was when I first ‘danced’ [was possessed]. It was a big party that day… my mother always put pressure on me, she always said I had a spirit (jany)” (Ougan Ronald).

Several other ougan interviewed described becoming a healer after a spiritual experience from a dream. One described how,

One night something appeared before me and told me to go get a rock in the ravine and I found something marked “Philomise” [the most prominent lwa in Limonade where he lives]. After that my sister became sick, it was then that the spirit first came to me (lespri a te monte) and it stayed inside me. People started asking me to work for them [as an ougan] (Ougan Jacques).

Another described an experience in which God spoke to him and gave him the power to cure sickness through a dream:

I had a dream. When I laid down, I saw God opened the sky. There was someone with a stomach ache, they were suffering. God told me to put my hands on them… After that when I passed my hands over people I could heal them (Ougan Pierre).

Dreams were also described by other ougan as a time in which they received messages from spirits in order to seek tools for treatment or cures for patients experiencing a variety of sicknesses. One study describes how “dreams are a powerful and recurring medium of interaction with the divine and the occult” and “are not necessarily juxtaposed against reality” (Falen 2018:105). Overall, little formal training was received by the majority of ougan interviewed with regards to either physical or mental health treatment.

For ougan who are called or claimed by the spirits, refusal is often not an option. Other studies describe the severe consequences of refusing a lwa resulting in either sickness, insanity, or even death (Kiev 1962; Régulus 2012). This was echoed by several ougan interviewed, who claimed that “you have to listen to it [the lwa] and obey it, or else” (Ougan Henri-Claude). Three ougan I spoke with claim that the lwa caused them physical harm during the period when they were resisting possession, with one showing me scars on her arm, stating that it repeatedly stabbed her during this period. Another claimed to have spent two years in a wheelchair as the lwa paralyzed her as punishment for her resistance. A third claimed he tried to escape the lwa by fleeing to the mountains, “but it brought me back down… we were forced to agree with it” (Ougan Jean-Louis). Ougan who are claimed therefore often feel an obligation to do the work of their spirit.

Rit Gine Versus Rit Lwa

It is important to note that in addition to the ougan who are “called” or “claimed”—or rit gine—there is a second category of ougan called rit lwa (or “rites of lwa”). Those that follow rit lwa are differentiated from rit gine as they did not inherit their spirit, but rather they purchased it. As one ougan put it, “there’s two types of ougan, the ones who bought a lwa and are trying to make money, and the ones who were chosen by spirits” (Ougan Jean-Louis). All ougan interviewed described significant differences between these two categories of ougan with the biggest difference being that “rit gine are the ones who use their power to do good not evil” and “rit lwa use their power more for evil” (rit lwa travay plis sou mal la) (Manbo Magalie; Manbo Manise). Rit lwa are commonly considered to hurt or even kill people using magic and are often referred to as bòkò—or sorcerers. As one ougan put it, “they kill people, raise from the dead, give diseases, poison people” (Ougan Claude). For this reason, the vast majority of ougan I interviewed claimed to solely be rit gine—even when this was not the truth, according to other sources who know ougan in this area. The few who admitted to being rit lwa all claimed that, unlike others who use rit lwa, they don’t hurt people and only use their power for good. Other studies on this subject similarly found that sorcerers claimed to only use their power for good when this clearly was not the case (Meudec 2007; Graeber 2007). In this sense, it was often difficult to gain understanding and insight into the experiences of bòkò who purchased their lwa, for the purposes of this study.

For Métraux, there is an important distinction between ougan who use rit gine versus rit lwa as this differentiates those who use white magic (maji blan) versus black magic (maji nwa) (1958). According to Tremblay, a large majority of Haitians believe in the power of black magic (1995). In my interviews with ougan, this distinction between maji blan—to help people—and maji nwa—to hurt people—was also commonly discussed and is common in West African Vodou as well (Falen 2018). In her wide ranging examination of Vodou and illness in Haiti, anthropologist Marie Meudec describes how ougan who use rit lwa can spend large sums of money to buy a pwen (or magical powers) from other bòkò, which allows them to perform black magic (2007). In order to make back the money they invested, they can often hurt or kill people—using magic—when requested by clients (Régulus 2012). In her 1953 examination of Vodou, Maya Deren also noted the phenomenon of purchased lwa and highlighted its association with more malevolent spirits (Deren 1953). A 2004 study argues that there was a proliferation of rit lwa starting with the exodus of Haitians from rural areas in the late nineteenth and twentieth centuries, as many rural dwellers sold their land and their ancestral spirits along with it (Bechacq 2004). This created a sort of commercialization of lwa as they were previously tied almost exclusively to family heritage. Today, however, the lines between the “good” ougan versus the “bad” bòkò in Haiti are frequently blurred, making it difficult to differentiate one from the other (Falen 2018).

