WORLDVIEW, MENTAL ILLNESS AND HEALING

1. WORLDVIEW, MENTAL ILLNESS AND HEALING Felipe P. Jocano Jr. Department of Anthropology CSSP, UP Diliman

2. INTRODUCTION • Ethnopsychiatry: the study of psychiatric phenomena and their treatment in a given society or cultural setting • Cultural psychiatry: the study and comparison of mental illness and its treatment in different cultures and social groups (Helman)

3. INVESTIGATIVE ROOTS • Western-trained psychiatrists encountering unfamiliar and bizarre syndromes in non-Western patients and who attempt to reinterpret and recast these in Western illness categories • Anthropologists interested in defining normality and abnormality across cultures, culture and the shaping of personality structure, and cultural influences on the cause, presentation and treatment of mental illness (Helman)

4. SHARED INTERESTS • Diagnosis and treatment of mental illness where both patient and health professional come from different backgrounds –even in the same cultural setting, i.e. differences in economic background • Effects of forms of social change such as migration, urbanization, poverty, disasters, and deprivation on mental health

5. FOCUS • Mental illness: the psychological, behavioral and socio-cultural dimensions associated with psychological disorders • How cultural factors affect patients’ perceptions and behavior, content of hallucinations and delusions, and the attitudes of others towards them

6. CULTURE: DEFINITION • Culture refers to symbols, meanings and practices shared and learned by a group and transmitted from one generation to another. • It covers ways of being well, being ill and getting well, including treating the ill.

7. CULTURAL CONTEXT OF HEALTH AND ILLNESS • Health and illness as physical characteristics are embedded in a wide range of culturally based beliefs and practices. These include not just those related to health alone, but other cultural domains as well, including beliefs about what makes a desirable body, religious observances, etc.

8. CULTURE IN MENTAL ILLNESS • Defines normality and abnormality in particular societies: pagpaparamdam is an accepted phenomenon on Philippine society after the death of a loved one, but is considered a depression-related hallucination in Western settings • Defines the difference between abnormality and mental illness • May be a part of the etiology of certain illnesses • Influences clinical presentation and distribution of mental illnesses • Determines the ways that mental illness is recognized, labelled, explained and treated by others in the society, including health professionals.

9. CULTURE AND NORMALITY: HELMAN’S MODEL • Normality varies according to cultural setting: what is acceptable may be unacceptable to another. • 2 axes of classification: • Normal – Abnormal • Controlled – Uncontrolled

10. CONTROLLED NORMALITY • Conformity to accepted norms • Idealized behavior characterized by appropriateness to particular settings/contexts such as work, leisure, social occasions, personal relations • Appropriateness may vary according to age, gender, occupation, social rank, being part of a majority or minority

11. CONTROLLED ABNORMALITY • Temporary inversions of otherwise controlled behavior; these inversions are still under control and are monitored • Acts as a form of relief from daily control, but still in a controlled and limited manner • Examples; festivals, carnivals, New Year’s parties, university events (Faculty Follies in UP Diliman) and other events; individual languages of distress such as stress, claims of possession, trance (in religious activity), shamanism (during healing trances), asceticism

12. UNCONTROLLED ABNORMALITY • Otherwise normal experiences and sensations are uncontrolled: these become the source of several social problems and issues across different cultural settings • These are the symptoms with which psychiatrists do their work. • Behaviors in this category are viewed as being without reason in different cultures. • Examples: walking around shouting or talking to someone who is not present

13. UNCONTROLLED NORMALITY • Bad or criminal behavior • Issues: determination of awareness or lack of it by person concerned

14. ADVANTAGE OF ABNORMALITY • Individual level – draws attention to distress, attracting support, care and attention, including financial benefits • Group level – catharsis (and economic benefits, since such behavior has an economic side in the form of sale and consumption of related goods) • Examples: Type-A personalities as assets in the corporate world; over time, bipolar and ADHD personalities have become assets as the corporate setting has become more flexible; and in some cases Asberger’s syndrome (functional autism) has become useful in some settings (e.g., the nutty professor)

15. APPROACHES • Biological – Western diagnostic categories as essentially fixed and universal • Issues: applicability of categories across cultures; the same mental illness may also play different social roles in different societies • Social labeling – mental illness is defined relative to the society in which it is found • Combined – there are certain universals in abnormal behavior, with wide variation in form and affect, e.g., recognition of madness in different societies

16. ISSUES IN DIAGNOSIS • Historical and cultural contexts in the creation of diagnostic categories: • Delirechronique in France; delusion in English; sakit sa isip in Pilipino • Subjectivity of diagnostic process • Even with guides such as DSM-IV and ICD-10, much of the diagnostic process is shaped by the psychiatrist’s gut feel for what the illness may be • Political and moral uses – including misuses • Dissent as illness; diagnosis as a weapon in court cases

