Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13082 Alternative treatment for schizophrenia with a local wisdom approach in the Tidung tribe community of Tarakan City: a descriptive qualitative study Darni Darni,1 Sulidah Sulidah,1 Ramdya Akbar Tukan,1 Rts Netisa Martawinarti,2 Siti Khadijah,3 Putri Irwanti Sari2 1Study Program of Nursing, Faculty of Health Science, University of Borneo Tarakan; 2Study Program of Nursing, Faculty of Medicine and Health Science, University of Jambi; 3Study Program of Nursing, Politeknik Kesehatan Kemenkes Surakarta, Indonesia Abstract The Tidung community employed traditional methods and botanical remedies to treat schizophrenia, which is part of their local expertise, particularly in public health. This generational knowledge encompasses skills such as massage, chants, mantras, and herbal remedies. The purpose of this study was to investigate whether the Tidung community can benefit from these traditional practices as alternative therapies for schizophrenia. The study involved thirteen participants who were conventional practitioners treating schizophrenia and employed a qualitative descriptive methodology. We collected data through field notes and in-depth interviews and then used Colaizzi’s approach for analysis. Four major themes emerged from the study: i) the conventional meth- ods used to treat schizophrenia; ii) the reasons for the shortcom- ings of these methods; iii) the role of supernatural elements in the therapeutic process; and iv) the expectations of traditional healers regarding patient recovery. The results showed that early use of spiritual therapies leads to higher recovery rates compared to physical therapy and herbal medications. We view traditional medicine in this context as a combination of prayer (supernatural components), action (administering potions), and therapy. Introduction Indonesia is a nation rich in cultural diversity, which is reflect- ed in its local wisdom, particularly in health practices. Traditional health services, governed by Law No. 36 of 2009,1 include skill- based and herbal medicine approaches. Traditional medicine plays a crucial role in treating mental health issues, with over 30% of patients in rural areas opting for traditional treatments, especially in regions with limited access to modern healthcare.2 Reports indi- cate that approximately 25% of families with schizophrenia mem- bers seek traditional healing methods, such as consulting shamans and employing herbal remedies.3 In developing countries like Indonesia, patients with mental disorders often combine traditional and alternative therapies, believing their conditions may stem from spiritual causes.2,4,5 While previous studies explored treatments involving shamans, this study focuses on the ruqyah spiritual method.6 Additionally, the treatment landscape varies significantly, with some patients receiving alternative therapies like traditional Chinese medicine, particularly for refractory schizophrenia cases.7 The previous research highlights the differences and similari- ties between Abraham Maslow’s and John Nash’s theories in rela- tion to mental health interventions, revealing significant discrep- ancies between the theoretical frameworks and empirical findings. While Nash’s theory integrates Maslow’s concepts, the study found no evidence to support the idea that appropriate interven- tions universally treat mental illnesses, particularly among non- schizophrenia patients. Key factors influencing the ineffectiveness of treatments were identified, including the lack of supernatural interventions in Maslow’s framework, which Nash includes.8 Additionally, the research indicates that traditional healing meth- ods, such as prayer and spiritual practices, are significant for treat- ing schizophrenia within the socio-economic context of Tarakan, Indonesia, where families often delay seeking modern medical Correspondence: Darni Darni, Study Program of Nursing, Faculty of Health Science, University of Borneo Tarakan, Indonesia. E-mail: darni.resky86@gmail.com Key words: local wisdom; schizophrenia; treatment; Tidung tribe com- munity. Conflict of interest: the authors declare no potential conflict of interest. Ethics approval and consent to participate: the research obtained ethical approval from the Ethics Committee of the Faculty of Health Sciences, University of Borneo Tarakan (ethical exemption No. 15/KEPK-FIKES UBT/X/2022). Participants were asked to provide their written consent to participate freely without coercion. They could withdraw from the study without giving a reason and could refuse to answer any questions. Furthermore, the researchers ensured their privacy during the interview process. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: research funding comes from the University of Borneo Tarakan Campus through DIPA funds. Acknowledgments: the authors would like to express gratitude to the Rector of the University of Borneo Tarakan, to the Research Institute of Borneo University Tarakan (LPPM), and to the professors and students of the Nursing Department at Borneo University Tarakan who con- tributed to the successful completion of this research. Received: 11 September 2024. Accepted: 7 November 2024. Early access: 29 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13082 doi:10.4081/hls.2024.13082 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13(s1):13082] [page 37] help until conditions worsen, complicating potential recovery.9,10 The Tidung people, predominantly Muslim, have interacted with various ethnic groups, enriching their cultural practices. Their ancestral