The Patient Relationship and Therapeutic Techniques of the South Sotho Traditional Healer

Objectives-To investigate the characteristics of the relationship between the South Sotho traditional healer and his/her patients;-To explore the therapeutic techniques used in the South Sotho traditional healing process;-To investigate the views of the South Sotho traditional healer regarding the South Sotho healing process;-To investigate the views of the patients regarding the South Sotho traditional healing process;-To formulate guidelines for possible incorporation of the South Sotho traditional healers in the National Health Care Delivery System. Design The research design used for this research is a qualitative survey within the context of three rural areas of Maokeng, Ikageng and Sebokeng in South Africa. Population and sample Two populations were identified. Population one consisted of South Sotho traditional healers practicing in Moakeng, Ikageng and Sebokeng in South Africa. Population two consisted of patients of each of the mentioned traditional healers, staying in the mentioned areas. A non-probability purposive voluntary sampling method was used for both populations. The sample size was determined by means of data saturation. Method Data collection was achieved by video recording of the South Sotho traditional healers in interaction with their patients as well as when they use their therapeutic techniques. Semi-structured interviews were also conducted with both the traditional healers and their patients re their views on the healing process. A pilot study was conducted to test the applicability of the questions. After the video recordings and the interviews field notes were recorded. The video recordings were translated to English and a checklist set to analyze these recordings. The audiotapes were transcribes verbatim and analyzed using content analysis. Findings and conclusions From the findings it can be concluded that the process of interaction between the traditional healer and the patient is built on a relationship consisting of various phases and based on mutual respect and understanding of each other's cultural views and beliefs. It is mostly the traditional healer that initiates the greeting. Consultation is always done in a sitting position with the traditional healer facing the patient. During consultation the fees to be paid are negotiated prior to resuming divination. The manner in which both the traditional healer and the patient perceive illness is strongly cultural based. The traditional healer becomes more authoritative while the patient adopts the attitude of following and becoming more submissive. The process of divination is an important part of the healing process and the traditional healer becomes active, while the patient becomes more …

T el: (018)299-1901 Fax: (018) 299-1827 E -m ail: vpkmg@puk.ac.za The researcher aimed at investigating the characteristics of the relationship between the traditional healers and the patients, explored the therapeutic techniques that are used in the South Sotho traditional healing process, and investigated the views of both the traditional healers and the patients about the South -Sotho traditional healing process, to facilitate incorporation of the traditional healers in the National Health Care Delivery System.A qualitative research design was followed.Participants were identified by means of a non-probable, purposive voluntary sample.Data was collected by means of a video camera and semi-structured interviews with the six traditional healers and twelve patients, as well as by taking field notes after each session.Data analysis was achieved by means of using a checklist for the video recordings, and decoding was done for the interviews.A co-coder and the researcher analysed the data independently, after which three consensus discussions took place to finalise the analysed data.
The researcher made conclusions, identified shortcomings, and made recommendations for application to nursing education, nursing research and nursing practice.The recommendations for nursing practice are reflected in the form of guidelines for the incorporation of the traditional healers in the National Health Care Delivery System.
Die navorser het tot sekere gevolgtrekkings gekom, tekortkom m ings is g e id e n tifise e r en aan b ev elin g s is geform uleer vir toepassing in die verpleegonderwys, verpleegnavorsing en verpleegpraktyk.Die aanbevelings vir verpleegpraktyk word as riglyne gestel om die tradisionele geneser in te skakel as deel van die Nasionale Gesondheid sorg sisteem.

