Integration of the Findings on Treatment Services and Modalities

The combined findings from the various manuscripts highlighted substantial differences in how HCPs and THPs approach the treatment of seizures. In Manuscript 4, it was described that THPs focus on the person as an individual with a unique diagnosis and treatment plan guided by divination. In TM, seizure treatment is individualized according to the patient’s needs and although it often includes the use of plant and animal material, it also focuses on the spiritual aspects of the disorder (Njamnshi et al., 2010). Looking at responses from HCPs during the interviews, it became evident that seizure control features highly on the agenda of biomedical practitioners. This was reflected in subthemes that described the importance of seizure control and the frequent reliance on AED treatment even before a definitive diagnosis had been made. However, it was found that seizure remission does not necessarily translate to improved outcomes and should therefore not be the main focus of treatment programmes (Reuber et al.,

2005). This state of affairs seemed to cause frustration among some of the HCPs who lamented the indiscriminate use of medication in seizure treatment. At the same time, it reflects the perception that seizures should primarily be treated with biological interventions, which results in a disregard for the psychosocial aspects of the disorder and an exclusive focus on the physical symptoms of the seizures (Blumer, 2008). Whereas biomedicine strives to “manage” the

condition, THPs strive to “cure” it. For this reason, THPs believe that Western medicine can only treat the symptoms, but is unable to relieve the patient of the seizures completely, whereas their own treatment success is measured by the complete absence of seizures.

However, the use of medication in the treatment of seizures presents its own challenges. One of the challenges is that although effective AED treatment is available in Namibia, it is not always within the financial reach of patients from lower SES. State medical facilities do supply AEDs, but again, this service is hampered by the reluctance of state healthcare workers to assist patients referred by private HCPs. Another challenge relates to the follow-up of seizure patients in general, but also specifically those on AED treatment. During the semi-structured interviews with HCPs reported in Manuscript 3, regular follow-up for patients on AED treatment were performed by only a minority of HCPs. However, in Manuscript 2, where the results of the surveys were disseminated, ES HCPs appeared to follow up on patients more regularly than PNES practitioners did. This discrepancy may be explained by the failure of PNES patients to respond to AED treatment, the resultant fatigue experienced by HCPs and the finding that HCPs feel more confident to treat ES than PNES. According to the literature, much harm is done by employing aggressive therapies and inappropriate treatments such as the use of AEDs in an attempt to stop seizures in PNES patients (LaFrance Jr. & Blumer, 2010). In fact, most PNES patients receive unnecessary AEDs even though extensive observational data suggest that such treatment is ineffective or may even worsen PNES symptoms (LaFrance Jr. & Blumer, 2010; Reuber et al., 2002). Furthermore, indecision regarding the most suitable treatment method for PNES often results in the perception that it is a difficult disorder to treat (O’Sullivan et al., 2006; Quinn et al., 2010).

This brings the discussion back to the role of psychotherapy in the treatment of seizures and that the most preferred and effective treatment for MUS, such as PNES, is found in various forms of psychotherapy (Krebs, 2007). At the same time, psychotherapy can play an integral part in the treatment of comorbid mental health disorders in PWE (Tang et al., 2014). Despite these findings and the HCPs’ opinion that effective therapy is available in Namibia, it was found that referring HCPs seldom make use of psychologists to treat or support people with seizures. Although this can partly be ascribed to a lack of knowledge about the benefits of psychotherapy, HCPs ascribed their failure to refer to psychologists to the patient’s lack of financial resources and a shortage of psychologists who are familiar with treating patients with seizures. The

possible role of THPs in the treatment of seizures is stressed in Manuscript 1, with the realization that conventional psychotherapeutic techniques may not make adequate provision for the unique cultural beliefs in non-Westernized populations. The THPs who participated in this study all believed that seizures can be attributed to the work of evil spirits, witchcraft and supernatural forces and that they can successfully treat patients when the origin of the disorder is grounded in spiritual beliefs and where the treatment approach is culturally appropriate.

The final treatment option open to patients with ES is surgery or vagal nerve stimulation (Moshé et al., 2015). These procedures are only available in neighbouring South Africa and come with a hefty price tag. HCPs therefore indicated that they seldom refer patients for surgery. They also raised questions about the success rate of these specialized procedures (S. P. Singh et al., 2017).

Faced with the above challenges, HCPs recognized that a multidisciplinary approach is needed to manage people with seizures successfully. However, multidisciplinary collaboration is often compromised due to a lack of coordination and communication between the different disciplines (Baslet et al., 2016; McMillan et al., 2014). HCPs also recognized that some patients prefer to be treated by THPs and they acknowledged that these practitioners might play a supportive role in the management of seizures. However, despite HCPs’ willingness to

collaborate with THPs, they did indicate their reluctance to refer patients to THPs as the role of THPs is seen as mainly supportive and not as critical to the diagnostic and treatment of seizures. However, THPs perceive their relationship with HCPs at state hospitals to be open and

reciprocal, with frequent patient referrals, encouragement to continue medication from Western doctors and advising patients to return to the hospital for follow-ups.