Additionally, many ougan noted significant differences between the fees for services of ougan who follow rit lwa versus rit gine. While the price for treatment among rit gine ranged from 5000 to 15,000 Haitians gourdes ($80 to $240) at most, fees for rit lwa would regularly go much higher. One manbo who practices rit gine claimed, “if you’re chosen by the spirits, you have to do what the spirit wants, you can’t exploit people” (Manbo Magalie). A common refrain among those practicing rit gine was “rit gine don’t make a lot of money” (gine pa fè kòb). Implicit in this is that rit lwa generally make significantly more money than their rit gine counterparts. As one ougan said,

Rit lwa are not tolerant. They can take 500,000 gourdes to treat someone, but they don’t really treat them. It’s a fake treatment. Rit gine don’t rip people off (rit gine pa manje lajan) (Ougan Jacques).

When asked about the practices of rit lwa, many rit gine said they would prefer not to discuss them for fear of reprisal. Even during the course of conducting this study, researchers were warned about asking to many questions about the livelihoods of powerful rit lwa in the area, at one point being threatened to discontinue the research.

Why do Haitians go to see Ougan?

In rural Haiti, ougan often have large numbers of people seeking their healing services, with some waiting all day. Estimates of the number of patients consulted daily ranged from 3 to 100 amongst ougan I surveyed, with an average of roughly 30 patients per day. The reasons people go to see an ougan however can vary, and it not solely related to illness. According to one study, farmers often go to increase the fertility of their fields, people go to cast spells due to jealousy in their relationships, while others go to seek advice during important points in their life—i.e., a new job, beginning or end of marriage, or the death of a loved one (Bechacq 2004).

Yet, illness is the primary reason for consulting an ougan, with an estimated 60 to 90% of the Haitian population consulting traditional healers due to poor health (Meudec 2007). One study argues that the vast majority go for mental illness in particular—which he refers to as “schizophrenia”—even though it is difficult to get specific estimates as there is no recorded data (Hurbon 1987). Among ougan surveyed, several said the majority of their patients have some form of mental illness—usually referred to interchangeably as maladi moun fou “crazy person disease,” maladi sèvo “brain disease,” or maladi move lespri “bad spirit disease”.

Explanatory Models of Illness in Vodou

There is a common expression in Haiti that “not all illnesses are for doctors to treat” (tout maladi pa maladi doktè). Reflecting this, there are two broadly different conceptions of illness type that lead to different paths for treatment. On the one hand, if it is determined that the sufferer has a disease of natural causes (maladi natirel, maladi peyi, maladi bondye), the sufferer should go to the hospital and see a doctor. However, if the illness is due to sorcery or other supernatural origins (maladi moun fè mal, maladi lwa, maladi satan/dyab), the sufferer should consult an ougan (Deren 1953; Kiev 1962; Tremblay 1995; Auguste and Rasmussen 2019; Jean-Jacques 2019). With regards to the latter, traditional medicine in Haiti intervenes in a profoundly religious universe in which illness is seen as a weapon in the battle between Good/God and Evil/Satan (Meudec 2007). Métraux (1958) talks about how supernatural illnesses can be either attributed to divine punishment for sins, or as a result of an act of sorcery. While ordinary people cannot perform sorcery themselves, they can pay an ougan or bòkò to do it for them. Though a large variety of diseases can be attributed to sorcery, chronic illnesses or ones that are particularly hard for doctors to treat (maladi difisil) tend to be associated with supernatural involvement (Falen 2018; Galvin and Michel 2020). For example, illnesses such as advanced elephantitis (gwo pye), epilepsy (malkadi), and in particular mental illness (maladi moun fou) are often attributed to mystical causes and thus referred to ougan for treatment (Métraux 1958; Delbeau 1990; Carrazana et al. 1999; Meudec 2007). In this sense, it is important to point out that mental illness is not conceived of as something separate from other forms of supernatural illness, but rather is an illness caused by spirit possession similarly to physical ailments.