Introduction and problem statement
In South Africa traditional healers are the health care choice of a large number of the African population.It is estimated that 80% of the black population uses traditional medicine (Freeman & Motsei, 1992a: 1185;Abdool Karim, Ziqubu Page and Arendse, 1994:3).The majority of black people reside in rural areas with the result that the country consists of a combination of a Third World and a developed country.It is in these rural areas and urban "townships" that many people turn to traditional healers because they are freely accessible and sometimes the only source of health care available (Mankazana, 1979(Mankazana, : 1005;;Freeman & Motsei, 1992a: 1186).Apart from the latter two reasons, traditional healing is also deeply rooted in black people's culture.Abdool Karim etal., (1994:3) mentions that black people's cultural heritage is linked to their religion.Arthur (1997:63) also argues that this religion is a frame of reference, which forms the "fabric" of traditional African life -a fabric that closely co n n ects all thoughts and activities of the people, where health and illness form an integral part of this religious system.A decision to consult a traditional healer in times of ill health is the beginning of the formation of a relationship between the traditional healer and the patient.This relationship is usually very close and intense (Gumede, 1990:164), because the traditional healer as an existing resource person, is accessible, popular (Hopa, Sim bayi and du Toit, 1998:8), and available to the black people.The traditional healer " is of the people and comes from among them " (Gumede, 1990:164).Abdool Karim et al., (1994:2) declares, that the traditional healer shares with the patient a view of the world and the way in which it works, something completely alien to biomedical personnel.Not only does he provide comfort and support to both the patient and relatives, he is also a good listener (Gumede, 1990: 153), and an expert in providing com fort and reassurance (Musi, 1996:31).Therapeutic techniques typically used in traditional healing, sometimes conflict with the therapeutic techniques used in biomedicine.Biomedical therapeutic techniques are based on a scientific approach (Arthur, 1997:63), while those of traditional healing, according to Gumede (1990:154), are unscientific, crude and unplanned and, therefore, perceived as strange in the view of biomedical personnel's understanding of healing.It is from this premise, that traditional healers' work continue to be shunned, kept secret (Freeman & Motsei, 1992a: 1188), and treated with suspicion to an undue degree (Mburu, 1977:167).Therapeutic techniques used follows different stages, startin g with supernatural divination.This is a process o f diagnosis to identify a p a tie n t's problems.After the identification of the cause through supernatural divination follows the removal of the hostile source or neutralization of the sorcerer (Yangni-Angate, 1981:24).If the hostile source is tran sg ressin g the an cesto rs, th eir forgiveness is sought by sacrifices, rituals and ceremonies or by using certain m edications (A bdool K arim et al., 1994:5).Fees are charged according to each therapeutic technique used, and this schedule is n eith er fix ed nor standardized and arrangem ents for postponed paym ent are easily made (Ngubane, 1977:103) Parallel to the relationship of trust and therapeutic techniques used, are certain perceptions of the traditional healer and the patients about the entire healing process.These perceptions are inherent in traditional beliefs, and are identified to be the driving force behind the patients' persistence to consult the traditional healer, even after the patient may have sought the therapeutic techniques of biomedical personnel (Abdool Karim et al., 1994:5).T hese sim u ltan eo u s consultations create a problem to both providers and recipients of health care.When complications ensue, one blames the other because o f lack o f communication and trust between the two health systems.Each protects its own domain by preaching the value of using one and not the other.This creates a dilemma to the consumer, who sees both systems as serving his/her needs.This dilemma, gives rise to confusion and as a result the consumer chooses the services closer to him/her.It is because of this dilemma, that there was a need to investigate the following aspects:

Research design and method
The re searc h design used for this research was qualitative in nature.The context was the South-Sotho culture of the Maokeng, Ikageng and Sebokeng townships.

Literature study
A literature study was undertaken to: • ground the check list and the semi-structured interview schedules.No perceptions were included; • confirm the study of the South-Sotho traditional medicine, the characteristics of the relationship between the South -Sotho traditional healer and his patients as well as the therapeutic techniques used in the South -Sotho traditional healing process.

Sample
For the purpose of this research, samples were selected from two populations, namely South -Sotho traditional healers and their patients residing in the three tow ns o f M aokeng, Ikageng and S ebokeng w here the research was undertaken.These two populations were chosen purposively and voluntarily and satisfied the criteria for selection, which in the case of the traditional healers were that they should have been practicing for two or more years, of South -Sotho ethnic group and be residing in one of the three towns where the research was to be undertaken.The criteria for the patients was similar and included that they sh ould be freq u en t users o f traditional medicines, and be prepared to be interviewed and video taped while interacting with the traditional healer and when using the prescribed therapeutic techniques.

Data collection method
Data collection was divided into two phases.The first phase was achieved by means of making video recordings of the interaction between the six traditional healers and their patients as well as of the p atien ts w hen they used the therapeutic techniques prescribed by the traditional healers.The video recordings were done by a technician, following the instructions of the researcher.Some of these recordings w ere done at the p atien ts' hom es, and others at the traditional healers' homes.
The second phase was conducted by the researcher using an audiotape to record the interviews of the six traditional healers and two of each of their patients (twelve patients in total).The semi structured interview s of the traditional healers consisted of the following questions: Field notes were taken at the end of each of the video recording and interviewing sessions.Data saturation for the video recordings was reached after the sixth videotape was recorded; for the semi structured interviews of the traditional healers, after the sixth interview; and for the patients, after the eighth interview.However, a further four interviews were conducted to confirm the findings.
The video and audiotape cassettes were transcribed verbatim and translated into E nglish in preparation for the data analysis which was conducted by the researcher and an independent co-coder.