knowledge of public health and traditional healing is vital for addressing mental health issues.10,11 Recent data from the Basic Health Research (RISKESDAS) indicates a notable increase in schizophrenia cases, highlighting the significance of traditional treatment methods within the Tidung community, where local wis- dom informs their healthcare approaches.12 In the past three years, there has been a continuous increase in the number of people who have been cured after receiving traditional treatments by the Tidung.13 The study examines the role of 23 traditional healers from var- ious Indonesian tribes, particularly the Tidung tribe, in treating schizophrenia, finding that ten Tidung healers have successfully cured patients without formal medical intervention.10,14 While some schizophrenia patients who received traditional treatment improved, others who sought medical care remained unhealed, indicating a complex interplay between community attitudes toward mental health and traditional practices.15-17 The research highlights local wisdom in traditional treatments, including herbal medicine, spiritual therapy, and prayer, which can alleviate symp- toms and reduce the stigma surrounding schizophrenia. The study aimed to investigate the effectiveness of these traditional practices, focusing on factors influencing treatment outcomes, including spiritual commitment and family acceptance. The findings empha- size the importance of preserving cultural practices while recog- nizing the potential health risks associated with exclusive reliance on traditional treatments. Materials and Methods Research methods This study employed a qualitative research design using a descriptive approach to explore alternative treatments for schizophrenia provided by the Tidung community, utilizing local wisdom in Tarakan City, North Kalimantan. The research focused on understanding how the Tidung community treats schizophrenia patients through traditional practices. The participants included practitioners or traditional healers who actively used herbs, rituals, mantras, remedies, therapies, and spirituality to aid their sick fam- ily members. Participants were recruited based on specific criteria: they had to be Tidung people residing in Tarakan, have successful- ly treated schizophrenia patients (as confirmed by their families), be willing to participate, and be able to understand and communi- cate in Indonesian. Recruitment involved approaching neighbor- hood heads and community leaders who could facilitate connec- tions with traditional healers. Ethical considerations Ethical approval for the study was obtained from the Ethics Committee of the Faculty of Health Sciences, University of Borneo Tarakan (ethical exemption No. 15/KEPK-FIKES UBT/X/2022). Participants were informed about the study’s pur- pose and provided their written consent freely and without coer- cion. They were assured that they could withdraw from the study at any time without consequence and could refuse to answer any questions. Participant privacy was maintained throughout the inter- view process, with all data anonymized during transcription using alphanumeric identifiers (e.g., P1, P2). Data collection and analysis Data collection occurred over four months from April 2022. Participants were visited at their homes to obtain consent, followed by semi-structured interviews that lasted approximately 30 min- utes each. The first session involved explaining the research and conducting the initial interview, while a second session, necessitat- ed by incomplete data, involved follow-up interviews with selected participants conducted by a team of three researchers. To minimize bias, data triangulation was employed, incorporating various sources and methods at different times. The interviews were recorded and transcribed, and Colaizzi’s method was used for data analysis. This manual analysis was cho- sen due to the rich variation in vocabulary among participants. The analytical process involved describing the research problem, col- lecting participant statements, re-reading transcripts for meaning- ful statements, and organizing data into thematic groups. Participants were engaged to validate the findings, and the final description was compiled based on these validated results. Key questions guiding the interviews included: i) What actions are taken in treating patients with schizophrenia? ii) What readings or prayers are employed in treatment? iii) How is ruqyah, a tradition- al spiritual therapy, utilized in treating schizophrenia? Probing questions were asked to ensure comprehensive understanding, and discrepancies in data were addressed through collaborative reviews of the transcribed interviews. Results This study presents its findings in two parts. The first part pro- vides general information about the participants’ characteristics, considering their backgrounds and contexts. The second part describes the research results, including the objectives and the- matic groupings that emerged from the transcripts and field notes collected during in-depth interviews about alternative treatments for schizophrenia. These treatments are explored through the local wisdom approach of the Tidung community in Tarakan City. Participant characteristics Participants in this study were selected according to the estab- lished inclusion criteria. An inventory identified 23 traditional healers in Tarakan City who treat schizophrenia patients, repre- senting various ethnic groups, including Javanese, Sulawesi, Banjar, and Tidung. Among them, 13 traditional healers from the Tidung ethnic group have successfully treated