Origins and history
From its origins in the late eighteenth century, clinical psychiatry recognized that mental illness might be influenced, sometimes even be caused, by a society’s mores, roles and sentiments. Generally, the patterns of severe illness (psychosis) identified in European hospitals were taken as universal, whilst it was accepted that wide variations existed in everyday psychological functioning which could be attributed to ‘race’, religion, gender and class. In the first explicitly cross-cultural comparison, the German hospital psychiatrist Emile Kraepelin (1904) concluded after a trip to Java that the illnesses, which were found universally, probably had a biological origin which determined their general form whilst local culture simply provided the variable content through which they manifested. He noted that local understandings could allocate the illness to categories quite different from those of Western medicine, such as spirit possession or a call to a shamanic role; yet, like the military doctors of the European colonies (Littlewood and Lipsedge 1989), he was confident he could distinguish the universal from the particular when attributing atypical illness to ‘a lower stage of evolutionary development’.
Locally recognized patterns which recalled mental illness but could not easily be fitted into Western nosologies were described as ‘culture-bound syndromes’ which represented a society’s character: the dhat syndrome being the exaggeration of Hindu preoccupations with purity; amok as a relic of precolonial patterns of redis-tributive justice; witiko as a cannibalistic impulse consequent on scarcity of food and abrupt weaning of the Ojibwa child; the kayak angst of the Arctic solitude; malignant anxiety as the individual manifestation of Yoruba sorcery preoccupations; the perennially interesting voodoo death (‘death by sorcery’); rarely, as with pibloktoq (‘Arctic hysteria’), as a biological disease such as avitaminosis. Extensive lists of these syndromes were compiled, many now recognized as folk-loric curiosities whose actual behavioural occurrence seems doubtful, but which provided some variety to leaven the mundane tasks of colonial asylum administration. Between World
War I and the 1950s, anthropological interest in mental illness was largely restricted to the American Culture and Personality school which, following Freud, emphasized variation in adult character and culture as originating in childrearing practices, and which had little interest in insanity. The standard procedure was to use psychoanalytical measures of personality across societies and relate the findings to levels of anxiety and sorcery accusations. Psychotic individuals occasionally appeared in the classic ethnographies (e.g. Nuer Religion) but with little comment, and those European anthropologists trained in clinical psychiatry or psychology (Rivers, C.G. Seligman, fFortes, Carstairs, Field) generally followed psychoanalytical models in examining neurotic illness as an exaggerated form of cultural preoccupations: the cognitive and neurosociological interests of fMauss excepted. The term ‘ethnopsychiatry’, coined by the Haitian psychiatrist Louis Mars in 1946 to refer to the local presentation of psychiatric illness, was popularized in the 1950s by fGeorges Devereux in his psychoanalytical study of the Mohave. Devereux, a Hungarian-French anthropologist (1961: 1—2), like Mars, used the term to refer to the medical study of illness in a particular community through looking at its ‘social and cultural’ setting, but he added a new emphasis on ‘the systematic study of the psychiatric theories and practices [of] an aboriginal group’, comparing this to the then established procedures of fethnobotany (see ethnoscience). It is in this second sense that the term is now generally recognized. In some hundred papers and books Devereux examined such conventional culture and personality interests as the mental health of the shaman, homosexuality and millenialism and dreams, together with studies of suicide and abortion among the Plains Indians and classical Greeks.
In an extended debate with the medical historian Erwin Ackernecht, who objected to the psychoanalytic ‘pathologization of whole cultures’ and preferred rather a simple comparison between local and Western ideas of illness, Devereux (1970) firmly privileged an etic (psychoanalytical) analysis, declaring shamans to be ‘surrogate schizophrenics’ on behalf of their community, insane in what he termed their ‘ethnic unconscious’ yet able to generate new ideas for their stressed fellows; he warned, however, that such solutions could only be irrational and lead to further ‘catastrophic behaviour’. He later developed his theory of complementarity: whereby any cultural pattern could be understood simultaneously from both psychoanalytical and sociological directions, but in practice he reduced sociology to psychology. Devereux’s ideas were taken to full development by La Barre who argued that all cultural innovators, successful or otherwise, have been schizophrenic. Psychiatric anthropology now favours Ackernecht’s more modest approach: whilst shamans and other inspirational healers and leaders may on occasion be psychotic by Western criteria (at least when they experience their initial ‘call’), practising shamans are rarely psychotic. Our etic (psychoanalytic or psychiatric) formulation may fit variously with emic (local) categorizations of illness.