Data analysis
Data analysis for this research was divided into two categories.Firstly, data analysis of the video tape recordings which was done by means of viewing and coding with a checklist (Mann, Walkup, Berryman, Palmer and Bassey, 1994:226-230) depicting behaviours and events that occurred or did not occur (Dorwick, 1991:131).Secondly an analysis was made o f the audiotape transcriptions which were transcribed verbatim and translated by the researcher.Open coding was done by m eans of a technique d escrib ed by Tesch (in C ressw ell, 1990:153-159).The use of double coding was employed which involved that a nurse sp ec ia list and the research er an alysed and coded the data in d ep en d en tly , after w hich three consensus discussions took place to finalise the analysed data.

Trustworthiness
In qualitative research trustworthiness is d escrib ed as a m easure to ensure reliability and validity.For this research a combination of the approach of Guba (in Krefting, 1991:214) and the model of Woods and Catanzaro (1988:136-137) was used to measure reliability and validity.Table one illustrates the measures for trustworthiness.

Ethical aspects
Ethical aspects specific to this research were taken into consideration as detailed in the guidelines for the Democratic Nurses' Organisation of South Africa (1998:1-7), as w ell as those o f the Department of Health (2000:1-75).These are as follows: • The quality of the research was ensured by thorough planning, implementation and documentation of the research findings.

•
Confidentiality and anonymity was ensured by not revealing the names of participants in the report, except to the researcher, supervisor and co-supervisor.

•
Privacy was ensured by putting up a "no disturbance sign" in the areas where the video and interviews were recorded.

•
Written consent was obtained from both traditional healers and patients before the study was commenced in a written format, and the right to withdraw was explained.

•
Risks were minimised by proper planning and implementation of the research process.

•
The research would be termination if relevant data could not be obtained.

and literature control
The resu lts and d iscu ssio n o f this research falls into two sections.The first sectio n d ep icts the re su lts and discussion of the video taped interaction between the six traditional healers and their twelve patients, and the use of therapeutic techniques.The second section, which was obtained by the use of semi-structured interviews, depicts the different views o f the six traditional healers and their twelve patients about the traditional healing process.The discussion in this section is illustrated w ith q u o tatio n s d eriv ed from the interviews with the traditional healers and th eir patients.The fin d in g s are confirmed by a literature control.

Results of the video recordings
The results of the video recordings depict the demographic data of the traditional healers and the patients, the interaction process and the use of the traditional therapeutic techniques.

Demographic data of traditional healers and the patients
The traditional healers who participated in this research consisted of four (4) females and two (2) m ales, with the average age being thirty nine (39).In terms of age and gender, the distribution o f patients who participated in the research was almost similar to that of traditional healers whom they consulted.Furthermore, the age of a traditional healer appeared to have no influence on the patient's choice to consult him/her.It also appeared that women seek the help of the traditional healer, more than m en.The p rocess o f co n su ltatio n consisted of two or more sessions and the consultations always took place at the traditional healers' premises.The initial contact made with the traditional healer appeared to be more out of the patient's own free will than in response to reference by friends or family.

The interaction between the traditional healers and the patients
The interaction between the traditional healer and the patient was based on a relationship consisting of a beginning, working and term ination phase.On entering the consulting room s, the patients show ed re sp ect fo r the traditional healers by entering in silence and removing their shoes at the door step.The traditional healer initiated the conversation by greeting the patient first in an atm osphere o f tran q u illity .Consultation was done with the patient sitting down on the floor facing the traditional healers.Those patients who sat on the chairs were beckoned by the traditional healers to do so.Consultation was the beginning of the