In my interviews with ougan, they often highlighted this same distinction between natural (maladi natirel) and supernatural or “given” (maladi bay) diseases. Reflecting the distinction between rit gine and rit lwa among ougan, one ougan described how there are two additional rites: “ougan rites” (rit ougan) and “doctor rites” (rit doktè) (Ougan Claude). In essence, just as there are two different forms of viewing treatment among ougan themselves, there are also two different forms of viewing treatment more broadly with ougan on the one hand and medical doctors on the other. As one ougan stated,

If you have a zonbi [supernatural illness] an ougan has to take it out, whereas if it’s a problem with the brain, you go to the hospital to get an injection [of a sedative] (Ougan Jean-Louis).

Ougan are thus considered able to treat a specific class of illness that doctors are unable to treat, as when the disease is attributed to a “bad spirit” or other supernatural causes, “you have to go to the ougan to get rid of it” (Ougan Gregoire).

When I introduced the concept of mental illness (maladi moun fou or maladi sèvo) in the beginning of each interview, nearly half of ougan immediately began referring to mental illness as maladi move lespri—or “bad spirit disease.” There are many different terms used by ougan to refer to these supernatural illnesses: mystical illnesses (maladi mistik), magic illnesses (maladi majik), spirit illnesses (maladi lespri), sent illnesses (maladi voye moun), fetishes (fetich), lwa illnesses (maladi lwa), batri illness (maladi batri, see below), and illnesses that someone put on you (fè y’ap fè’w). While there are subtle differences between some of these—which we discuss in the following paragraphs—many of these terms are used interchangeably. In general, these sent spirits are considered to be the soul of a dead person intentionally sent by someone supernaturally with the intent to harm or even kill (Métraux 1958; Pierre et al. 2010). In this sense, many assume the illness was sent to them by someone who wishes them harm—a malfektè or evil-doer.

Batri, Nanm, and Zonbi

Sent illnesses are most commonly expedited in the form of a batri—sometimes also referred to as kout poud (attack of powder) or kout batri (Davis 1988; Meudec 2007; Kaiser and Fils-Aimé 2019; Jean-Jacques 2019). Very little research exists on batri. However, based on my interviews, a batri is a composition—often of powders—made by an ougan (usually rit lwa as most rit gine claim not to use them) to send illness or misfortune onto an unsuspecting victim at the direction of someone who wishes them harm. Davis describes them as “a magical powder that may cause illness and/or death” (1988:280). As one ougan described it,

Batri can kill all the cells in the body… there are batri that can kill you the same day and there are batri that hurt you little by little over time… The ougan takes this and that and mixes them. Then they mix it with something else and put it in your path. The body has cells inside, and the batri will get inside and make your leg inflamed… or it can make a zonbi get inside you. In my experience, this is how they give people zonbi (yo ka prepare zonbi epi fè ekspedisyon voye souw) (Ougan Wilfrid).

While batri can sometimes be composed of poison or other toxic materials, Davis writes that things such as tarantulas, sea worms and sea toads are essential components of batri (1988). Batri also contain a spiritual force (yon fòs spirityèl) that lead to possession by sent spirits (ekspedisyon move lespri) (Ougan Jacques). These spirits are usually taken from the cemetery via exhumed corpses, as one ougan describes: “they send the dead spirit (ansyen mò yo) from the cemeteries as they have techniques to transfer the spirits from the dead” (Ougan Ronald). Another adds that these spirits can have different names, “sometimes it’s a zonbi sometimes it’s a nanm” (Ougan Etienne). The spirit possession that results from the batri can then result in inflammation or mental illness, requiring the intervention of an ougan to remove it (Manbo Guerline).

In my interviews with ougan, two types of spirits were repeatedly referenced as the cause of mental illness: nanm (also the Kreyòl word for “soul”) and zonbi. Despite repeated probing on the difference between the two types of spirits, responses were often inconsistent, as they both were accused of being “like an insect” (tankou yon bèt li ye), and that the sufferer can feel like it’s “walking all around the inside of the body” (li mache toupatou sou kò a) and can cause problems like inflammation, agitation, and mental illness (Ougan Guillaume; Ougan Claude). Hurbon (1987) references consequences of ekspedisyon similarly writing that “some demons walk all around the inside of the body.” Ougan attempted to describe the subtle differences between the two spirits: “Nanm can suck your blood, it can eat your flesh, it can eat all the cells in your blood” (Ougan Wilfrid) whereas “zonbi are old spirits from the cemetery that get inside your head” (zonbi kap chita andann tèt la) resulting in mental illness (Ougan Dervilus). However, other times the ougan contradicted each other with some saying that nanm is more common and harder to treat and others saying that zonbi are more common and harder to treat.