Devereux focused interest on the problem of etic/emic and normal/abnormal distinctions in psychiatry where, in contrast to medical anthropology’s more evident distinction between disease and illness, its analytical construct — mental illness — was less evidently an object of observation in nature and indeed on examination appeared closely related to the ideological concerns of Western medicine. His associate Roger Bastide (1965: 9—12) restricted the term ‘ethnopsychiatry’ to the study of local conceptualizations which recalled those of Western psychiatry, and distinguished it from social psychiatry (the social context of a mentally ill person) and from the sociology of mental illness (its epidemiology and social causes). The latter two are now generally elided. It would be appropriate to see the various overlapping sub-disciplines as ranging from medical to anthropological interests, each marked by fluctuating popularity and influence: starting from the medical end with epidemiology and social psychiatry, through comparative psychiatry, transcultural and cross-cultural psychiatry, cultural psychiatry, and anthropology and psychiatry, ethnopsychiatry and cognitive anthropology. This closely parallels the spectrum (and recent shift) from empirical cross-cultural psychology to interpretive psychological anthropology, psychoanalytical and evolutionary interest being replaced by ethnoscience with more detailed studies of the context and local meaning of the phenomena. The key issues, though, remain the same.
Are mental illnesses universal?
The epidemiologists of the 1950s to the 1970s, who carried out the first direct questionnaire-based cross-cultural comparisons, had remained influenced by psychoanalysis. They included the McGill group (Wittkower, Murphy, Prince) with its important journal, the Transcultural Psychiatric Research Review (Murphy 1982), the North American Society for the Study of Culture and Psychiatry (Lebra, Lin, Westermeyer, Tseng, Jilek, Wintrob), the French-influenced Dakar school (Collomb, Diop) and the Cornell-Aro (Nigeria) study by Leighton and Lambo. The more recent World Health Organization’s international studies of schizophrenia and depression similarly use detailed questionnaires, standardized and backtranslated, which are derived from Western descriptions. Like Kraepelin, they conclude that formal characteristics of severe psychotic illness can be identified universally and that these are ultimately biologically determined, although the better prognosis identified in non-Western societies may be attributed to local categorization and a less stigmatizing response. These studies do not include small-scale relatively isolated cultures, among which psychosis has been argued to be rare (Fortes, Seligman, Torrey). Recovery may be less likely in capitalist societies due to their delineation of full personhood through the performance of industrial roles (Fortes, Warner). "Arthur Kleinman, the leading American anthropological psychiatrist, has argued that cross-cultural comparisons derived from Western criteria are in themselves inadequate, and that the full range of local meanings must always be explored before any comparison (Kleinman and Good 1985). ‘Depression’ for instance, with its connotation of some downward movement of the self, can be traced as a European idiom for distress only to the eighteenth century, and some alternative idiom of ‘soul loss’ seems to be more common outside the urban West. Whilst the form/content distinction is widely criticized, it remains debatable as to how in Kleinman’s ‘new cross-cultural psychiatry’ we can derive practical comparative measures from a multiplicity of contexts and at which point local particularity can be ignored (Littlewood 1990). The official diagnostic manual of American psychiatry (DSM IV) now includes a brief cultural section on each category and a glossary of culture-bound syndromes written by ethnop-sychiatrists; following recent anthropological and historical interest in Western psychiatry, many Western illnesses such as anorexia nervosa, post-traumatic stress disorder or drug overdoses are now regarded as somehow ‘culture-bound’. Are eating disorders to be attributed to a recent ‘fear of fatness’ or are they rather just a variant of more general gender-based renunciations within the family? If, as Loudon argued, periodical rituals of symbolic inversion in Southern Africa are being ‘replaced’ by individual neurosis, what sort of social psychological analysis can simultaneously deal with both? Or with the reframing of Western ‘hysteria’ by the women’s movement into a sort of political resistance?
The mechanism of psychological healing
Psychotherapy has often been said to derive from traditional and religious healing patterns (Janet 1919), contemporary illnesses such as hysteria and multiple personality disorder being closely allied to spirit possession states. The efficacy of both Western (‘cosmopolitan’ or ‘bio-medical’) medicine and local healing has been argued to be non-specific (empathy and suggestion: Frank) but others have favoured rather a close ‘symbolic congruence’ between affliction and shared social meanings (Dow, Torrey) or taken the illness as the individual representation of ‘social tensions’ in a pivotal individual (Turner, I.M. Lewis, Littlewood). Levi-Strauss has proposed that whilst shamanic healing deploys communal myths, Western psychotherapy facilitates the development of private myths: recent interest in the political and gender history of psychoanalysis would argue against the latter assertion. Prince has argued that healing is just the systematization of existing coping styles. Phenomenological and semantic anthropologists (Kleinman, Good, Kapferer, Csordas) criticize the essentialism implicit in a single notion of ‘healing’, and look rather at the particular reconstruction of self and agency in a performance of ritual, together with an interest in how both medical and local therapy can be reconfigured in the other context. Whilst Western psycho-therapies are rarely available in developing countries, a number of local practices — shamanism, vision quests, fire walking, acupuncture, meditation, sweat lodges — have been assimilated into the ‘human potential therapies’ of metropolitan North America; whilst ‘spirit possession’ has emerged again as an acceptable diagnosis among evangelical Christian psychiatrists and social workers.