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working phase, which was started by negotiating the fees to be paid prior to resuming divination.The fees varied depending on the problem o f the patients.Money was used as means of payment and was agreed upon by both the traditional healers and the patients.The paym ent d iffe red from one traditional healer to the other, with some requesting payment after the treatment is completed and the patient has been cured, or when the funds are available.
The process of divination involved a procedure which was perform ed to assess and diagnose the patient by using the divination tools, which differed from one traditional healer to the other.Some used "holy" bones and others used a lit candle and a glass o f w ater.The consultation consisted of three phases, namely, the beginning phase, the working phase and the termination phase.During the beginning phase, rapport was built between the traditional healer and the p atien t and during this phase the traditional healer came to a meaningful diagnosis.The process of divination was an important part of the healing process and the traditional healer became active, while the patient was more passive and reacted only to the questions asked by the traditional healer.The period of divination varied amongst the traditional healers and depended on the patients' problems.
During divination all the traditional healers started with a prayer and made contact with the ancestors, even though the manner in which the prayer was said varied.They sprinkled snuff around the divination tools and spat saliva on the area where the "holy" bones were used.Objects in the form of a whisker, a spear or a stick were used to point at the divination tools as they interacted with the patients.
As part of the divination process, the problem was clarified.Patients had to agree to confirm the findings by saying "siya vum a" .T hey seem ed to understand the events that followed because they accepted the support and treatment offered by the traditional healer.A fter m aking the d iag n o sis, the traditional healer was seen to wrap the medicines, with the instructions written on the brown paper wrappers.If the m edicine was wrapped in plastic, a separate piece of paper was wrapped inside with the medicines.It was also noted th at certain m edicines w ere im m ed iately ad m inistered by the traditional healer, while others were given as treatm ent to take home.It was observed that all the patients were satisfied with the prescribed treatment, as well as with the answers which they received to their questions.The interaction between the traditional healers and the patients ended in the termination phase.This phase included summaries of the conversations made during divination and when the treatment was prescribed.All the traditional healers invited the patients for a follow up visit but none referred the patients to other traditional healers or health care services.
It was observed that when the patients left the consulting rooms they did so in silence, put on their shoes at the doorstep and exchanged no greetings.

The use of traditional therapeutic techniques
The use o f trad itio n al th erap eu tic techniques was seen as an important aspect of the healing process.As the traditional healers worked from home, m ost o f the treatm ent was used immediately after divination.The manner in which both the traditional healer and the patient used these techniques stems from the agreement into which they entered regarding the implementation process.The implementation process varied from one traditional healer to the o th er, acco rd in g to th eir p a tie n ts ' problems.One could decide to start with oral administration while another may start with an enema.
The techniques that were used were mostly non invasive and consisted of natural herbs and plants.Much emphasis was placed on the way in which these m ed icin es w ere to be used.The implementation process consisted of the following components: • application of oily/fatty medicines to the skin , • pricking with a porcupine quill, • tapping with a horn of a goat or ram, • administration of oral medicines constituted the major route, • enema, • steam inhalations, • steam baths and bathing, and • eye, ear and nose instillation.Home protection was done by means of spraying and burning incense inside and outside the house.

The results of the semi structured interviews
The traditional healers' and the patients' views of the traditional healing process reflected three main categories, each with a num ber o f su b -categ o ries.The discussion below firstly focuses on the three main categories of the traditional healers' views regarding the healing process, therapeutic techniques carried out and the context o f various relationships.

The traditional healers' views about the traditional healing process
The follow ing discussion o f the traditional healers' views are supported by quotations of the respondents and literature control.
* Views regarding the healing process.

Role expectations
The tra d itio n a l healers view ed themselves as having a role in healing people.A ll six traditional healers involved in this research, in principle supported the view that they heal people by giving them medicines suitable for their type of illness.The following quotations illustrates this: '7 heal ill people, 1 give them medicines that are suitable fo r their illness."

"I o ffe r p eo p le d iffe ren t types o f treatment"
Nzima, Edwards and Makunga, (1992:82 -93) confirms the results by stating that as a result of his/her ability to treat the patients, the traditional healer is known through ou t the land.N gubane (1977:109), Gumede (1990:65) and Abdool Karim et al., (1994:5) agree that the tra d itio n a l h e a le rs' ab ility to cure illn e sses o f su p ern atu ral o rig in is obtained from the use of herbs, rituals and ceremonies.