In his 1988 work on zombification in Haiti, Davis describes how there are two different types of zonbi. One is the type we commonly think of in terms of the zombification process resulting in the “living dead,” whereas another is referred to as “zombi éfface” and is simply the “death spirits” used in ekspedisyon (Davis 1988:281). The latter is what ougan we spoke with were referring to, as Davis writes, “the zombi éfface is the spirit of a dead person that you send on someone [to harm them]” (1988:281).

In descriptions of people with mental illness who are possessed by these sent spirits, ougan generally emphasize behavioral disturbance and disruption of social norms, rather than symptoms related to thought disturbance or perceptual symptoms, similar to findings from studies in sub-Saharan Africa (Ventevogel 2016). Several described violent behavior as a result of spirit-induced mental illness, with one saying, “there are people who are crazy (fou) and they have a zonbi, it makes them run around breaking things” (Ougan Jean-Louis). Others referenced throwing rocks, destroying property, fighting, hitting people, eating dead animals in the street, talking a lot, or being unable to sleep. Another ougan said,

When they have a bad spirit inside them (move lespri sou li) it causes them to fight, to throw rocks… it makes them run around (kouri kouri) and become crazy (vinn fou) (Ougan Jacques).

Yet, others expressed sympathy as they too could have been rendered mentally ill by sent spirits as punishment had they refused their calling to become ougan:

They [mentally ill people] might spend 7 days outside, running around… but if I didn’t accept the spirit I could have become like that too (Manbo Magalie).

Interpretation of Mental Illness by Ougan

The interpretation of illness in Haiti is rarely done by the individual alone. Rather, patients often interpret their illness with family members and community leaders—such as ougan, pastors, or priests—who also participate in the elaboration of strategies for treatment (Meudec 2007). In the case of ougan however, the final interpretation of the illness and its causes is done by the spirit or lwa (Hurbon 1987; Meudec 2007). This takes place during a ceremony in which a candle is lit, usually alongside rum (kleren) and water, and the ougan “conjures the spirit” (fè limyè or literally “making light”). There are many different names for these spirits—often referred to as jany, or “angels,” a term specific to northern Haiti—including Sebosu, Sagawi, Ti Jean, Jean Loreng, Jean Krab, Seboran, Segranbwa, Erzulie Freda, Maîtresse Erzulie. In line with earlier comments about syncretic Catholicism in Haiti, each spirit is generally associated with a different Catholic saint.

Conjuring the spirit (fè limyè) is the first step in treating a patient for ougan. All 20 ougan interviewed emphasized the importance of this step. As one manbo says, “you have to look into the light” (chache nan limyè) to see what illness they have (Manbo Guerline). In this process of conjuring the spirit, several ougan describe how it is no longer they who are communicating with the patient, but rather the spirit itself. In three of my interviews, ougan told me I wasn’t actually speaking with a person, but rather with the spirit itself. Therefore, it is not the ougan who diagnoses the illness, instead it is the “spirit that knows” (se lwa ki konnen). Other researchers also documented hearing this phrase often (Meudec 2007). In this sense, the experience is very different than with biomedical approaches as described by one ougan: “when you go to the doctor, the doctor is the one that talks to you, tells you what’s wrong. But with us it’s not us it’s the spirit that tells you… you light a candle (fè limyè) and figure out what the problem is” (Ougan Ronald).

In the Vodou cosmology, the significant power wielded by spirits emerged as a theme multiple times. Not only do spirits possess ougan against their will—and enforce consequences if refused, as described earlier—but they also tell the ougan when to start working each day, what illnesses patients have, and how to treat them. As one manbo says, “I use the spirit that inhabited me to treat them [patients]” (Manbo Magalie). Communication with the spirits is constant, as one ougan describes, “he [the spirit] tells you everything. He tells you to start work at 1 pm or 2 pm each day. He also told me to start working [as an ougan] in 2001” (Ougan Wilfrid). In this sense, ougan often see themselves simply as vessels for the spirit to act through, absolving themselves of significant responsibility in the interpretation and treatment of illness. As another manbo described,

The mystery [spirit] knows everything, it writes down what we need for treatment on the paper and we go and get it (se mistè ki konnen tout bagay lè mistè ekri nan papye nou ale) (Manbo Manise).