schizophrenia patients. In the Tidung community, patients seeking traditional treatment have reportedly recovered without any medical inter- vention (such as that from hospitals, midwives, nurses, or clinics). Additionally, those who did not respond to medical treatment later improved after receiving traditional care. The treatments employed included local wisdom practices such as the use of medicinal plants, spiritual therapy, and prayers. From the initial pool of 23 traditional healers, 13 participants were selected based on the inclusion criteria set by the researchers (Table 1). These criteria specified that participants must be mem- bers of the Tidung community residing in Tarakan City, have experience in treating schizophrenia patients, and be recognized as having achieved healing by their families. All participants will- ingly agreed to participate in the study by signing a consent form and were proficient in Indonesian, which ensured effective com- munication between the researchers and the participants. Based on the participant codes used during the interviews, the Special issue Pathways of Change [page 38] [Healthcare in Low-resource Settings 2025;13(s1):13082] codes ranged from Participant One (P01) to Participant Thirteen (P13), with variations in the initials of the participants’ names. The research results identified four key themes (Table 2). Themes 1. Traditional treatment methods for schizophre- nia patients Treatment of schizophrenia often employs indigenous knowl- edge, including medicinal herbs, spiritual therapy, and prayer. The community’s attitudes towards schizophrenia present challenges for government health initiatives. While it is crucial for Indonesia to preserve these traditional practices as cultural assets, their appli- cation can lead to health risks and complications. We identify three sub-themes influencing the healing of schizophrenia patients through traditional methods: spiritual treatment, treatment com- mitment, and self-efficacy. Sub-theme 1. Spiritual healing Participants frequently mentioned ruqyah healing, a practice involving Qur’anic recitation. Statements included: “We perform ruqyah, akin to reciting the Qur’an” (P1). The significance of solawatan, a communal prayer, was also highlighted: “Solawatan can be performed independently, while we guide their actions” (P3). Additionally, participants noted the importance of neutraliza- tion in treatment, stating, “The neutralization we perform is crucial for facilitating the treatment process” (P4). Sub-theme 2. Gravity in treatment Participants emphasized the necessity of gradual treatment. One remarked, “If you wish to recover, the process must be grad- ual” (P1). Many noted that traditional treatments are administered one to three times, with a participant stating, “Individuals receiv- ing treatment may require up to three sessions” (P4). Adherence to treatment protocols was deemed essential for optimal outcomes, with one participant asserting, “The patient must adhere to the treatment rules; otherwise, the results will not be optimal” (P1). Sub-theme 3. Self-efficacy in treatment. Participants expressed confidence in the efficacy of traditional medicine. One stated, “Patients often report expedited recovery with traditional treatments” (P1). Many shared that when conven- tional hospital treatments failed, they turned to traditional meth- ods, believing they would find healing: “They receive treatment at the hospital but remain uncured; traditional medicine provides cures” (P1). Themes 2. Treatments affecting the effectiveness of heal- ing in schizophrenia patients The traditional healing process’s success is influenced by sev- eral factors, categorized under spiritual treatment. Observations and interviews highlighted the use of herbal remedies and natural ingredients, particularly leaves and pure coconut oil. Sub-theme 1. Traditional treatment carried out by traditional practitioners. Traditional practitioners often use leaves and coconut oil in their treatments. Participants noted, “I use leaves for treatment; these are the ones my ancestors used” (P1). Regarding coconut oil, one participant stated, “I have been using pure coconut oil in this treatment for decades” (P2). Themes 3. Supernatural treatment for schizophrenia patients A lack of familial understanding regarding the effects of con- ventional medicine can adversely impact education, employment, and social inclusion. To improve awareness, educational initiatives targeting families about traditional medicine are vital. Community counseling, mass media outreach, and educational resources can enhance understanding, while health services can provide educa- tion to prevent chronic illnesses and reduce stigma associated with schizophrenia. Sub-theme 1. Spiritual treatment. Belief in the divine origin of illness influences treatment effec- tiveness. Many participants expressed, “I only treat; the rest is left to God” (P3). The belief in recovery was also prevalent: “I believe I can recover if I keep trying and praying” (P4). Such spiritual con- victions play a significant role in traditional healing practices. Themes 4. Traditional healers’ hope for patients with schizophrenia Traditional healers express strong hopes for the recovery of patients with schizophrenia, emphasizing the critical role of family support throughout the treatment process. They focus on the fami- ly’s acceptance of the condition, facilitating ongoing treatment until the patient recovers. Key themes identified in interviews include the potential for recovery, returning to normalcy, resuming work, returning to roles such as