T he p a tie n ts' s e lf responsibility for healing
The traditional healer viewed the patient as part o f the healing process, and expected the patient to take care of herself.The following remarks confirm these perceptions: "I expect the patient to be responsible fo r her healing.The patient as part o f healing is an honour to me, her role is largely determined by her illness and what she is able to do fo r herself.""When / give them medicines to take home, I ask them to carry out the instructions as I tell them, we understand each other."Mburu (In Singer, 1982:173) and Aakster (1989:298) support the findings and point out that carefully managed treatment and the satisfactory disclosure of information to the patient, as important aspects of healing.Holdstock (1979:119) and Levitz (1992:23-25) confirm s these findings that the patients are given an opportunity to be partners in health care provision.

Culture and belief system.
The traditional healer and the patient shares the same worldview, as determined by culture, because they live in the same neighbourhood.The following remark is an example of this: "Our understanding stems from the fa ct that I am the traditional healer.The patient has illness, she comes to me with the need to be cured.This makes us share the world which is controlled by culture." Holdstock (1979:120) and Abdool Karim et al., (1994:2) confirm the research findings that the traditional healer shares with the patient a view of the world and the way in w hich it works.A rthur (1997:63) also concurs the findings that the traditional healer is seen as providing the solution for preventing and curing culturally perceived illnesses.

-Therapeutic actions implemented by the traditional healer
The traditional healer used divination to understand the patient's problem and to d eterm in e the n ecessary treatm ent.The follow ing quotation illustrate this:

"When a person is ill, then I start to get deeper into his illness by first finding out what the "holy" bones have to say. "
Staugard (1985:81); Hammond Tooke (1989:119) and Ingstad (1989:256) confirm these fin d in g s by saying th at the th erapeutic techniques, w hich the traditional healer uses, are many and includes divination, which is achieved by the use of "holy" bones.Abdool Karim etal., (1994:5) come to the same conclusion as the above authors when they find that divination is the first technique that the traditional healer uses, in o rd er to co m m u n icate w ith the ancestors to find out what the patients' problem is prior to giving medications.

Various therapeutic actions used as part of healing
The traditional healers identified the following therapeutic actions as part of the healing process they use:

"I p refer to use bathing, enem ata, steaming if it is necessary. "
" When a person starts to come to me, I give her oral medicines to drink after boiling it." Ngubane (1977:102); Gumede (1990:79) and Abdool Karim et al., (1994:5) made sim ilar fin d in g s and in d icate that medicines are prescribed and given by various routes.Edwards (1986:89) also co ncurs w ith th is, in fin d in g that medicines are administered by various ro u tes, in clu d in g m ethods such as boiling or burning.

Wrapping medicines for use at home
This m ethod is used to ensure the continued use of therapeutic techniques at home.Medicines are wrapped to be used at home according to instructions.The fo llo w in g tw o q u o tatio n s are examples of what was said in this context:

"I am now g o in g to give her prescriptions, medications that are fo r use at her home. " "Ihave each medicines' uses written out properly on a piece o f paper, and this piece o f paper is wrapped inside the plastic that I use to cover medicines with. "
Literature does not make mention of the method that the traditional healer uses to give the medicines which are to be used at home, or whether they are wrapped up or placed in bottles.From the research findings, it appears that the traditional healer uses brown paper and plastic to wrap medicines for the patients to use at home, according to instructions which are w ritten on a piece o f paper that accompanies.If a medicine is wrapped in plastic, a piece of paper with instructions is placed inside and wrapped with the medicine.

Carrying out home visits
The traditional healer visits very ill patients in their homes.In some cases where the traditional healer is unable to come to the patients' home, relatives or family members bring this patient to the traditional healers' home, or alternatively they come to fetch the traditional healer so that he treats the patient in his/her own home.These following responses were made in this regard:

"Yes, I do visit them when I have a chance, and when that patient is very ill, I do go over to see what is going on. "
"Sometimes I am called to heal people at their homes, and these people come to fetch me, again this is where the family is involved in the healing process" L iterature is not specific about the trad itio n al h ealer v isitin g patients voluntarily at their homes.However Ngubane (1977:103), Staugard (1985:123) and Abdool Karim etal., (1994:2) explains that the traditional healer relates best with the patient at home because of the relaxed and quiet atmosphere where individuality is maintained.

The follow up process
The patients were also expected to report back for review of their condition and to discuss the problem area if it was noticed that their conditions did not improve: '7 do ask them to return and tell me how they progress because I need to know if the patient feels better or not." Levitz (1992: 36) supports these findings and argues that the ab ility to give answers about what is wrong in relation to problems of misfortune, is an important skill of the traditional healer.Gumede (1990:98) also agrees with this, by saying that the traditional healer treats the patient until he/she is satisfied with the treatment that has been given.