When conjured, the spirit thus not only diagnoses the illness, but also determines the treatment and ultimate resolution of the problem: “when you have a jany [or angel] that’s working for you, it can see how to get the bad spirit out” (Ougan Dervilus).

Treatment of Mental Illness by Ougan

In addition to conjuring the spirits (fè limyè), ougan treat patients with a variety of different medicines or remedies (remèd). It is important to emphasize however, “it is the spirit that cures, the remedies just help” (se lespri ki geri, remèd yo selman ede) (Ougan Gregoire). For the purposes of this research, we identified five different remedies that ougan can use to treat mental illness: prayer, leaves, perfumes, fiksyon, and human skulls.

The first remedy for patients suffering with mental illness is prayer (lorasyon). This is usually an extension of conjuring the spirits (fè limyè), and involves similar practices to prayer in Catholicism—i.e., lighting a candle, talking to God. As one ougan says, “it means the same thing as when the Bible says to pray for people” (Ougan Ronald). However, the ceremonial prayer in Vodou can have some differences, such as putting powder on patients as a way to heal them (Manbo Manise). Other ougan will put their hands on a patient’s head or body during a prayer ceremony as a way to heal them, though these practices are common in some Christian communities as well (Ougan Jacques).

Two ougan interviewed referred to Haiti as “leaf country” (peyi fèy) in reference to the common use of leaves to treat illness. The use of leaves to treat mental illness in Haiti is widely documented (Métraux 1958; Weniger et al. 1986b; Hurbon 1987; Meudec 2007; Vonarx 2008). Significant overlap exists between diviners like ougan and herbalists, called “leaf doctors” (medsen fèy), though only ougan were interviewed for this study. Medsen fèy are not generally inhabited by a spirit like ougan. This division between diviners and herbalists has also been documented in studies from sub-Saharan Africa (Graeber 2007; Ventevogel 2016; Falen 2018). There are a variety of leaves used to treat mental illness by ougan, most commonly langachat (cat’s tongue), fèy koray (coral leaf), eucalyptus, and many others: kaka poul, fèy kapab, revni bon anj, jambe lè, madam kaya, kacheman, fèy loni, fèy kè, brital, fèy sed. While this study did not examine the exact usage of different leaves, other analyses have assessed their particular uses in Haiti—including several of the leaves mentioned above (Weniger et al. 1986a, b; Davis 1988; Volpato et al. 2009). Though these studies examined the cultural use of leaves for different ailments among Haitians, no study to date has analyzed the chemical components of leaves for effectiveness against any specific mental or physical illness. Ougan who are part of rit gine are particularly likely to use leaves in their treatment, as “leaves are really good at treating bad spirits” (fèy bon anpil pou trete move lespri) (Ougan Ronald). Most commonly, ougan said they brew the leaves in a bath for their patients and bathe them in it. Also common is brewing tea for patients as several ougan interviewed said they used a variety of teas to treat different mental illnesses. One manbo said she tied leaves to her patients’ foreheads and left them there for three days as a treatment for certain mental illnesses (Manbo Magalie).

Next, it is common for ougan to use perfumes and deodorants in their treatments. In particular, many ougan use Florida Water—a type of cologne—which is considered a staple of Vodou rituals (Ainsworth 2013). A mixture of essential oils and perfumer’s alcohol, Florida Water gained popularity in the southern United States and Caribbean in the late nineteenth century when it began to be used in ritual traditions such as Haitian Vodou. While some ougan interviewed said they only used it on the skin of patients, many others said they had patients drink it. While Florida Water and other perfumes contain alcohol, this is not alcohol meant for human consumption and thus can result in toxic effects. As one ougan described it, “it can make people crazy, or even violent” (Ougan Dervilus). Another said people who drink it can “fight a lot or be aggressive” (Ougan Pierre). Yet, it continues to be widely used as one ougan claimed,

It has magic inside, white people don’t use it in every way (sa gen majik ladann, blan pa itilize nan tout sans); we drink it, we put it on our body, we mix it with things (Ougan Jacques).

Most commonly, consuming Florida Water is considered effective in battling nanm as “when you mix it with powdered tobacco [and drink it], it kills the nanm disease” (Ougan Joseph). Other perfumes or deodorants used in treatment of mental illness include Hombre—an aerosol deodorant spray from the Dominican Republic—and Pompeïa, Rêve d’Or, and Bien Être—three French perfumes (Manbo Manise; Manbo Magalie).