housewives, and regaining the ability to communicate. Sub-theme 1. Family accepts the situation. One healer shared, “Yes, my hope is that this patient can recov- er as they did before experiencing this mental disorder” (P1). This sentiment resonated with others, who expressed concern for their patients, saying things like, “I hope he can recover as before; it’s sad to see him in this state” (P3), and “As a healer, I have high hopes... hopefully, he can recover as before” (P5). A significant aspect of the healers’ hopes is the desire for patients to return to their original state before the onset of their illness. One healer stat- Special issue Pathways of Change Table 1. Participants demographic data (N=13). Characteristics Percentage (%) Age (mean) 53.1 years Gender Female 53.8 Male 46.1 Religion Islam 100 Education Elementary School 54.0 Junior High School 15.3 Senior High School 30.7 Duration as a traditional healer (mean) 21.9 years Age <50 years 46.2 >50 years 53.8 Occupation Farmer 46.2 Housewife 38.4 Entrepreneur 15.4 [Healthcare in Low-resource Settings 2025;13(s1):13082] [page 39] ed, “I hope this patient can recover and return to their original state before this mental disorder” (P1). Another remarked, “Hopefully, he can return to normal; it’s disheartening to see him struggling” (P3). The aspiration for patients to regain their ability to work is also a prevalent theme among traditional healers. One participant articulated, “I hope I can recover and be able to work again as before” (P1), while another added, “Yes, I hope he can get better and work again like before” (P2). Moreover, the ability to commu- nicate is paramount in the healing process. Healers noted, “I hope this mother can talk again because she’s been silent since her ill- ness” (P2), and “Many patients come in who don’t want to talk, so I hope that after treatment, they can communicate again” (P5). Discussion In the study on alternative treatment for schizophrenia through a local wisdom approach in Tidung, four main themes emerged. These themes encompassed traditional treatment methods, the fac- tors influencing healing effectiveness, supernatural interventions, and the hopes of traditional healers for their patients. Traditional treatment methods included practices that had been passed down through generations, such as massage, mantras, recitations, and regular therapies.4 However, many patients experienced boredom with their medications due to side effects like body stiffness and drowsiness, compounded by minimal family support for adhering to treatment regimens.18 This lack of support often led to stigma within families and communities, with sick members rarely receiv- ing visits, prompting some patients to seek solace in traditional medicine and practitioners.19,20 Spiritual healing practices, like those offered by Al-Fateh, played a significant role in the treatment of mental disorders. These practices included herbal remedies and psychoactive mush- rooms to enhance physical well-being, alongside spiritual activi- ties such as zikir and prayer to promote awareness and sanity.21 Special issue Pathways of Change Table 2. The main themes and sub-themes. Quotes Code Category Theme "Yes, we perform ruqyah, like teaching them regular Ruqyah Doing spiritual therapy Traditional treatment methods Quranic recitations, and we neutralize them first before for schizophrenia patients we start the treatment." (P1), "Regular prayer is performed independently, while we guide Prayer Doing spiritual therapy them properly in what they do." (P3) "In treatment, apart from prayer, we also cleanse them before Sholawat Doing spiritual therapy we perform the treatment." (P2) "In the ruqyah treatment we provide, in addition to reciting the Ruqyah Doing spiritual therapy Quran, we also suggest prayers." (P6) "Uh, this treatment we do, if they want to recover, Treatment must be gradual Routine treatment for early-stage the treatment must be gradual." (P1) schizophrenia patients "Those who seek treatment, not just once, Treatment to three times Routine treatment for early-stage they must receive treatment up to three times for any changes to happen." (P7) "In the healing process, patients must follow the treatment Gradual treatment Routine treatment for early-stage guidelines we provide because if they don't, the results won't be as effective." (P8) "Actually, during my treatment, I've heard from patients Healed with traditional medicine Believe the disease can be cured that they recover faster with traditional remedies than in the hospital. That's what the patients tell me." (P6) "Sometimes I get confused when patients trust me and come, Healed with traditional medicine Believe the disease can be cured saying they didn't recover in the hospital but did with traditional remedies." (P7) "Oh, well, in my treatment, I usually use leaves, the same ones Usually use leaves Treatment with herbal remedies Treatments affecting the that have been used for generations." (P5) effectiveness of healing in schizophrenia patients "In my treatment, I use pure coconut oil because we know Using pure coconut oil Treatment with herbal remedies its contents are beneficial." (P6) "If we believe the illness is from Allah, then, God willing, Believing the illness is from Allah Treatment based on faith Supernatural treatment for schizophrenia patients we can recover with the effort we make and the patient's belief." (P9) "When I treat them, my hope and belief are that they will recover Believing in recovery Treatment based on faith if they continue to make an effort." (P8). Yes, I believe everything can be resolved, as long as we remain All problems can be solved Treatment based on faith determined to find a solution." (P9) "The patients who seek treatment receive Islamic treatment, Treatment for patients of the Islamic faith Religion-based treatment as I use ruqyah in my treatments." (P10) "I hope that these patients can recover and return to their normal Returning to normal Regular treatment Traditional healers' hope for patients with schizophrenia state before experiencing this mental disorder." (P12) "I hope they recover and can work as they used to." (P13). Can recover Regular treatment “Sangat besar harapan saya tuh bu,, semoga bisa sembuh dan Can work again Regular treatment bisa bekerja lagi seperti dulu.”