Referral of patients
If the traditional healer realises during the follow up process that the patient's problem has not been resolved, he/ she would request the patient to go to the clinic or surgery, or use other traditional healer's medicines.The following remarks are used as examples: "When I start to realise that this patient is becoming worse, that is when I start to change from the treatment that I have been giving her." "When still things do not work out according to plan then I request them to go to the hospital." Watt and Van Warmelo (1960:47-63) and Ngubane (1981:361-367) made similar findings and indicate that when the traditional healer is faced with a disease he/she cannot handle, he/she requests the patient to seek other treatment or may change that treatment as the need arise.Green and Makhubu (1984:1071-1079) explains that although the traditional healer does not possess surgical skills, he/she is able to assess the problems and therefore change treatment whenever necessary * The context of various relationships within the healing process.

Relationship with God and the ancestors
This relationship stems from the fact that the traditional healer is given powers by the ancestors to deal with sick people.The follow ing tw o q u o tatio n s are examples of this: "Traditional healing is a gift that you are given by God and the ancestors " "It is healing given by our forefathers who have instructed us on the type o f work that we are to treat people " In the literature these findings are confirm ed by N gubane (1977:142), Gumede (1990:75) and Levitz (1992:23-26), who have found that the traditional healer view traditional healing as an effective form of healing and as a gift from God and the an cesto rs.The respondents also believed that they are guided and directed about what to do and where to look for the treatment.

Relationship with the patient
The relationship between the patient and traditional healer centres on the patient's illness and their mutual understanding to work together as far as the illness is concerned.The follow ing resp o n se from a participant confirm this: "Our understanding stems from the fa ct that / am the traditional healer and the patient has an illness, she comes to me with a need to be cured."Mburu (in Singer, 1982:172) and Abdool Karim et al., (1994:5) made sim ilar findings, namely that the patient believe that his/her illness results from natural and supernatural causes, hence the need for the traditional healers' help in this situation.

Relationship with the family
In the view of the traditional healer, he/ she also has a clear relationship with the patient's family, in that the family must assist a patient who refuses to take medicines, must accompany the patient to the biomedical personnel and must report the progress of the patient to the traditional healer: '7 ask the relatives to send them to the doctors." "I do request them to keep me informed about their progress." Holdstock (1979:119), Freeman andMotsei (1992a: 1186), Levitz (1992:135) and Abdool Karim et al., (1994:2) come to the sam e co n clusion about the importance of family involvement in the application of traditional therapeutic techniques, and points out that it plays an important role in maintaining social stability in the black society.

R ela tio n sh ip w ith the community
The community views the traditional healer as a leader who helps with life and cures illn ess, and who is a happy, honoured and respectable person in the community.The following responses are used as examples: "A leader that helps with life and cures illness." "His healing you see it as the healing that helps." Staugard (1985:112) as well as Freeman and M otsei (1992b: 119) confirm the findings about the traditional healer' popularity in the communities because of his/her supernatural powers which are used to find the cause of the perceived disorder, and to correct or resolve it.

The patients' views about traditional healing process
The research found that the patients' perceptions of traditional healing, corresponds to that of the traditional healers.These views may be classified in the following main categories: the healing process; therapeutic actions carried out by the traditional healer; and the characteristics of the relationship between the patient and the traditional healer.

The traditional healers' ability to treat cultural illness
The patient viewed the traditional healer as able to treat black people's illnesses that are caused by transgressing cultural norms.These illnesses are viewed as culture bound, and this study has found that this aspect is not understood by biomedical personnel.These views are reflected in statements such as: "One has to be treated by the traditional h ea ler when having illness that is directed at traditional healing, illness like pollution where taboos are not respected." Staugard (1986:99); Gumede (1990: 89) and Abdool Karim etal., (1994:2) concur with the findings about the belief of patients, and show that illness resulting from natural and supernatural causes are treated only by the traditional healer.