17. CULTURAL PATTERNS IN DIAGNOSIS • Political economic differences shape the content of mental illnesses, especially schizophrenia. • In Western countries, technology and government institutions are themes in the content of delusions and hallucinations • In non-Western agricultural countries, spirits and ghosts are prevalent in the content of delusions and hallucinations

18. CULTURAL PATTERNS IN DIAGNOSIS • In some contexts, the symptoms of mental illness are actually valued and the person who manifests these is respected. • Thus in a predominantly Buddhist country like Sri Lanka, despair and hopelessness are not necessarily seen as symptoms of depression (as they would be in Anglo-American psychiatry) but rather as the first stages towards the attainment of enlightenment (samadhi) and therefore are highly valued.

19. SOMATIZATION • A frequently encountered phenomenon is that of somatization, whereby psychological distress is manifested as physical distress for which no known physiological cause can be detected • Anxiety as headaches, loose bowel movements; stress as chronic fatigue; headache as a signal of distress

20. CONTEXT-BOUND DISORDERS • Folk illnesses with a particular range of symbolic meanings for the victims and those around them; • Spirit and ancestor possession • Amok • Latah (also known as mali-mali in the Philippines) • Koro –the belief that the penis will retract into the abdomen and cause death (Chinese) • Susto – fright illness (Latin America) • Parasuicide • Agoraphobia • Kleptomania • Exhibitionism

21. CONTEXT-BOUND DISORDERS • Domestic sieges • Road rage • Serial killing • Child abuse • Bullying • Workaholism • Chocoholism • Sex addiction • Internet addiction

22. CONTEXT-BOUND DISORDERS • Can a context-bound disorder be transmitted from one culture to another? Given the speed of globalization and the transfer of elements of popular culture from one site to another, this is an issue that bears investigating, especially in the light of recent events widely reported in the news. • E.g., road rage in the US, road rage in the Philippines

23. THE ROLE OF THE FAMILY • Mental illness usually manifests within a social context. • Family dynamics may either be source of distress or recovery for a patient. • Family types may include: ideal nuclear family; polygamous; blended; single-parent; informal (living together); same-sex unions • Issues revolve around whether the dynamics actually help or harm afflicted individuals • E.g., choices of treatment

24. MENTAL ILLNESS IN LOCAL CONTEXT • Some local terms for mental illness – baliw, bu-ang, loko-loko, sira-ulo, wala sa sarili, etc. • Local descriptions of mental illness include mostly extreme behavior such as dancing, singing and talking in public to one’s self; violent or aggressive behavior; crying for no reason; • Icon: Jose Rizal’s Sisa

25. MENTAL ILLNESS IN LOCAL CONTEXT • Other descriptions include wandering off and sitting by one’s self or staring blankly into space. • These behaviors are sudden and often unexpected.

26. THE LANGUAGE OF DISTRESS • Sapi/sinapian – literally joining, spirit possession • Sira-ulo, baliw, natuluyan, bumigay – closest terms for psychosis • Sobranglungkot, lumbay– closest terms for depression • Nagaalala, nababalisa – closest terms for anxiety • Makulit, super-kulit, sobrana – possible closest term for OCD • Nawawala sa sarili– possibly covers both dissociation and psychosis • I-stressed awt – direct translation for stressed out

27. CAVEAT • While the preceding slide may show some of the local terms for changes in behavior and the closest possible equivalents in the language of psychiatry, it does not mean that there is a one-to-one correspondence between the two. • There are cultural nuances involved in both sets of terms, so the clinician has to be able to navigate between two linguistic worlds at the same time.

28. RANGES OF BEHAVIORS • The preceding examples of the local language of distress also carry within themselves the idea of a continuum or range of severity of symptoms. • Severity is noted by the people closest to the patient, who are often the ones who bring the patient for treatment. • Prevailing notions: excess/lack, balance/imbalance

29. LOCAL MODELS OF ILLNESS CAUSATION • Mystical theories • Personalistic theories • Naturalistic theories (Tan 1987:17)

30. MYSTICAL THEORIES OF ILLNESS CAUSATION • Contagion or pollution – contact with objects or people that have strong life force, e.g., usug; • Mystical retribution – violation of social norms naturally results in punishment and suffering, e.g., gaba; • Fate – that some illnesses are meant to be, e.g., kapalaran, malas/suwerte; • Soul loss – the soul wanders off, e.g., nawawala sa sarili, nagwawala, bangungot.