Somatization and the idioms of distress
That something like ‘psychological conflict’ may be expressed through bodily preoccupations and physical pain is commonly accepted, and was regarded by psychoanalysts as a primitive psychological defence against anxiety. ‘Somatization’ is now recognized by ethnopsychiatrists as occurring in all societies; the universal recognition of bodily illness makes pain an available idiom of distress, whether the affliction is to be considered analytically as more truly political or individual (Kleinman and Good 1985). Theoretical approaches to somatization derive from attribution theory and systems theory, and from ethnoscience particularly its interest in local concepts of self and emotion (Marsella and White 1982), bringing the area close to the psychological anthropology of Shweder and D’Andrade in the United States, and Jahoda, A. Lock and Heelas in Britain. Debate continues in Britain and North America as to whether to take such concepts as actual psychological states, or else as social meanings — and thus, following Wittgenstein, whether we can distinguish the two. The individual in ethnopsychiatry is now less some unity to which explanations are to be referred than the embodied locus of contested meanings. A tension remains, as in other areas of contemporary social science, between those naturalistic approaches which emphasize causality and constraints on the individual (whether these are biological or cultural), and those personalis-tic approaches which emphasize representation, intentionality and instrumentality. In the case of self-starvation, drug overdoses and possession states, should we see these as reflections of male power or some disease process, or rather as active resistances and struggles for identity against the given constraints? Are mental illnesses expressing personal dilemmas or are they standardized strategies to enlist support and influence others (what Devereux called chantage masochiste – masochistic blackmail)? Breakdown or restitution? What has been lost from the earlier psychoanalytical approach is its easy conflation of naturalistic and personalistic, with its moralistic equation of health and value, together with the now unfashionable idea that psychopathology may not only be a personal creative act but may at times have a wider importance in social innovation (Littlewood 1990).
Clinically applied ethnopsychiatry
The work of Bateson and Turner has had a direct influence on family therapy and the newer ‘expressive’ European therapies. Psychiatric anthropologists increasingly work on health and development projects, refining epidemiological measures, evaluating community reception of mental illness, the attribution of responsibility, doctor-patient communications, the pathways into psychiatric care, networks of care and such Western ‘cults of affliction’ as Alcoholics Anonymous, the consequences of stigma, and the daily life of psychiatric institutions and patients, and have recently turned to record personal narratives of illness and mental handicap (Goff-man, Estroff, Skultans, Janzen, Kleinman, Lang-ness and Levine). A particular concern for European anthropologists has been the psychiatric care provided for ethnic minorities and, following the work of Mannoni and Fanon, the psychological consequences of racism, and how Western ideals of health and maturity replicate entrepreneurial values of the self-sufficient individual (Littlewood and Lipsedge 1989).
In the last decade ethnopsychiatry has been profoundly influenced by critical theory, the feminist health movement and by the studies in the epistemology and politics of psychiatry initiated by "Foucault. Against the North American ‘critical medical anthropologists’ (Singer, "Scheper-Hughes, "Taussig, M. Lock, Young) who have argued that much of ethnopsychiatry’s interest in ‘meaning’ and ‘communication’ is intended to accommodate patients to medical treatment through co-opting their own beliefs, Gaines (1992) had objected that these Marxist theorists assert an empirical reality for mental illness more than they admit. He proposes to restrict the term ‘ethnopsychiatry’ to the study of local meanings alone, arguing that Western science is as much an ethnoscience as any other, and that its various national schools can be examined like other social institutions. How do ethnopsychiatrists deal currently with the natur-alistic—personalistic dichotomy? The Nouvelle Revue d’Ethnopsychiatrie (France and Quebec) follows Devereux with an eclectic mix of psychoanalysis, biology and romantic ethnography. The interests of the United States and Klein-man’s journal Culture, Medicine and Psychiatry have remained individualistic and psychological, always more ‘cultural’ than ‘social’, and now semantically focused and not easily distinguished from medical anthropology; the Canadians retain an interest in the psychobiology of trance and hypnosis, psychoactive substance use, and other altered states of consciousness; the British and Dutch remain theoretically close to general social anthropology but with a strong emphasis on conflict and on the mental health of minority groups. Increasing numbers of psychiatrists in other countries (Norway, Japan, South Africa, Australia, India, Brazil) and in the World Health Organization now incorporate anthropological critiques into their cultural and epidemiological studies. Psychoanalytical influences on ethnop-sychiatry are increasingly marginal, but remain significant in Latin American medical ethnography and in the ‘cultural and media’ studies inspired by Lacan and Kristeva.