Fiksyon is what one ougan referred to as “mystical medications” (medikaman mistik) (Ougan Paul). Usually kept in unlabeled semi-transparent white plastic bottles, many ougan say they do not know what exactly is in these compositions though they are usually powders mixed with water or alcohol. While little is written about fiksyon, Meudec (2007) says they originate primarily from “plants (leaves and extracts from sap) and animals (frogs, lizards, snakes) that are ground, as well as pharmaceuticals in powder form. No chemical analysis has been performed on these powders to date” (p. 84). There are a variety of different fiksyon that treat mental illness. Most commonly cited are pèdi nan vyann, (used by 6 ougan interviewed), fok mol (5), kampe lwen (3), tablantin (2), and others such as zo devan, vapè minwi, detowo, demen kontre, timinot, kadalgate, detowokontre, repiyans, repouse, and pa kampe la. While each of these fiksyon have different uses, the purpose of this research was to examine the use of fiksyon to treat mental illness more broadly. Fiksyon tend to be used by ougan who practice rit lwa as they are often considered black magic, though some rit gine use them too (Ougan Ronald). One ougan says he first uses leaves to weaken the bad spirit, and then will use magic in the form of fiksyon to send it away permanently (Ougan Claude). Another claimed that if you’re rit lwa “you have to use magic, you have to buy magic [in the form of fiksyon] to use on patients” (Ougan Jean-Louis). Fiksyon can be used either on the skin or ingested. When interviewing ougan, I had the chance to examine and smell several of the fiksyon. Oftentimes the smell was too pungent to even remain near them for more than a second, leaving an extended burning sensation in the nostrils. The majority of ougan purchased their fiksyon at special pharmacies for ougan on 9th street in Cap-Haïtien.

The final remedy used by ougan elucidated in my interviews was the use of human skulls (tèt mò). Skulls were almost exclusively used by rit lwa, as many rit gine claimed that the use of skulls is purely black magic. While two rit lwa ougan claimed they did not use skulls due to the risk of bacterial contamination from the dead body, five others said they did use skulls for the purposes of treating mental illness.

When people send an illness to someone else [ekspedisyon], I have to go to the cemetery to get a human skull. I ask permission to go in the cemetery from the bawon [the spirit of the first person buried in the cemetery]. The bawon gives me permission to take a skull and then I can use it to treat someone (Ougan Claude).

Once procured the ougan will grind the skull and mix the shavings with rum for the patient to drink. This remedy is claimed to work on both nanm and zonbi as, with “people who have a force on them, it [the skull] can get rid of the disease” (Ougan Jacques). Another ougan mixed the skull shavings with Florida Water, highlighting how many of these remedies are not mutually exclusive and can be used in combination with one another (Ougan Joseph). While the majority of ougan interviewed claimed they did not have their patients ingest skull shavings, nearly all ougan had a human skull for ceremonial purposes:

We take the skull of someone who uses magic (mason loj) who died, and then we use the skull during ceremonies. That makes the bad spirit go away, the person can be cured (Ougan Charles).

While the idea of such remedies might be difficult to understand for an outsider, there is a common belief that treatments such as this provide faster relief than leaves for example: “rit gine treatments are slow, rit lwa on the other hand work really quickly” (Ougan Guillaume). This appeared to be the primary factor influencing a patient’s decision to see a rit lwa versus a rit gine, despite the increased cost.

Collaboration Between Traditional Healers and Hospitals

Haiti represents a system that is often described as “medical pluralism” in that the country has two types of “medicine” that co-exist and aren’t used in the same way: namely, allopathic medicine (lopital) and traditional medicine (lakay ougan) (Benoist 1996; Vonarx 2008). With regards to mental health, while modern psychiatry has made some inroads, interpretations of mental illness continue to remain strongly embedded in “magical” or “spiritual” explanations (Jean-Jacques 2019). Nevertheless, traditional healers in Haiti will often send their patients to the hospital if they determine the illness is not within their realm of expertise (Meudec 2007). In this study, all 20 ougan interviewed said they send patients to the hospital in cases where they feel their treatment did not or will not work.