31. PERSONALISTIC THEORIES OF ILLNESS CAUSATION • Animate • Ghosts – includes ancestral spirits; either due to retribution for unfulfilled obligations, affection, caprice or simply malevolence • Supernatural entities – engkanto, duwende, etc.; may be either malevolent or capricious or desire humans

32. PERSONALISTIC THEORIES OF ILLNESS CAUSATION • Magical • Sorcery – also known as kulam, barang, etc; may take different forms; sorcery can include object intrusion, soul theft, sending evil spirits; sorcerers can heal or harm; • Witchcraft – witches are also known as aswang; malevolent in nature; includes capacity to transform into animals; hereditary power.

33. NATURALISTIC THEORIES OF ILLNESS CAUSATION • Natural phenomena – some natural phenomena can cause illness, e.g. lanti or fright caused by thunder; illnesses caused by winds or hangin; • Humoral pathology – balance between forces in the body, e.g. init/lamig or heat and cold; • Diet – the nature of some foods may cause illness due to their nature if taken in excess or at the wrong time, e.g. upset inner balance;

34. NATURALISTIC THEORIES OF ILLNESS CAUSATION • Infections – or hawa – refers not only to physical illnesses but also particular behaviors as well; • Natural processes – folk physiology and anatomy, such as concepts of blood, circulation, heart and liver; • Stress – when under great strain; often refers to emotional distress but felt in the body

35. LOCAL ETIOLOGIES OF DISTRESS • Mystical retribution – moral issues, i.e. gaba • Fate • Soul loss – nawawala sa sarili • Visitations by ghosts and other supernatural entities • Humoral pathology – nainitan • Natural processes, e.g. mahina ang pag-iisip • Infection or contagion, although often applied in a joking context, but raises issues of stigma

36. CONCEPT OF THE BODY • In addition, recent work suggests that the local concept of the body is implicated in local theories of illness. • The body is a container or dwelling place. • The body is the locus of forces. • The body is the site of conflicts and contests of power.

37. CONCEPT OF THE BODY • Local concepts of the body are also implied in these etiologies. • Mental illness connected to local explanation of the body as a container (soul loss, visitations). • Mental illness connected to local explanation of the body as the site of forces – humoral pathology, e.g. hot and cold or init and lamig. • Mental illness as a result of political economy acting upon the body, e.g., poverty • Mental illness as a direct result of physical distress, e.g., torture

38. HARMONY AND BALANCE • Harmony and balance are also important aspects of local concepts of illness causation. • Thus, balance is restored to bodily processes in order to ensure recovery. • Similarly, issues of social harmony are addressed when healing.

39. BALANCE AND HARMONY IN MENTAL ILLNESS • Issues of balance and harmony also emerge in local data. • Physical balance – in restoring harmony among the natural forces of the human body. • Social harmony and balance – both in attribution and treatment; in daily activities

40. MENTAL ILLNESS AS INITIATORY STAGE • In some cases, initial manifestations of mental illness may be seen as part of a calling towards being a healer. • These may include symptoms otherwise described as schizophrenic; hearing voices, seeing visions, disruptive behavior, etc. • These may end when either the person or a family member accepts the call to heal.

41. INDIGENOUS HEALING • Refers to local ways of healing. • Indigenous healing practices are holistic – physical, psychic and social dimensions are addressed by the healer. • Healing practice operates within a local cosmological framework that accounts for all events that happen and that links personal experience, social relations and cultural meanings

42. PHYSICAL DIMENSIONS • Treatment may include massage, bone-setting, application of oil, etc.

43. PSYCHIC DIMENSIONS • Healing procedures also include calling upon assisting spirits for help as well as identifying the spirits responsible for the illness. • At times, the procedures involve a contest of power between the healer and the spirit(s) involved. This then becomes an exorcism ritual.

44. SOCIAL DIMENSIONS • Since the illness may also be perceived to be due to a disruption in social harmony, part of the cure includes advising the patient or the patient’s family to address the relevant issues. • The social dimension also includes reintegration of the patient into society. • This runs parallel to current psychotherapeutic practices. • In the case of a calling, the healing process includes acceptance of the call to healing and the necessary rituals to facilitate this acceptance.

45. CONTEXTUALIZATION • Local healing traditions are not simply an exotic “other” practice of medicine – they are a living part of our cultures. • There are some parallels between professional medical practice and models and local healing practice and models, e.g., power, combat, balance, harmony.

46. CONTEXTUALIZATION • In learning from local healers and their work, professionals would be better able to address issues of contextualization and policy.

47. THE END THANK YOU VERY MUCH!