(P3) "Yes, I hope that they recover and can speak again as they used Can talk again Regular treatment to because, during their illness, they wouldn't speak; they would just remain silent." (P9) [page 40] [Healthcare in Low-resource Settings 2025;13(s1):13082] Most patients initially sought treatment from shamans or local healers, such as teungku, before turning to health facilities like community health centers and mental hospitals. In cases where the initial spiritual treatment did not yield results, patients often sought medical intervention.22 The study emphasized that different interventions had an impact on the recovery of individuals with schizophrenia. The tra- ditional healing process’s effectiveness could depend on multiple factors, with three primary healing methods identified: supernatu- ral, herbal, and equipment-based approaches. The role of tradition- al healers was crucial, as they could significantly impact commu- nity mental health efforts.23,24 Supernatural treatment, character- ized by spiritual practices that invoke inner energy and meditation, offered another dimension to healing. It was rooted in the belief that illnesses were divinely ordained, reinforcing the notion of potential healing through faith and communal support, particularly within the Islamic context.25 Traditional healers expressed their aspirations for families to care for members suffering from schizophrenia, emphasizing that family support could alleviate burdens and influence coping mechanisms.26,27 The study also explored the relationship between the research findings and Abraham Maslow’s theory, which was adapted by John Nash.28 Discrepancies arose, particularly regarding the treat- ment of mental disorders and the lack of evidence supporting Maslow’s hierarchy of needs as a central theme. Notably, the research did not identify the first treatment for mental disorders, leading to insights that emphasized factors influencing the ineffec- tiveness of healing in schizophrenia. Despite the differences, con- gruences existed between the findings and Maslow’s principles. For instance, factors such as recitation of the Qur’an and the calm- ing effects of prayer were highlighted as beneficial for healing. Traditional healers’ aspirations for their patients included recovery, reemployment, and regaining responsibilities, mirroring Maslow’s concepts of self-actualization and belonging. The study recognized limitations in applying Nash’s interpre- tation of Maslow’s theory to respondents from Tarakan, Indonesia, a region classified as underdeveloped. This context contributed to gaps in understanding schizophrenia and initial treatment approaches. Many families allowed conditions to worsen before seeking hospital treatment, which complicated recovery prospects. The stigma surrounding schizophrenia often deterred individuals from pursuing care, resulting in varying outcomes for those who turned to traditional practitioners. While some patients experi- enced improvement, especially in the early stages of their condi- tion, others struggled with recovery. The research underscored the importance of educating families about the effects of conventional medicine and the consequences of untreated conditions. Community-level initiatives aimed at enhancing understanding of traditional medicine could help reduce stigma and foster support for schizophrenia patients. These initia- tives could include health education programs, media dissemina- tion, and educational resources to improve awareness. Collaborative efforts from families and communities could miti- gate stigma and encourage collective action against the persistence of schizophrenia, especially in its early stages, by leveraging tradi- tional healing methods. Ultimately, enhancing knowledge and understanding would empower communities to tackle the chal- lenges of schizophrenia more effectively. Conclusions This research suggests that communities in underdeveloped areas, such as Tarakan, could implement the Tidung tribe’s local wisdom approach as an alternative treatment for schizophrenia. This approach incorporates practical skills, herbal remedies, prayer, and spiritual therapy. The findings underscore the impor- tance of early intervention in addressing the symptoms of schizophrenia, as traditional methods can facilitate recovery in the initial stages of the illness. There is an urgent need to raise public awareness about the significance of early treatment. Furthermore, combining medical and traditional treatment methods can optimize the chances of recovery for patients with schizophrenia. References 1. Listyarti R. Pendidikan Kewarganegaraan. Jakarta: Erlangga; 2008 p. 126–213. 2. Anggraini Y, Wahyudi A, Intan Larasati D, Yusuf A. The effec- tiveness of occupational therapy on patients with schizophre- nia or another mental illness: a systematic review. 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