As this data was collected during the coronavirus pandemic, several ougan discussed an interest in learning about the coronavirus during the initial outbreak in order to identify cases to send to the hospital rather than treat themselves. As one described, “with coronavirus I was interested in how people could get treatment, since it was something that made everyone anxious” (tout moun tèt cho) (Ougan Ronald). Ougan are largely responsive to epidemics since the 2010 cholera outbreak which infected nearly 700,000 people in Haiti and sparked a public health campaign that attempted to target ougan for education and training (CDC 2014). Yet, outside of epidemics, illness is still largely classified as natural or supernatural in origin which determines whether a doctor or an ougan should provide treatment. As one ougan said, “some diseases I can treat with magic (maji)… but doctors can’t treat with magic” (Ougan Joseph). In addition, some ougan argued it is dangerous for doctors to attempt to treat illnesses of supernatural origin as the provision of medications or injections by a doctor are said to worsen symptoms of people with “bad spirits” (move lespri) (Ougan Ronald). Yet, another ougan pointed out that treating someone for move lespri when they don’t in fact have one is similarly risky: “if someone is sick and they don’t have move lespri, then we [ougan] can make people feel even worse [by treating them]” (Ougan Wilfrid). Thus, in the eyes of ougan, it is key to determine if the illness is natural or supernatural prior to treatment.

All ougan interviewed live and work in the communities immediately surrounding SSMMP. As the first biomedical treatment facility specialized in mental illness in northern Haiti, SSMMP represents a unique opportunity to provide high quality psychiatric care to the primarily rural population of this region for the first time (Galvin and Michel 2020). All ougan were asked whether they knew of SSMMP, and only two ougan reported that they did not know it. One manbo reported having a sister who was treated at SSMMP for mental illness: “I have a sister with mental illness (twoub mantal) who was treated there and now is more or less recovered, thanks to the doctors” (Manbo Magalie). Another ougan said he had gone to SSMMP for treatment himself, albeit only to see the doctor due to a physical ailment (Ougan Charles). Several ougan also reported referring patients with mental illness to SSMMP after determining they could not treat them. “They’re good over there [SSMMP]… when I send people there they never come back to see me again” (Manbo Guerline). Some ougan also claimed they received patients who were referred by SSMMP when they couldn’t treat illnesses of supernatural origins, though staff rebutted this suggestion arguing they would never refer a client to an ougan under any circumstances.

Despite the relatively common practice of ougan referring patients to hospitals, there exist few instances of professional development trainings or collaborations between hospitals and ougan. Of the 20 ougan interviewed, only six reported having previously attended trainings at hospitals. The majority of these trainings took place in 2001 when several ougan described having attended large meetings at Sacré Cœur hospital in the nearby town of Milot; however, two ougan reported attending meetings there more recently. When asked what they learned at these trainings, ougan generally mentioned basic medical screenings, treatments, and hygiene practices. As one ougan said,

I learned if an illness is not for me to treat, I shouldn’t treat it. If I can’t treat them, I should send them to the hospital because they can better treat the body [as opposed to spirits] (Ougan Etienne).

This suggests that ougan respond well when trainers highlight the distinction between physical and spiritual causes, and leverage this to encourage ougan to refer physical-caused ailments to hospital.

Similarly, one ougan described an important training on the identification of three serious physical illnesses: tuberculosis, AIDS, and syphilis (Ougan Wilfrid). After this training he was able to identify a woman with AIDS who came for treatment, describing to me that despite sending her immediately to the hospital, she ultimately died several days later due to complications from the illness. Trainings such as these are important for healthcare in Haiti, as other researchers have documented cases in which ougan regularly claim to be able to cure certain types of HIV/AIDS which they assert are of supernatural origin (Farmer 1990; Bernard and Désormeaux 1996).

The vast majority of ougan interviewed wanted to take part in trainings and collaborations with hospitals and medical providers. They described wanting “more knowledge” and “to understand better,” arguing that “there needs to be a big relationship between bòkò [ougan] and doctors” in Haiti (Manbo Guerline; Ougan Wilfrid; Ougan Jacques). Despite this enthusiasm and clear need for additional cooperation, there remains some hesitation about collaboration for several reasons. Firstly, there are stark differences in the vision of disease etiology and treatment with one ougan arguing, “there are sciences that aren’t the same as the hospital [medical sciences]” (Ougan Dervilus). Another ougan stated, “what we do is just different [from doctors]” (Ougan Paul). Other ougan insisted that collaborations should focus on incorporating ougan into hospital facilities in order to offer consultations for supernatural illnesses as well, with one saying, “all hospitals need an ougan working there too” and another describing how hospitals that hire ougan to provide services “work better”—though no hospitals were identified which actively work with ougan (Ougan Ronald; Ougan Dervilus).