T he p atien t sh ares the traditional healers' worldview
The patients' and the traditional healers' worldviews are similar, and are based upon the sam e prem ise o f w hat co n stitu te s illn e ss/h e alth .The experience of a shared worldview is enhanced by the fact that the traditional healer is also black, speaks the same language as the patient, lives in the same area and is accessible when needed.
'7 say they know our customs, the way we black people live, it is their way o f life, because they are black they have the a b ility to treat black p e o p le 's illness " Freeman andMotsei (1992a: 1186) and Abdool Karim et al., (1994:2) confirm the above argum ent that the traditional healer shares with the patients a view of the world and the way in which it works.Arthur (1997:67) supports this notion of a different worldview that is shared by the patient and the traditional healer, and refer to it as something completely alien to biomedical personnel.

H an d lin g p rob lem s and difficulties
Problems and difficulties are handled by paying a return visit to the traditional

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healer to get more information and clarity on the illness.The following remark is an example of this: '7 go back to the traditional healer to get more information and clarity." Ngubane (1977:238) and Gumede (1992:5) affirms the findings that the patient returns to the traditional healer when there are no results or when he/she does not remember how the medicine must be used.Levitz (1992:16) also supports these results and explains that the patient returns to the traditional healer for a review of his /her progress when there are no evident results from the treatment which has been used.
* Therapeutic actions carried out by the traditional healer.

Different types of treatment used in traditional healing
Patients view the therapeutic actions carried out by the traditional healer, in the same fashion as the traditional healers view them.The manner in which the divination is performed as well as the various routes of administering medicines are seen as methods used to solve or heal their culture bound illnesses or problems: "The traditional healer uses his 'holy' bones to see what is wrong with me and to tell me what I must do to be cured." "The traditional healer treats me by giving me medicines to drink, others to vomit with and fo r enemas." Ngubane (1977:106) refers to the use of d iv in atio n before any treatm en t is com m enced.S taugard (1 9 8 5 :9 ), Hammond-Tooke (1989:119) and Gumede (1990:116) all confirm these various routes o f ad m in isterin g trad itio n al m edicines.T hese routes may vary according to the type of problem which is diagnosed during divination.
The problems and difficulties encountered when using traditional medicines When problems and difficulties were encountered during the use of traditional medicines, the patient paid a return visit to the traditional healer to get more clarity on these problem s.This situation is illustrated by the following responses of patients: "I did forget how to use these herbs and I went back to ask fo r a re-explanation."1 go there m yself to ask fo r clarity with these medicines." Literature does not make mention of the instructions which the traditional healer gives to the patient.According to the information yielded by this research, however, it was identified as a reality, by the respondents, because they had to make a decision to return to the traditional healer to request for an explanation if there were misunderstandings about the use of medicines.

Uses of medicines at home.
Medicines for use at home should be used as prescribed, otherwise they would loose th eir effec tiv en e ss.P atients com m ented on th is aspect in the following manner: "The medicines that are used at home are fo r protecting the home and the children against evil.There are many types and he tells you how they work." "These that are used at home are used under strict instructions, i f you do not use them in this way, they do not work." Ngubane (1977:161) andStaugard (1985:65) come to a similar conclusion and mention that in the event where ancestral protection is withdrawn and problems of misfortune are experienced, it becomes necessary to perfo rm ritu a ls and ceremonies at home.Gumede (1990:88) also found that medicines may be at home for purposes of protecting the home as well as family.

F ollow up p rocess by the traditional healer
During follow up by the traditional healer, the procedure of divination is repeated to further determine whether the problem could be solved and if it is necessary, to change the treatment.Patients m ade rem arks such as the following about this: "Then he changes the medicines and gives me another one to use afresh and throws away the first one." Ngubane (1977:102), Mburu (in Singer, 1982:177) and Abdool Karim et al., (1994:5) found that the traditional healer will identify the cause of the problem through supernatural divination, after which he will recommend a further course of action to the patient.

The sources of medicines
Medicines are obtained from the veld as roots of plants, barks from trees.Where m ed icin al herb s are not used, the traditional healer uses prayer, ash and "holy" water.One respondent gave the following account of this process: "This healing is important to us because it is healing using herbs and plants." W att and Van W arm elo (1960:53); Hammond-Tooke (1989:119) and Gumede (1990:112) indicate that 80% of medicines are of vegetable origin and that these medicines are picked from the "veld"; w hereas S taugard (1 9 8 5 :1 0 7 ) and Freeman andMotsei (1992a: 1186) make reference to prophets who use ash and water that have been prayed for.
* The characteristics of the relationship between the patient and the traditional healer

Interactive relationship
The patient views the traditional healer as having an interactive relationship with him/her, based on the humane treatment by the healer, accessibility of the healer and the fact that h ealer listens to problem s.This is illustrated by the following responses: "This person, the traditional healer, he talks to us as human beings, not puppets or clowns." "Yes, unlike you nurses who scolds and scolds when we do not remember or when we m ake m istakes, o u r peo p le understands us better than you." Staugard (1985:123) and Levitz (1992:35) likewise refer to the phenomenon that the traditional healer has time to talk and listen to his/her patients.Freeman andMotsei (1992a: 1186) and Musi (1996:31) also came to conclusion that biomedical personnel concentrate on the medical aspect of the disease and less on the patient as a human being.