However, the primary concern among ougan regarding collaboration reflected the fears of conflict expressed by SSMMP staff in interviews from 2019. While cooperating with ougan would have little threat of conflict with rit gine, several ougan expressed concern about collaborating with rit lwa: “rit lwa you can’t work well with them. These are people that kill people… you could work with the jany [rit gine] but not really with the rit lwa” (Ougan Pierre). Yet others downplayed this fear with one rit lwa saying there really isn’t a great fear and adding, “sometimes ougan have a fever and go to the hospital too. Some things ougan can’t fix, so you have to go to the hospital” (Ougan Jean-Louis). Therefore, there may be ougan who are less cooperative or open to collaboration—primarily rit lwa—however, on the whole increased cooperation between ougan and hospitals is essential as they represent the two primary pillars of the existing healthcare system in the country and currently function virtually completely independent of one another with little to no communication.

Conclusion

The material present in this study provides a brief sketch of traditional healing for mental illness in early twenty-first century northern Haiti. To some extent, this portrait confirms what has already been depicted in the largely French-language literature on this subject. However, some of the findings in this study have not previously been explored in the literature. In particular, little to no research exists examining forms of treatment that include perfumes such as Florida Water, fiksyon, or treatments utilizing human skulls.

A large study on the history of Vodou in Haiti noted that no religion has been subject to more attack or misrepresentation by outsiders than Haitian Vodou (Ramsey 2011). It has survived centuries of slavery and conflict with the Catholic and Protestant churches until it was declared an official religion of Haiti in 2003 (Méance et al. 2014). Against all odds, Haitians have managed to maintain systems of African belief to a larger extent than any other society in the global African diaspora. For these reasons, this study attempted to speak directly to those that maintain the practices of Vodou themselves, the ougan, in order to limit distortion of beliefs and spiritual practices. However, other studies examining practices related to sorcery and healing have pointed out that since these practices are inherently mysterious, perspectives can vary greatly and often be difficult to verify, making these problematic subjects about which to write authoritatively (Graeber 2007).

As the primary role of the ougan is to heal, it is important to understand the perspectives, experiences, and treatment practices of ougan with regards to mental illness. As this study has shown, the relationship between Vodou and mental health in Haiti is complex. The cosmocentric worldview in which Haitians see themselves as impacted by powerful spiritual forces stands in stark contrast to the anthropocentric worldview in most Western understandings of self (Sterlin 2006; Pierre et al. 2010). This has resulted in the formulation of mental illness as an ailment which is a result of spiritual forces, requiring the services of spiritual healers, ougan, to alleviate the pain of sufferers. The literature on etiology of mental illness in sub-Saharan Africa similarly emphasizes spiritual causes (Ventevogel 2016). Due to these belief systems, some argue that traditional Western psychotherapeutic approaches may be less effective for Haitians, as they strongly associate their condition with God or sent spirits (Bibb and Casimir 1996). Nevertheless, it is important to recognize that the practices of ougan are “not institutionalized, with no controls, resulting in widespread abuses” and can represent significant risks to the health and well-being of patients—such as the ingestion of perfumes, deodorants, or human remains (Meudec 2007:57).

However, ougan unquestionably represent the first responders for people living with mental illness in Haiti today. In addition, they have several commonalities with psychotherapists in that they listen carefully to a patient’s story and perception of the causes of suffering and validate their experiences of pain and distress in an attempt to begin the process of healing. Consequently, with the added spiritual component ougan provide, they are likely to remain a strong substitute for mental health care in Haiti—despite the risks inherent in some of their treatments (Méance et al. 2014). Other studies have highlighted how local conceptualizations of mental illness have significant implications for the planning of treatment interventions in settings such as sub-Saharan Africa and Haiti (Ventevogel 2016). For these reasons, increased collaboration between medical providers and ougan is critical for the future of mental health service provision in Haiti. As the results of this study exhibited, there is a strong desire for increased training and cooperation with hospitals and biomedical care providers among ougan interviewed. Yet, the training is perhaps not unidirectional as Auguste and Rasmussen (2019) write, “any practice of psychology should try to integrate an understanding of Vodou into its toolbox” as “Vodou is central to any understanding of mental health in Haiti” (p. 5). Though Vodou may be considered as a barrier to care by many mental health providers, it will likely remain the primary pathway to address and treat mental illness in Haiti for the foreseeable future, and therefore is an important component in culturally competent and responsive care.