The tr a d itio n a l h e a le r s' relationship with the ancestors
In the patient's views the traditional healer's ability and powers to treat their culturally perceived illness is a gift bestowed upon him/her by God and the ancestors, and he/she has the ability to communicate with God and the ancestors, through the use of the "holy" bones: '7 prefer to go to him because he is able to com m unicate with the ancestors through the "holy " bones, therefore help me with the problems I have." Ingstad (1989:251), Gumede (1990:90) and Abdool Karim etal., (1994:5) explain that the traditional healer communicates with the ancestors through offerings and mediates between the people, God and the ancestors.Levitz (1992:23) also supports the results and states that the ability to heal people is based on the answ ers the an cesto rs give during divination.

Payment for the treatment
It was noticed that the traditional healer did not expect immediate payment and that treatment was offered even when there was no payment.This is unlike the biomedical people who expect immediate payment for treatment and may even pursue patients for the payment.The following examples of the patients' responses illustrate this: "Yes and more, he allows me to be treated without money, my family can go to him even when I am not around, he looks after us all." "The fact that when I also owe him he does not follow me to ask fo r his money, biomedical people, yes they sent you letters at home to remind you to come and pay." Green and Makhubu (1984:1074), Ingstad (1989:256), Gumede (1990:90) and Musi (1996:31) also found that the treatment o f one fam ily m em ber enables the traditional healer to have a relationship with the family where all the family m em bers are treated even w ithout immediate payment.

Conclusions
The dem ographic data o f both the traditional healers and the patients, showed that both groups appeared to be younger than anticipated.This age factor did not affect the patien ts' decision to consult the traditional healer in times of need.The video recordings depicted the interaction between the traditional healer and the patient as a process involving divination (diagnosis) which was to be paid for in advance.During divination the traditional healers w ere seen to be em o tio n al when "communicating with the ancestors."Once the problem was identified, the traditional healer and the patient agreed on the treatment to be used to resolve the problem.The treatment came in a form of various medicines, which were used immediately or were wrapped with the option to use at home.The patients posed no questions and accepted the medicines, with the instructions on how to used them.The traditional healers placed much emphasis on the manner in which the medicines should be used.
The conclusion regarding the traditional h ealer and the p a tie n ts ' view s of traditional healing process was that the traditional healer's were endowed by the ancestors with the ability and power to treat the illnesses from which black people suffer because of transgressing cultural norms.Biomedical personnel were seen as unable to cure culture bound illnesses, and their services were only u tilise d as an altern ativ e to traditional medicines when the latter did not to yield the expected results.The traditional healer and the patient both viewed the family as a support system in the healing process, and both felt that the patient was responsible for his/her ow n h ea lin g , because h e/she was expected to carry out the instructions himself/herself when using the traditional therapeutic techniques.The research must be replicated with the same traditional healers and patients to produce the same results Auditability to increase reliability.

Recommendations
Clear connection between sources of data and data description L iterature study was undertaken to ground the interview schedules and video recordings.
Field notes taken were made after video recordings and the co n du ctin g of interviews.
Cross validation was used during data analysis by means of independent data analysis and a consensus discussion between the researcher and the co coder.
E xtensive lite ratu re review was undertaken.Use o f video re co rd er and sem istuctured interviews for data collection.Field Notes were taken after video recording and interviews.Use o f double coding during data analysis.
In this research, a dense description and consistent reporting on the data that that was collected were offered, in case other researchers may want to criticise it or conduct further studies.
The context was the three aforementioned townships.
The researcher gave a dense description of data collection method, and of data analysis.
A full description of the results and discussion was presented.
The transcriptions and raw data are available for auditing.
Neutrality was ensured by use of experts in the auditing of the check list for the video recording and for the format of questions for the sem i-stru ctu red interviews.